CMS-Wesley-Medical-Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, document review and policy review the Hospital failed to ensure a central log was maintained for each patient that comes to the emergency department (ED). The hospital also failed to ensure an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ED) was provided to each patient presenting to the ED to determine whether or not an emergency medical condition (EMC) existed for one of 20 (Patient 1) patient records reviewed from 07/07/20 through 02/21/21.

The cumulative effects of the hospital ED's failure to log and track patients and failure to conduct an appropriate MSE has the potential for all patients to be discharged or leave the ED with an unidentified EMC which may lead to deterioration of the person's condition including death.

Findings Include:

Review of the Hospital's document titled, Medical Staff Rules and Regulations Manual, dated 02/20/20, showed patient's presenting to the ED for treatment, shall be treated by a member of the ED staff ...a medical screening exam shall be performed by a qualified medical individual on all patients who present for emergency care or are in labor. The exam will include a history, physical examination, and ancillary studies and procedures to determine that an emergency condition does or does not exist or that the patient is stable or can be transferred appropriately. A log of patients who present and who are transferred shall be maintained by the hospital.

Review of the Hospital's policy titled, EMTALA - Definitions and General Requirements, dated 02/01/16, showed in part, the hospital ...must provide to any individual ...an appropriate medical screening exam ...to determine whether or not an emergency medical condition exists. ...an acute care or specialty hospital with an emergency department provides an appropriate medical screening examination and any necessary stabilizing treatment to any individual ...who comes to the Emergency Department and requests such examination, as required by EMTALA and all Federal regulations and interpretive guidelines...to determine whether or not an emergency medical condition (EMC) exists ...the Chief Executive Officer of the Hospital, the executive officer responsible for the emergency department, and the Emergency Department director are responsible for implementing the EMTALA policies ...each facility must develop and implement state-compliant facility-specific policies regarding the screening and treatment of patients with emergency conditions. These governing policies must support compliance with federal and state regulations. ... Leaving Dedicated Emergency Department (DED) after Triage but before an MSE. If an individual present to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE (LPMSE), the facility should use its best efforts to: ...c. offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC; d. log the individual in the Central Log; e. discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same; f. ask the patient to sign the Waiver of Right to Medical Screening Examination form; ...

Review of the Hospital's policy titled, EMTALA-Central Log, dated 02/2019, showed in part, the hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance ...whether he or she left before a medical screening examination could be performed ...whether he or she refused treatment ...or whether he or she was refused treatment.

Review of the Hospital's policy titled, EMTALA - Medical Screening Examination and Stabilization, dated 05/2017, showed in part, the hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely log in or triage an individual with a medical condition and not provide an MSE.

Review of the Hospital's undated document titled, Facility Summary of Self-Reported EMTALA Incident, showed EMS rolled the patient ...into the ED ...patient does not put a mask on at the screening station ...the Advanced Practice Registered Nurse (APRN) stated that she would not see the patient if she did not wear a mask ...the triage RN stated that the patient could not wear a mask because she had a medical exemption and could not breathe with a mask on ...the APRN was able to do a quick examination of the patient's ankle to determine that the patient had pulses and her ankle was pink ...the patient stated that she would not put on a mask because she had asthma and chronic obstructive pulmonary disease (COPD- a chronic respiratory disease) ...the APRN stated that she never said she would not care for the patient but that the patient said she did not want to be seen if she had to wear a mask...there is no documentation of an MSE ...there is no documentation of refusal of treatment or leaving prior to medical screening examination (LPMSE) ...a lack of adherence to hospital policy related to initial and repeat vital signs and assessment of ED patient ...withholding examination and treatment based on patients refusal to wear a mask ...situation not elevated per chain of command to resolve.

Review of a document title, Prehospital Care Report, dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of the Hospital's document titled, Central Log, dated 02/02/21 to 02/28/21, showed Patient 1 failed to be entered on the log upon arrival to the hospital on [DATE] at 12:16 PM.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed, left before seen by health care provider.

During an interview/phone call on 03/24/21 at 9:00 AM, Staff G, ED RN, stated that Patient 1 refused to be COVID-19 screened, that she brought the patient a mask, the patient's verbal and body language were strong, security, the police department (PD), the advanced practice registered nurse (APRN) all came in to help her get the patient to put on a mask on and the patient's anger escalated. Staff G stated that she saw another patient come to check in, so she walked away and sometime within that time frame she saw security taking the patient outside. Staff G stated that she did not spend much time convincing the patient to be seen, offer the patient paperwork for leaving against medical advice (AMA) or leaving prior to medical screening examination (LPMSE.)

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that the patient was argumentative and refused to wear a mask. Staff L was instructed by the triage nurse Staff G, Registered Nurse (RN) to get the patient out of here, if she will not wear a mask, get her out. Staff L stated that he explained to the patient if you do not put a mask on we will need to ask you to leave and the patient stated that she wanted to be seen, but she could not wear a mask.

The evidence showed the hospital denied the patient a medical screening examination because she was not wearing a mask. There was no evidence that staff intervened on behalf of the patient, or attempted to move her to a safe place in the ED while waiting for an examination. There was no evidence that the hospital offered Patient 1 further medical examination and treatment as may be required to identify and stabilize an EMC or discussed the medical risks associated with leaving prior to the medical screening.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, document review and policy review the Hospital failed to maintain a central log for each individual who comes to the emergency department seeking for one of 20 patients (Patient 1.) The hospital's failure to maintain a central log has the potential to create loss of information related to the treatment and disposition of patients.

Findings Include:

Review of a document title, Prehospital Care Report with EKG, dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed, left before seen by health care provider.

There was no documented evidence that an appropriate MSE was completed and no documentation of the events that occurred while Patient 1 was in the ED or while sitting outside in a wheelchair.

Review of video footage on 03/23/21 at 12:59 PM, with Staff Y, Ethics/Compliance/Privacy and Contract Manager showed at 12:15 PM the ambulance arrived at the ED, and the patient was wheeled in by EMS on a gurney not wearing a mask at 12:16 PM. The patient was in a triage room from 12:16 PM to 12:24 PM (eight minutes), At 12:24 PM, she was wheeled outside and sat in a wheelchair, facing the street, in front of windows that could be seen by the screener/triage desk until 4:44 PM (4 hours and 20 minutes.) At 2:43 PM, the triage RN comes out (2 hours and 19 minutes later) to check on the patient and she walks back into the ED at 2:44 PM (one minute later.) At 4:44 PM, the patient is seen walking back into the ED caring a blanket then back out without the blanket. She then gets into the back seat of a truck and it pulls away at 4:45 PM. The hospital staff failed to obtain patient information to enter into the central log throughout the patient's four hour and 20-minute stay.

During an interview on 03/24/21 at 10:55, Staff BB, Paramedic/ Emergency Medical Service (EMS), stated that they tried to give the nurse report, but she was more worried about the patient not wearing a mask and she did not seemed worried about getting report. The nurse failed to get patient information to enter into the central log from EMS.

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that he was instructed by the triage nurse Staff G, Registered Nurse (RN), to get the patient out of here, if she will not wear a mask, get her out. Staff L stated that he explained to the patient again, if you do not put a mask on we will need to ask you to leave, the patient stated that she wanted to be seen, but could not wear a mask.

During a telephone interview on 03/24/21 at 9:00 AM, Staff G, ED, RN, stated that EMS brought Patient 1 past the check in to the triage room. Staff G remembers EMS came up to her to give report and she told them she would get it from the patient. Staff G stated that she thought she could get the patient's information once the patient had calmed down, but when she went outside, one or two times, to check on her, the Patient 1 refused to give her any information.

Review of the Hospital's document titled, Central Log, dated 02/02/21 to 02/28/21 showed Patient 1 failed to be entered on the log upon arrival to the hospital on [DATE] at 12:16 PM.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, document review and policy review the Hospital failed to ensure an appropriate medical screening examination (MSE) was completed to determine whether or not an emergency medical condition (EMC) exists for one of 20 patients (Patient 1.) The hospital's failure to ensure a MSE was completed has the potential for patients to be discharged or leave the emergency department with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition including death.

Findings Include:

Review of the Hospital's undated document titled, Facility Summary of Self-Reported EMTALA Incident, showed EMS rolls patient ...into Emergency Department (ED) ...patient does not put a mask on at the screening station ...the APRN stated that she would not see the patient if she did not wear a mask ...the triage RN stated that the patient could not wear a mask because she had a medical exemption and could not breathe with a mask on ...the APRN was able to do a quick examination of the patient's ankle to determine that the patient had pulses and her ankle was pink ...the patient stated that she would not put on a mask because she had asthma and chronic obstructive pulmonary disease (COPD- a chronic respiratory disease) ...the APRN stated that she never said she would not care for the patient but that the patient said she did not want to be seen if she had to wear a mask...there is no documentation of an MSE ...there is no documentation of refusal of treatment or leaving prior to medical screening examination (LPMSE) ...a lack of adherence to hospital policy related to initial and repeat vital signs and assessment of ED patient ...withholding examination and treatment based on patients refusal to wear a mask ...situation not elevated per chain of command to resolve.

Review of a document title, Prehospital Care Report dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of the Hospital's document titled, Central Log, dated 02/02/21 to 02/28/21 showed Patient 1 failed to be entered on the log upon arrival to the hospital on [DATE] at 12:16 PM.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed left before seen by health care provider.

There was no documented evidence in Patient 1's medical record to show that an appropriate MSE was completed or that that staff explained the benefits versus risk of leaving prior to an MSE. There was no documented evidence in the medical record of the events that occurred while Patient 1 was in the ED or while sitting outside in a wheelchair.

Review of video footage on 03/23/21 at 12:59 PM, with Staff Y, Ethics/Compliance/Privacy and Contract Manager showed at 12:15 PM the ambulance arrived at the ED, and the patient was wheeled in by EMS on a gurney not wearing a mask at 12:16 PM. The patient was in a triage room from 12:16 PM to 12:24 PM (eight minutes), At 12:24 PM, she was wheeled outside and sat in a wheelchair, facing the street, in front of windows that could be seen by the ED screener/triage desk, until 4:44 PM (4 hours and 20 minutes.) At 2:43 PM, the triage RN comes out (2 hours and 19 minutes later) to check on the patient and she walks back into the ED at 2:44 PM (one minute later.) At 4:44 PM, the patient is seen walking back into the ED caring a blanket then back out without the blanket. She then gets into the back seat of a truck and it pulls away at 4:45 PM.

During an interview on 03/24/21 at 10:55, Staff BB, Paramedic/ Emergency Medical Service (EMS), stated that they tried to give the nurse report, but she was more worried about the patient not wearing a mask and she did not seemed worried about getting report.

During an interview/phone call on 03/24/21 at 9:00 AM, Staff G, ED RN, stated that the patient came to the ED via EMS, the patient refused to be COVID-19 screened, and Staff G had EMS bring the patient directly into the triage room. Staff G stated that she brought the patient a mask, the patient's verbal and body language were strong, security, the police department (PD), the advanced practice registered nurse (APRN) all came in to help her get the patient to put on a mask on and the patients anger escalated. Staff G stated that she saw another patient come to check in, so she walked away and sometime within that time frame she saw security taking the patient outside. Staff G stated that sometimes the APRN's will perform a medical screening examination (MSE) and dismiss the patient. Staff G remembers asking the patient if she wanted to be seen and the patient told her she did not. Staff G stated that she did not spend much time convincing the patient to be seen, offer the patient paperwork for leaving against medical advice (AMA) or leaving prior to medical screening examination (LPMSE.) Staff G stated that she collaborated with Staff Q, APRN who told her she was not going to fight the patient over foot pain.

Staff G failed to discuss the risks and benefits involved in leaving prior to the medical screening and document same and failed to asked Patient 1 to sign the Waiver of Right to Medical Screening Examination form

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that the patient was argumentative and refused to wear a mask. Staff L was instructed by the triage nurse Staff G, to get the patient out of here, if she will not wear a mask, get her out. Staff L stated that he explained to the patient if you do not put a mask on we will need to ask you to leave and the patient stated that she wanted to be seen, she could not wear a mask, and the triage nurse instructed us to get the patient out, so they followed her directions.

During an interview on 03/24/21 at 11:38 AM, Staff M, Security Supervisor stated that the patient refused to wear a mask and Staff G, ED, RN told them they needed get the patient out of here.

During an interview on 03/23/21 at 11:47 AM, Staff GG, Hospital Security stated that if a patient refuses to wear a mask and the nursing staff cannot convince them to wear a mask, security would be called. He stated that all patients presenting to the ED for care must wear a mask and if they refuse they would walk the patient outside.

During an interview on 03/24/21 at 2:39 PM, Staff O, PD, stated that he remembers hearing the nurse telling security the lady needs to go, and she would call to have someone pick the patient up. Staff O clarified there was not a legal issue concerning this patient and he did not have to trespass her off the grounds.

During an interview/phone call on 03/24/21 at 4:15 PM, Staff Q, APRN stated that when the hospital staff asked the patient to wear a mask she became belligerent and loud. Staff Q remembers the patient reported she had ankle pain for 2 weeks, and Staff Q decided it was not a life-threatening emergency. Staff Q told the patient it's the hospital policy wear a mask, the patient stated that she did not want to be treated, she asked to be put in a wheel chair, taken outside and she would call someone to pick her up. Staff Q stated that she did not document anything since the patient was not registered. Staff Q was asked if she ever went outside to check on the patient and perform an MSE, and she stated that she could see the patient was fine, and never went outside to see her since she refused to be patient and wear a mask.

During an interview on 03/24/21 at 4:54 PM, Staff D, ED Nursing Director stated that if a patient refuses to wear a mask we are to escalate the situation through the chain of command, and if the charge nurse needs help the ED manager, house supervisor or administrator on call are available. Staff D clarified if a patient refuses to wear a mask the patient can be placed in a room, staff can wear an N95 mask and still treat the patient. Staff D stated that all patient's need to receive an MSE if they come to the ED.

The hospital failed to perform an appropriate MSE to determine whether or not an EMC existed for Patient 1 and left her sitting in a wheelchair, outside with a blanket, in 50 degree weather, in front of windows where she could be seen by the screener/triage desk for four hours and twenty minutes on 02/21/21.

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Based on observation, interview, and policy review, the facility failed to ensure a peripheral intravenous (IV) catheter was inserted in a manner that prevented the possibility of cross contamination for one of eight sampled patients (Patient 8). The failure to employ methods such as the use of clean gloves when inserting an IV catheter had the potential to cause a blood stream infection for the patient observed and could affect any of the 500 patients currently inhouse if they had an IV inserted with the same technique failure.

Findings Include:

Review of the facility policy titled Catheter Peripheral, Intravenous - Insertion, Maintenance and Discontinuation (Adult), last approved 06/2020, showed multiple steps for insertion of an intravenous catheter. The policy stated that staff were to wash their hands and don (put on) gloves after opening the IV start kit, setting up needed supplies, and preparing the insertion site.

Observation of a peripheral IV insertion for Patient 8 in the Emergency Department (ED) on 01/08/21 at 3:10 PM showed the patient reclining on a gurney. Staff N, Registered Nurse (RN) was wearing gloves and was retrieving supplies for the procedure. While wearing these gloves, Staff N, RN opened a drawered cart, retrieved supplies from the cart, and then placed them on a Mayo stand (a removable instrument stainless steel tray for instruments or supplies positioned near the procedure site). Wearing the same gloves, Staff N, RN then placed a tourniquet on Patient 8's arm and palpated the skin for veins and removed the tourniquet. Staff N, RN then opened all packaged items on the Mayo stand and flushed (pushed normal saline through) the loop (the catheter extension tubing that attaches to the intravenous catheter). Staff N, RN then went to the cabinet to the right of the gurney, opened the cabinet door and retrieved a towel, which was placed under Patient 8's arm. Still wearing the same gloves, Staff N, RN then reapplied the tourniquet, cleaned the right antecubital (inside the elbow) site with a chlorhexidine swab, allowed the area to dry and inserted a 20-gauge intravenous catheter. Staff N, RN then attached an empty syringe for a blood draw, attached the loop tubing and secured the IV site. Staff N, RN next cleaned the blood from Patient #8's arm and filled the lab tubes with the blood, then removed her gloves and used hand sanitizer.

During an interview on 01/08/21 at 3:18 PM, regarding the failure to change to clean gloves prior to the actual IV insertion, Staff I, ED Nurse Manager (NM) stated that a peripheral IV was a clean procedure not a sterile procedure, and the RN should have minimized touches. Staff I, NM continued by stating that the best practice would be not to touch anything prior to the IV start.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the hospital failed to follow their policies and did not provide a medical screening exam (MSE) sufficient to determine if an emergency medical condition existed for one of 20 patient records reviewed (Patient 1). Failure of the hospital's ED to provide a sufficient medical screening exam places patients at risk for an undetected emergency, further deterioration in their condition, or even death.

Findings Include:

Review of a hospital policy titled, EMTALA (Emergency Medical Treatment and Labor ACT)-Medical Screening Examination and Stabilization reviewed 08/2018 showed, the Purpose: to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment ... Procedure: When an MSE is required: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an EMC exists ... ...Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's symptoms: Depending on the individuals presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and other diagnostic tests and procedures. ...Stabilizing Treatment and Individuals Whose EMC's are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist.

Document review of the hospital policy titled, EMTALA-Definitions and General Requirements, revised 02/01/16, showed, Medical Screening Exam (MSE) is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not and EMC exists ...

Review of the hospital document titled, Medical Staff Bylaws dated December 2015, showed, Qualified Medical Person or Personnel: In addition to a physician, Qualified Medical Persons may perform a Medical Screening Examination. Individuals in the following professional categories who have demonstrated current competence in the performance of Medical Screening Examinations, and who are functioning within the scope of his or her license and policies of the Hospital, have been approved by the Board as Qualified Medical Personnel: Registered Nurse in Perinatal Services and newborn areas; an APRN or physician assistant for low acuity Emergency Department/Section patients per their protocol; a registered nurse or an APRN/PA for ground or air transport.

Review of Patient 1's medical record showed she (MDS) dated [DATE] at 3:42 PM with complaint of chest pain that radiated from the center of her chest to her back that started about 3:30 PM. After her arrival she started feeling nauseated (sick stomach). Patient 1 initially rated her pain intensity at 5 on a scale of 0 to 10 with 10 being the worst. ED physician assistant-certified (PA-C) staff O, performed an initial history and physical (H&P) exam at 4:06 PM and documented patient # 1 complained of chest pain of unknown etiology, nausea, right arm numbness, and neck pain. PA-C staff O documented patient # 1 complained of substernal chest tightness and initiated the chest pain protocol which included blood testing, a chest x-ray, and an ECG (a recording of the electrical activity of the heart). Further documentation showed that patient # 1's cardiac (heart) risk factors included obesity (over weight) and family history of cardiac disease.

At 4:32 PM documentation showed that patient # 1 received an intravenous (IV) dose of Morphine (pain medication) 4 mg for pain she rated a 6 on a scale of 1-10 in addition to an IV dose of Zofran (anti-nausea medication). The medical record did not contain a description of the type, duration, quality or location of patient # 1's pain or the cause of her nausea or vomiting.

At 6:55 PM documentation by the ED nurse showed that patient # 1's pain intensity had decreased to 4 (moderate pain).

At 8:23 PM the ED physician printed discharge instructions and provided them to patient # 1. The discharge instructions specified that patient # 1 should make a follow up appointment with a cardiologist (contact information provided) and instructions for how to take Zofran (anti-nausea medication). The instructions continued and indicated that the cause of patient # 1's chest pain had not been determined and specified when chest pain is caused by a dangerous condition like a heart attack, aorta injury, blood clot in the lung, or collapsed lung. The discharge instructions continued It is unlikely that your pain is caused by a life-threatening condition if : Your chest pain lasts only a few seconds at a time; you are not short of breath, nauseated (sick to your stomach), sweaty, or lightheaded; your pain gets worse when you twist or bend; your pain improves with exercise or hard work.

At 8:40 PM documentation showed that patient # 1 received an IV dose of Fentanyl 100 mcg (powerful narcotic similar to Morphine but is 50 to 100 times more potent) for complaints of pain rated a 6 on a scale of 1-10. In addition, the ED nurse administered an IV dose of Zofran (anti-nausea medication) and Maalox mixed with viscous Lidocaine (a gastrointestinal cocktail to treat stomach upset). The medical record did not contain a description of the type, duration, quality or location of patient # 1's ongoing pain or the cause of her nausea and vomiting.

At 9:38 PM documentation showed that patient # 1 left the ED.

Review of a second record showed that Emergency Medical Service (EMS) was contacted at 1:14 AM on 1/2/20, less than 4 hours after patient # 1 was discharged from the ED. Further documentation showed that EMS could not resuscitate patient # 1 and declared her deceased at 2:02 AM.

During a telephone interview on 02/04/20 at 9:00 AM ED physician staff N stated the majority of the patients that come through the ED present with chest pain but not all patients with chest pain are admitted . He further stated part of the process of determining patient treatment as an inpatient or outpatient when a patient presents with chest pain is to consult the cardiologist on call who reviews the presentation with the ED physician and makes recommendations regarding further care. He also stated that he assessed and reassessed patient # 1 during the ED visit and the nursing staff kept him aware of her status when he was out of her room.

Refer to tag A 2406 for further details.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, record review and interviews the hospital Emergency Department (ED) failed to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for one of 20 patient's records reviewed (Patient 1).

Failure of the hospital to provide an appropriate MSE for every patient presenting to the ED has the potential to allow an EMC to go unidentified which could place patients at risk for worsening of their condition, further complication or even death.

Findings Include:

Review of Patient 1's medical record showed she (MDS) dated [DATE] at 3:42 PM. The rapid initial assessment showed she complained of chest pain that radiated from the center of her chest to her back that started about 3:30 PM. After her arrival she started feeling nauseated (sick stomach). Patient 1 rated her pain intensity at 5 on a scale of 0 to 10 with 10 being the worst. Her initial vital signs showed her blood pressure (B/P)129/62 (normal B/P is less than 120/80), Pulse (P) 70 (normal 60-100 beats per minute), Respiration (R)18 (Normal 12-20 breaths per minute), and oxygen saturation (SPO2) 97% (normal 95-100% saturation). Her cardiac (heart) risk factors included obesity (over weight) and family history of cardiac disease.

ED physician assistant-certified (PA-C) staff O, performed an initial history and physical (H&P) exam at 4:06 PM, documenting the patient's chief complaint was chest pain of unknown etiology, nausea, right arm numbness, and neck pain. Further documentation showed the patient complained of substernal chest tightness that began at 3:30 PM on 1/1/2020. The chest pain protocol was initiated including obtaining laboratory blood tests, a chest x-ray, and an electrocardiogram (a recording of the electrical activity of the heart).

At 4:15 PM documentation showed that patient # 1's respiratory rate increased to 33 breaths per minute (normal respiratory rate at rest is 12 - 25). Further documentation showed that patient # 1 received Morphine (pain medication) 4 milligrams (mg) intravenous (IV) for pain intensity rated 6 on a scale of 1-10, 10 being the most severe pain, and Zofran 4 mg, IV (a medication used to treat nausea). There was no documentation of the type, duration, location or quality of patient # 1's pain at the time the ED nurse administered the morphine.

At 5:33 PM documentation showed that PA-C staff O contacted the on-call cardiologist staff R and reviewed patient # 1's lab results (normal), chest x-ray (normal) and EKG findings. Further documentation showed the cardiologist requested a second Troponin Level (test that measures Troponin in the blood, indicating a heart attack) and advised PA-C staff O to instruct patient # 1 to make an appointment with cardiology the following day. At 6:16 PM shift changed and PA-C staff O transferred patient # 1's care to ED physician staff N.

At 6:55 PM the ED nurse re-assessed patient # 1's pain and documentation showed the patient rated her pain intensity level a 4 (moderate) on a scale of 1-10.

At 7:53 PM ED physician staff N determined the repeat Troponin Level requested by the on-call cardiologist was less than 0.04 ng/ml (normal is less than 0.11 ng/ml, elevated levels may be an indication of heart damage or heart attack).

At 8:23 PM ED physician staff N printed discharge instructions and provided them to patient # 1. The discharge instructions specified that patient # 1 should make a follow up appointment with a cardiologist (contact information provided) and instructions for how to take Zofran (anti-nausea medication). The instructions continued and indicated that the cause of patient # 1's chest pain had not been determined and specified that Sometimes chest pain is caused by a dangerous condition like a heart attack, aorta injury, blood clot in the lung, or collapsed lung. The discharge instructions continued It is unlikely that your pain is caused by a life-threatening condition if : Your chest pain lasts only a few seconds at a time; you are not short of breath, nauseated (sick to your stomach), sweaty, or lightheaded; your pain gets worse when you twist or bend; your pain improves with exercise or hard work.

At 8:40 PM documentation showed the ED nurse administered an intravenous (IV) 100 mcg dose of Fentanyl (powerful narcotic similar to Morphine but is 50 to 100 times more potent) for complaints of pain rated a 6 on a scale of 1-10. In addition, the ED nurse administered an IV dose of Zofran (anti-nausea medication) and Maalox mixed with viscous Lidocaine (a gastrointestinal cocktail to treat stomach upset). The medical record did not contain a description of the type, duration, quality or location of patient # 1's unresolved pain or the cause of her nausea and vomiting or whether her pain was resolved following administration of Fentanyl. At 8:55 PM the ED nurse documented that patient # 1's oxygen saturation level dropped to 84% after receiving the pain medication and placed patient # 1 on 2 liters of supplemental oxygen. At 9:06 PM a different ED nurse documented that the flow of oxygen was lowered to 1 liter. Approximately 1 hour after receiving Fentanyl, the nurse documented that patient # 1 left the ED at 9:38 PM.

Review of a second record showed that Emergency Medical Service (EMS) was contacted at 1:14 AM on 1/2/20, less than 4 hours after patient # 1 was discharged from the ED. Further documentation showed that EMS arrived at patient # 1's location and was unsuccessful at resuscitating the patient. At 2:02 AM documentation showed patient # 1 was declared deceased in the field (non-hospital setting).

During an interview on 01/08/20 at 4:55 PM, Staff R, Cardiologist stated that he is available for consultation and to give recommendations only and that the ED physician is responsible for determining a diagnosis. He stated that there is no magic level of troponin showing a patient is in trouble, it is only part of the picture and the physical assessment must be included in the determination.

During a telephone interview on 02/04/20 at 9:00 AM, ED physician staff N, stated the majority of the patients that come through the ED present with chest pain but not all patients with chest pain are admitted . He further stated part of the process of determining patient treatment as an inpatient or outpatient when a patient presents with chest pain is to consult the cardiologist on call who reviews the presentation with the ED physician and makes recommendations regarding further care. ED physician staff N further stated it is not always possible to relieve all pain and Patient 1 was discharged to home with a pain level of four (not documented in the medical record). He stated he discussed her pain with her and patient # 1 was agreeable with discharge. He further stated he did give the patient a prescription for nausea medication but did not give her a prescription for pain medication because she did not feel she required it. He further stated, we were not able to get a clear picture of the cause of her chest pain; however, she was stable when discharged and she was deemed stable for outpatient cardiology workup.

During a telephone interview on 01/08/20 at 10:11 AM, a family member stated they brought patient # 1 to the ED because she complained of chest pain and thought she was having a heart attack. The family member stated this was the first time patient # 1 complained of these symptoms. The family member stated that at some point patient # 1 received morphine which affected her speech and she became groggy, however she was able to talk with family. About 9:30 PM patient # 1 called and said the doctors could not find anything wrong and to come and get her. The family member stated that someone brought patient # 1 out of the ED in a wheel chair and that she had a gray tub with her. The family member stated that Patient 1 threw up in the ED, in the car and then at home. The family member stated that they decided to call 911 around 11:00 PM and emergency medical services (EMS) came about 15 minutes later. The family member stated that EMS personnel worked on patient # 1 for about 45 minutes and they had to shock her 3-4 times. The family member stated that EMS finally said there was nothing else that could be done for her and they called the coroner and police.

Show Text of Violation

Based on observations, interviews, current and discharged record reviews, and document reviews the hospital failed to provide a sanitary dietary service area and patient care areas to include 2 of 2 kitchens with trash/dirt and food debris on floor,1 of 2 kitchens with broken floor tiles, moldy food, lime build up to dishwasher and a cockroach on the floor, 5 of 8 patient tower units (tower 3, 7, 8, 9, and 10) with mobile patient equipment with dirt build up on the bottom, 2 of 8 patient tower units (tower 7 and 8) had soiled utility rooms with dirty floors and unflushed flushable basins, 1 of 8 patient towers (tower 3) had clean utility rooms with uncovered linen carts, 2 of 8 patient towers (tower 3 and 8) had clean supply rooms with boxes on the floor, 1 of 1 dietary hostess in and out of patient rooms without cleaning computer equipment, 1 of 4 ICU's (SICU) had unflushed flushable basins, and 1 of 4 ICU's (SICU) with dust coated equipment cart with items for repair. The hospital's systemic failure to ensure a sanitary environment has the potential for serious negative impact on patient health, increases the patient risk for hospital acquired infection and the spread of communicable disease to patient, staff and visitors.

Findings include:

Document review of the hospital's policy titled Infection prevention and Control Plan revised 07/2018 showed the Infection Prevention and Control program is to protect patients, visitors and healthcare professionals from harm due to infectious agents and promote safety, quality and value in the healthcare services delivered.

Document review of the hospital's policy titled, Patient Care Equipment and Cleaning, revised on 02/2017 showed staff must clean and disinfect all reusable patient equipment within the facility after each patient use.

Document review of the hospital policy titled Prevention of bed bug, cockroach and other pest revised 03/2018, showed that plant operations is responsible to coordinate with environmental services and exterminator if base cover or wall coverings need to be removed for further inspection or extermination.

1. Observation on 08/20/18 between 9:15 AM and 10:15 AM and 08/21/18 of the main kitchen between revealed the following:

a. one live cockroach on the kitchen floor by the food prep sink.

b. dishwasher with lime deposit on side of machine

c. dishwasher parts laying on the floor coated with lime deposits

d. multiple missing and broken floor tiles

e. food splashes dried on multiple walls

f. food crumbs under dry goods shelving and kitchen equipment

g. dry goods shelving located near employee timeclock with food dried and stuck to it

h. floor drain with trash and food built up near the kitchen manager entrance

i. line of refrigerators with dried food spills on the surface

j. kitchen fan with dirt buildup on the fan cage

k. kitchen floors with dirt, small trash, and food items

l. produce cooler showed a putrefied cucumber with liquefied moldy growth and three hamburger buns with greenish moldy growth.

m. Food Cooler located in the public service area showed three peanut butter and jelly sandwiches with a use by date of 08/20/18.

During an interview on 08/22/18 at 11:15 PM in the conference room, Staff W, Food and Nutrition Services (FNS) Director, stated that the staff are responsible for cleaning the area they work in. Staff W stated that the chef is responsible for ensuring that staff complete all cleaning as well as checking the coolers and refrigerators for outdates and removing foods as needed. Staff D stated that he performs random spot checks in the kitchen but realizes now that he must increase his efforts.

During an interview on 08/20/18 at 9:30 AM in the kitchen, Staff D, Executive Chef, stated that kitchen staff clean their kitchen instead of environmental services (EVS). Staff D stated that he is responsible for providing oversight and making sure things are clean. Staff D stated that staff should have cleaned all the items identified and does not know why they had not been and failed to answer why he had not reported cleaning failures to the department manager.

During an interview on 08/20/18 at 9:45 AM in the kitchen managers office, Staff G, Kitchen Retail Manager, stated that she put in work orders for the broken tiles, but EVS denied them. She stated that plant operations staff told her to put in a small project request. Staff G stated that she needed to do that today.

During an interview on 08/22/18 at 11:45 AM via telephone, Staff W, FNS Director, stated that kitchen staff reported the broken and missing floor tiles to EVS on 01/01/18 but EVS told them they were going to be fix it as a big project. Staff W stated that kitchen staff have not done anything to reduce infection risks that broken floor tiles cause.

During an interview on 08/22/18 at 1:30 PM in the conference room, Staff X, Plant Operations Director, stated that he has two million square feet, so he must rely on the department managers to tell him if the need for repairs are necessary and need immediate attention. Staff X stated that of we put a repair request on hold the manager should notify us if there is an immediate necessity for us to complete the repair.

During an interview on 08/22/18 at 12:00 PM in the conference room, Staff W, FNS Director, stated that he does not receive reports from the contracted pest control company and was not aware of any repairs they may have recommended.

Review of contracted pest control company's records on 08/22/18 at 2:00 PM showed customer service report findings from the service date of 08/03/18 were that cockroaches were noted during service; cockroaches noted at bread wall, wall void in main kitchen. A hole/gap noted Steele plate on bread wall is loose and there are gaps on the other side of wall under the sink in main kitchen. Please seal to help prevent pest activity.

Review of the kitchens pest sighting/evidence log from 01/01/18 through 08/20/18 showed the following entries:

a. 03/13/18 Bugs; cooks hot line

b. 05/30/18 roach; behind food line

c. 06/20/18 three roaches; under warmer on cafT

d. 07/27/18 roach; main kitchen around small ice machine

e. 08/13/18 roach; main kitchen, cold prep by cooler holding patient fruit and liquids

During an interview on 08/22/18 at 1:00 PM in the conference room Staff Y, EVS Director, stated typically he would put in a work request based off their pest control contractors report and communicate with the necessary parties. Staff Y stated he does not recall ever getting that report or the contractor communicating with anyone about the needed repairs. Staff Y stated that either he or the kitchen manager should have put in the work order

2. Observation on 08/20/18 at 10:00 AM of the Four Corners CafT showed an island containing soda and condiments with food and trash underneath.

During an interview on 08/20/18 at 9:45 AM Staff D, Executive Chef, stated that staff can not the island, but they should still be sweeping and mopping underneath it.

3. Observation on 08/20/18 at 11:30 AM of the 10-Tower Stroke Unit showed the following:

a. clean supply room with two mobile vital sign monitoring machines with dirt buildup on the base.

4. Observation on 08/20/18 at 11:45 AM of the 9-Tower Orthopedic/Neurological Unit showed the following:

a. two rolling patient equipment stands with a white powdery substance on the base of the stand and one with a thick layer of dust on the base of the stand.

5. Observation on 08/20/18 at 12:00 PM of the 8-Tower Oncology Unit showed the following:

a. soiled utility room with dirty floors and a white powder (Absolute Solidifier used in suction containers that contain bodily fluids to make the fluid gel like) spilled all over the counter

b. unknown fluids in the unflushed basin

c. one clean supply room with four boxes containing patient supplies laying directly on the floor

d. four rolling patient equipment stands with dust and build of dirt on the base of the stands in several locations throughout the unit.

During an interview on 8/20/2018 at 12:15 PM in the clean supply room staff B Registered Nurse (RN) Director of Quality and staff N RN stated that staff must not store boxes of supplies on the floor. Staff B explained the staff from purchasing unload the supplies in the loading dock area and bring them up to the units.

6. Observation on 08/20/18 at 2:45 PM of the 7-Tower Medical/Trauma Unit showed the following:

a. soiled utility room with dirt and a dried spill on the floor

b. In the alcove where they store clean equipment showed two rolling patient equipment stands with dust and dried spills on the base of the stand

c. unknown fluids in the unflushed basin

7. Observation on 08/20/18 at 3:05 PM of the 5-Tower Pediatric Unit showed the following:

a. glove on the floor near room 517

b. trash on floor near the clean utility room

8. Observation on 08/20/18 at 3:25 PM of the 3-Tower Cardiac Step-Down Unit showed the following:

a. South side clean utility room with open door to the linen cart

b. full bag of trash leaking onto the floor outside of room 4-310. No unit staff members were nearby with knowledge of the trash bag on the floor

c. North side clean utility room with three boxes stored directly on the floor and a three-tiered utility cart in the clean utility room with uncovered laundry on it.

d. in the nourishment kitchen showed a microwave oven with food spills inside of it

e. a soiled utility room with a sticky substance on the floor

f. Point of use room contained two WOWs (work station on wheels) with dirt and dried spills on the base and five rolling patient equipment stands with dust and dried spills on the base of the stands.

During an interview on 08/20/18 at 3:25 PM near the clean supply room, Staff Z, an unidentified Registered Nurse (RN), stated she put in a work order for the broken door. Staff Z failed to place a cover over the clean linen cart until EVS could repair the door leaving them exposed to dust and dirt buildup.

During an interview on 08/20/18 at 3:30 PM near room 4-310, Staff B, Director of Quality, stated that staff should never leave trash unattended and on the hallway floor.

9. Observation on 08/20/18 at 3:55 PM of the 2-Tower Endoscopy/Pediatric Sedation Unit showed the following:

a. missing ceiling tile in the clean supply room

b. sharps container secured to a workstation on wheels (WOW) with a zip tie

During an interview on 08/20/18 at 4:00 PM near a hallway charting station, Staff AA, RN, stated that she knew staff should not have attached it to the WOW like that and said she had never seen anything like that before. Staff AA stated she didn't know who to call to get it removed. Staff B directed Staff AA to cut the zip tie with a pair of scissors to remove the sharps container from the WOW.

10. Observation on 08/21/18 at 9:20 AM in the Medical Intensive Care Unit (MICU) showed staff K, dietary hostess, typing on a small computer that she placed on the patient's overbed table in patient room #4. Staff K exited the patient's room performed and entered another patient's room without disinfecting the small computer's surface.

During an interview on 8/21/18 at 9:25 AM at the nurse's desk Staff K stated that they go to each patient's room to review the days menu with the patient and enter what the patient wants to eat for that day.

During an interview on 8/21/18 at 9:25 AM at the nurse's station Staff A, Infection Control Officer, confirmed they observed Staff K going from one patient's room to another patient's room without disinfecting the surface of the computer.

11. Observation on 08/21/18 at 9:50 AM in the Surgical Intensive Care Unit (SICU) showed a soiled utility room with dirty water in the flushable basin. A utility cart on the unit with a gray bin containing the following items for repair; patient call lights and castor wheels for a chair. The bin had a heavy buildup of dust in the bottom of the bin.

During an interview on 08/21/18 at 9:55 AM with Staff M, Registered Nurse (RN), observed and confirmed the dust build up in the bin that held items for repair.

During an interview on 08/21/18 at 9:50 AM in the soiled utility room with Staff L, Director of Critical Care, stated that it probably was housekeeping staff because they dump the dirty water from the floor cleaning machine in the flushable basin.

12. Observation on 08/21/18 from 10:20 AM to 10:40 AM in the Emergency Department (ED) showed in the Ready Care area one rolling patient equipment stand with dust and dirt build up on the base and one trash can with a blood droplet on the outside surface, in the Triage area one rolling patient equipment stand with dust and dirt build up on the base, and in the Trauma Room area four rolling patient equipment stands with dust and dirt build up, one metal stand with dust and dirt build up, eight wood documentation stations on wheels with chips and gouges in the surfaces of the wood exposing the bare wood, rendering them uncleanable.

During an interview on 8/21/18 at 10:40 AM, Staff A, Infection Control Officer, stated that the documentation stations have uncleanable surfaces because of the exposed bare wood.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview, and policy review, the hospital failed to ensure that each patient admitted to the hospital received a copy of their patient rights and had a signed consent for treatment for 3 of 16 patients reviewed (Patient # 6, 7, and 16). The hospital's failure to ensure that patients receive and understand their Patient Rights put all patients at risk for not understanding their rights to information about their care, their privacy, participation in the planning of their care, and the safety, protection and their comfort during their admission to the hospital.

The findings include:

- Patient # 6's medical record reviewed on 8/9/2016 revealed the patient was admitted on [DATE] with a diagnosis of severe sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or the patient's representative consented to treatment at the Hospital.

- Patient #7's medical record reviewed on 8/9/2016 revealed the patient was admitted on [DATE] with a diagnosis of sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or the patient's representative consented to treatment at the Hospital.

- Patient # 16's medical record review on 8/9/2016 revealed the patient was admitted on [DATE] with a diagnosis of sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs) and pneumonia (inflammatory condition of the lung). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or patient's representative consented to treatment at the Hospital.

Policy titled Procedure for Registration Forms and Signatures reviewed on 8/9/2016 at 3:00 PM directed ...obtains signatures on all registration forms, form the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance ...and ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ... and ... A physician or licensed clinical person should document a medical reason why the patient is unable to provide a signature within the medical record ... and ... If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency ...

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, medical record review and staff interview the hospital failed to ensure patient safety was met in that the nursing staff failed to provide ongoing nursing assessments and activation of safety devices and alerts for 6 of 32 patients sampled (Patients #1, #17, #18, #19, #20, and #21). Failure by nursing staff to provide ongoing assessments and activation of safety devices and alerts had the potential to increase the risk of patient falls. The facility failed to ensure nursing staff followed physician orders for the removal of a Foley catheter (removal of a tube placed in the bladder to collect urine) for one of 32 patient's sampled (Patient #1). This failure had the potential to place patients at an increased risk for infections.

The findings include:

- Patient #1's medical record reviewed on 8/8/2016 revealed the patient was admitted on [DATE] and discharged on [DATE] with a diagnosis of a sigmoid stricture (bowel obstruction). After the surgical procedure the patient was taken to 8T (tower) room 4-810. The medical record revealed the nursing staff failed to round on the patient at least every two hours on 6/4/2016 and 6/5/2016. Nursing assessment documentation revealed the bed alarm was not recorded as on during the evening shift and night shift of 6/4/2016. The medical record revealed the patient fell in their room at approximately 5:45 AM the morning of 6/5/16.

Patient #1 interviewed on 8/8/2016 at 1:30 PM revealed they had fallen in the early morning of 6/5/2016 after being woken up by a beeping IV machine. Patient #1 stated they tried to use the call light but no one came. The patient indicated they were instructed to use the hospital telephone at night, but the telephone in their room was on a high shelf in the corner of the room away from their bed. The patient confirmed the bed alarm was not turned on as no alarm sounded when they got out of bed. The patient revealed no nurses had been to their room for hours before they fell .

- Patient #1's record also revealed an order was placed on 6/2/2016 at 5:54 PM to discontinue the Foley catheter at 10:00 AM on 6/3/2016. A second order to discontinue the Foley catheter was placed on 6/4/2016 directing staff to remove the Foley catheter at 10:15 AM. Nursing documentation revealed the Foley catheter was not removed until 6/4/2016 at 7:00 PM. Failure of the nursing staff to remove the foley catheter as directed placed the patient at a higher risk for a urinary tract infection.

- Patient #17's medical record reviewed on 8/10/2016 revealed the patient fell on [DATE] at 3:50 AM on the 8T unit fall report. Fall recorded in medical record by RN Staff F. Documentation stated patient #17 was found on the floor by nurse assistant. Documentation noted that patient stated s/he did not fall but sat on floor because s/he was tired of waiting for someone to comne to take her to the bathroom and did not want to pee the bed. RN Staff F documented non-skid socks were put on patient #17 by RN Staff F but patient #17 had removed them. Documentation states the patient refused to have bed alarm set and that patient was non-compliant with fall risk safety education. Documentation stated that patient was wearing a fall risk wrist band and a fall risk sign was at the door. Post fall assessment documentation stated patient did not hit head.

- Patient #18's medical record reviewed on 8/10/2016 revealed the patient fell on [DATE] at 7:00 AM on the 8T unit fall report. Fall recorded in medical record by Staff RN G. Documentation stated patient #18 was found on floor, leaning on door rail at 8:30 AM and was recorded at 8:39 AM. Shift assessment on 4/25/2016 at 9:30 PM revealed bed alarm was not set. Documentation after the fall revealed patient #18 had non slip socks on, but was unclear if socks were in place before the fall. Following the fall, documentation revealed bed alarm was set and fall risk arm band was in place. Post fall assessment documentation stated it was unknown if patient #18 hit head. The medical record failed to indicate the bed alarm was on prior to the patients fall.

- Patient #19's medical record reviewed on 8/10/2016 revealed the patient fell on [DATE] am at 4:34 AM on the 8T unit fall report. Fall recorded in medical record by Staff RN H. Nursing assessment documentation stated patient #19 was a high fall risk. High fall risk checklist was not completed. Documentation revealed the fall occurred at 1:19 AM and was recorded at 1:30 AM with an addendum made at 7:52 AM. Patient #19 was found on floor at 4:30 AM and post fall protocol completed. Post fall assessment documentation stated patient did not hit head.

- Patient #20's medical record reviewed on 8/10/2016 revealed the patient fell on [DATE] am at 6:55 AM on the 8T unit fall report. Nursing assessment performed by Staff RN H documented on 5/24/2016 at 0300 am that patient #20 was a moderate fall risk, bed was low to floor, call light was present, and the patient was restless. Ativan (for the treatment of anxiety) was given to patient #20. Documentation of the fall by RN Staff I on 5/24/2016 at 12:00 PM stated, patient #20 fell last night.

- Patient #21's medical record reviewed on 8/10/2016 revealed the patient fell on [DATE] am at 8:00 am per unit fall report. Documentation by RN Staff J on 2/4/2016 at 10:00 PM patient #21 was high fall risk. High fall risk check list was not completed. Documentation by RN Staff K on 2/5/2016 at 8:15 AM revealed patient #21 was a high fall risk, with a fall alert arm band, a specialty low bed, documentation that patient #21 was not to be left unattended. Bed alarm activation was not documented. RN Staff K documentation revealed patient #21 was found on the floor on 2/5/2016 at 8:45 AM. Post fall assessment documented by RN Staff L on 2/5/2016 at 9:10 AM stated the fall occurred at 9:00 AM and documented patient did not hit head ....

Administrative Staff A interviewed on 8/11/2016 at 11:05 AM revealed nursing staff are educated using the StuderGroup Hourly Rounding:101 document stating ...When Hourly Rounding is implemented effectively, a staff member visits each patient every hour during the day, and every two hours during the night. During these rounds, eight very specific behaviors are utilized that contribute to improved safety for patients and efficiency for staffing ...

- Review of policy Fall Prevention directed ...Patients will be assessed for potential to fall upon admission ...and reassessed with each shift assessment ... Policy further directs ...moderate fall risk will be identified with a yellow arm band and high risk for fall will be identified by a yellow arm band with high risk indicator lettering ... Policy further directs ... a safe environment is to be provided for every patient...and ...use properly fitting non-skid footwear, keep bed in lowest position ...bedrails up times two unless contraindicated ... Fall Prevention policy further directs ...moderate fall risk supervise and or assist bedside sitting, personal hygiene, and toileting as appropriate ...evaluate need for activation of bed and chair alarm. High fall risk ...implement measures listed under moderate risk and activate bed alarm, remain with patient while toileting ...It is the responsibility of every employee to provide ongoing surveillance of the environment to ensure patient safety. Patient ' s fall risk and/or need for assistance with activities will be communicated between shifts during bedside report ...

Show Text of Violation

The hospital reported four dedicated emergency department(DED) locations with an average six month patient census of 9,257 a month. Based on document review, policy and procedure review and staff interviews the hospital failed to follow their policy and procedure to provide a medical screening exam(MSE) for one of one individual (Unknown #1) who presented on the hospital property via ambulance while the hospital was on diversion (an occurrence when the hospital lacks beds to admit new patients requiring in-patient services and patients coming to the emergency departments are diverted to another hospital that has beds available).

The hospital self-reported the Emergency Medical Treatment and Labor Act(EMTALA) violation to the Centers for Medicare and Medicaid Services(CMS) Region V11 on 1/30/2014. The hospital has had no EMTALA violations since at least 2003. A review of randomly selected emergency department records revealed no EMTALA concerns. A review of documents with corrective actions taken and planned by the hospital revealed appropriate education and policy revision to address the deficient practice.

Findings include:

- Policy titled EMTALA-Definitions and General Requirements, Reference Number: LL.EM.001 reviewed on 2/6/14, directed staff to perform an MSE (medical screening examination) on any individual who comes to the emergency department, when an individual comes on hospital property and requests emergency medical care (other than the Dedicated Emergency Department (DED), or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made.

- The hospitals documentation reviewed on 2/6/14 at 9:00am of the self reported (to the regional Centers of Medicare Services (CMS) possible EMTALA investigation revealed on 1/12/14 area hospitals experienced high numbers of patients coming into the Emergency Department (ED) with flu like symptoms, pneumonia and other related illnesses causing many of the local hospitals to go on diversion status for adult critical care. On the afternoon of 1/13/14 as the hospital prepared to go on diversion status for all adult Intensive Care Unit(ICU) beds and the ED on the main campus because all ICU beds were full (except for one bed for a potential trauma patient). In house patients were being held in the catheterization lab, postoperative recovery areas, and the ED while waiting for ICU bed availability. The ED had five potential ICU patients in ED rooms. At 1:50pm the hospital notified One Call Center(the ambulance transfer center used to initiate transfers to or from the hospital) that the hospital was on diversion status.

During this time, the county's emergency medical service (EMS) had been called to transport a patient who was at an acute treatment center. The patient had requested to go to another area hospital (hospital #2) but EMS learned that hospital #2 was on diversion. The EMS driver began driving towards the hospital and radioed at 1:52pm saying they were en-route with the patient. The hospital informed EMS they were on diversion and should take the patient to the hospital of the patients preference. EMS stated they wanted to go to hospital #2 so the hospital instructed them to proceed to hospital #2.

The hospital investigation document revealed at approximately 1:55pm the house supervisor and the ED's Assistant Nurse Manager (ANM) were implementing diversion status and discussing resources when a female paramedic entered the ED and asked can we still come here? The ANM responded that they thought EMS were going to transport their patient to hospital #2. The house supervisor advised the paramedic that their hospital was on diversion. EMS then asked if they could go to the ED location and they responded yes and informed EMS that site C was not at capacity. The paramedic ran out the door and it was at this point the ANM realized that the patient may have been in the driveway with the paramedic, and even though they were on diversion status the patient must be seen in the ED, and provided an MSE.

Staff A, Registered Nurse (RN), house supervisor interviewed on 2/6/14 at 10:30am acknowledged they were on duty on 1/13/14 the day of the ED incident. Staff A said on 1/13/14 with the approval of the Chief Executive Officer the hospital went on diversional status because of lack of beds and high patient census. Staff A indicated on 1/13/14 they were unable to see the ambulance parking area when the paramedic came running in from the ambulance bay area. Staff A stated after the paramedic left the ED they went to ambulance bay area to see if the ambulance and patient were still on the hospital property since they realized the possible EMTALA violation and reported the incident to administration.

Administrative Nursing Staff B interviewed on 2/6/14 at 4:00pm reported the hospital recognized the potential Emergency Medical Treatment and Labor Act (EMTALA) violation, investigated the incident, self-reported the incident to the Centers for Medicare and Medicaid Services (CMS) and provided education to managers, directors, and staff in the hospital's ED, all staff involved in the incident, local Emergency Medical System (EMS), and One Call Service. Staff B provided the following corrective actions the hospital implemented and mandatory staff education outline to be completed by 3/31/14:

A.) The house supervisor was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and the necessity of providing a medical screening examination (MSE).

B.) The Emergency Department (ED) Assistant Nurse Manager (ANM) was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment, even if the facility is on diversion status, and the necessity of providing a medical screening examination.

C.) All ED staff members and house supervisors at each of the hospital's ED campuses have been educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and necessity of providing a MSE. A formal EMTALA class had been assigned in Health Stream with a completion date by 3/31/14.

D.) To ensure a clear understanding of EMTALA obligations the hospital has incorporated this information into the Diversion Process Policy.

E.) The house supervisor orientation checklist was updated to include EMTALA obligations when the ED is on diversion status.

F.) The hospital's senior management, directors, and managers will be educated on the EMTALA requirements including providing a medical screening examination while on hospital property at leadership meetings on 2/6/14 and 2/16/14.

G.) The hospital EMS coordinator requested the EMS supervisor educate the EMS paramedics on all EMTALA regulations to be followed when a patient arrives on hospital property and the necessity of the hospital to provide a MSE.

Administrative Nursing Staff B interviewed and documents reviewed on 2/6/14 between 3:00pm to 5:25pm revealed the hospital provided education to the house supervisors, updated the house supervisors orientation checklist, provided EMTALA education to the ED registration staff, security staff, senior management/directors and managers power-point education, and revised the policy for emergency treatment while on diversion status.

Show Text of Violation

The hospital reported four dedicated emergency department(DED) locations with an average six month patient census of 9,257 a month. Based on document review, policy and procedure review and staff interviews the hospital failed to follow their policy and procedure to provide a medical screening examination (MSE) for one of one individual (Unknown #1) who presented on the hospital property via ambulance while the hospital was on diversion (an occurrence when the hospital lacks beds to admit new patients requiring in-patient services and patients coming to the emergency departments are diverted to another hospital that has beds available).

The hospital self-reported the Emergency Medical Treatment and Labor Act (EMTALA) violation to the Centers for Medicare and Medicaid Services(CMS) Region V11 on 1/30/2014. The hospital has had no EMTALA violations since at least 2003. A review of randomly selected emergency department records revealed no EMTALA concerns. A review of documents with corrective actions taken and planned by the hospital revealed appropriate education and policy revision to address the deficient practice.

Findings include:

- Policy titled EMTALA-Definitions and General Requirements, Reference Number: LL.EM.001 reviewed on 2/6/14, directed staff to perform an MSE (medical screening examination) on any individual who comes to the emergency department, when an individual comes on hospital property and requests emergency medical care (other than the Dedicated Emergency Department) (DED), or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made.

- The hospitals documentation reviewed on 2/6/14 at 9:00am of the self reported (to the regional Centers of Medicare Services (CMS) possible EMTALA violation revealed on 1/12/14 area hospitals experienced high numbers of patients coming into the Emergency Department (ED) with flu like symptoms, pneumonia and other related illnesses causing many of the local hospitals to go on diversion status for adult critical care. On the afternoon of 1/13/14 as the hospital prepared to go on diversion status for all adult Intensive Care Unit(ICU) beds and the ED on the main campus because all ICU beds were full (except for one bed for a potential trauma patient). In house patients were being held in the catheterization lab, postoperative recovery areas, and the ED while waiting for ICU bed availability. The ED had five potential ICU patients in ED rooms. At 1:50pm the hospital notified One Call Center(the ambulance transfer center used to initiate transfers to or from the hospital) that the hospital was on diversion status.