**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36206 Based on record review and interview, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of thirty sampled patients (Patient 1) on [DATE] emergency room visit. This deficient practice resulted in Patient 1 not having a medical screening examination (MSE) to determine if Patient 1 had an emergency medical condition, on [DATE] at 8:03 p.m Patient 1 was found unresponsive in the waiting room, on [DATE] at 10:52 p.m. (2 hours and 49 minutes after arrival) and subsequently expired at 11:13 p.m. Findings: A review of Patient 1's Patient Care Report with Attachments, by the EMS (Emergency Medical Services, dated [DATE] at 7:39 p.m., indicated Patient 1 was brought to the facility at 8:04 p.m (as indicated on the record), for alcohol intoxication, chest pain, and cardiac issue. A review of Patient 1's In /Out /ER Patient Admission Record, indicated Patient 1 was admitted to the Emergency Department (ED) on [DATE] at 8:03 p.m. (as written on the record). A review of Patient 1's Emergency Medical Record, indicated Patient 1 was triaged on [DATE] at 8:07 p.m., Patient 1 was brought by Fire/Rescue ambulance. Patient 1 was assessed as a priority level 3, and expired at 11:17 p.m. A review of the triage notes titled, Rapid Initial Assessment, dated [DATE] at 8:07 p.m., indicated Patient 1 was brought in by rescue ambulance (RA) for ETOH (alcohol). Per Emergency Medical Services (EMS), a bystander called 911 due to Patient 1 found laying on the ground by the street, intoxicated. Patient 1 had a strong smell of alcohol. Chief complaint: ingestion and Priority : ESI 3 / Urgent ( Level 1 / Resuscitation: patient presents with a condition that requires immediate , aggressive attention, Level 2 / Emergent: indicates a patient presents with a condition posing a potential threat to life, limb, or function and requires a medical screen within 10 minutes of arrival. Level 3 / Urgent: patient presents with a condition that could progress to a serious problem requiring emergency intervention. Patients should have a medical screen within 30 minutes of arrival. Level 4 / Semi-Urgent: a patient condition is stable. Level 5 / Non-Urgent: patient has a minor illness, injury, or stable chronic condition). A review of a note titled, RME (rapid medical evaluation) Attestation, dated [DATE] at 8:20 p.m., indicated Patient 1 was brought in by EMS after running in and out of traffic. He has been cooperative. ETOH. No complaints. Spanish speaking. No orders were placed for Patient 1. A review of Patient 1's Emergency Notes, dated [DATE], indicated the following; a. At 8:20 p.m., per charge nurse (CN 1), Patient 1 to ED lobby. No change in Patient's condition. Alert and oriented times three. b. At 8:20 p.m., Patient 1 appears in no apparent distress (NAD), awake and alert. c. At 10:51 p.m., Emergency Department (ED) technician (tech) notified me that she noticed Patient 1 slumped over in chair. ED tech checked for pulses and got me for help. Code Blue initiated. CPR started in lobby. Patient 1 then taken to room [ROOM NUMBER] for MD care. d. At 10:55 p.m., CPR in progress. e. At 11:13 p.m., no pulse, no breathing, unresponsive, no signs of life. CPR stopped and Patient 1 was pronounced dead. A review of a document titled, Code Blue Record, dated [DATE] at 10:53 p.m., indicated a Code (a cardiopulmonary arrest happening to a patient) had been activated at 10:52 p.m. for Patient 1. Code team arrived at 10:53 p.m Patient 1's condition upon Code Team arrival; unconscious (a person is unable to respond to people or activity), cyanotic (a bluish color to the skin or mucous membranes I usually due to lack of oxygen in the blood), pupils dilated (when the black center of the eyes are larger than normal), not breathing, no pulse, and temperature was cold. CPR (cardiopulmonary resuscitation) was started at 10:53 p.m The code was stopped at 11:13 p.m Code outcome: Patient 1 expired. A review of a note titled, HPI-General Illness', dated [DATE] at 10:53 p.m., indicated Patient 1 brought by EMS after a bystander saw him running in and out of traffic and appeared to be intoxicated. Patient's vital signs upon arrival were: BP (blood pressure) ,d+[DATE], HR (heart rate) 100, RR (respiratory rate) 19, SPO2 (percentage of oxygen in the blood) 98 %. Patient was placed in the waiting room when he became unconscious, and CPR was in progress at 10:52 p.m Patient 1 was taken into critical care room for further resuscitation .Time of death was called at 11:13 p.m Primary impression: cardiac arrest. During a concurrent interview and record review of a note titled RME, on [DATE] at 11:30 a.m., the Director of the Emergency Department (DED) stated the physician assistant (PA 1) initiated a greeting (a polite word or sign of welcome or recognition) at triage, no orders were placed for Patient 1. The DED stated that after triage, the charge nurse (CN 1) instructed the Fire and Rescue ambulance personnel to take Patient 1 to the lobby. The DED stated that neither CN 1 nor the ambulance personnel (EMS, staff) handed off (gave report of patient condition) the patient to the Emergency Medical Technician (EMT) in the lobby. The DED stated there should have been a hand off. The DED stated Patient 1 was seen at the time of triage by PA 1, at 8:20 p.m., who conducted an RME (rapid medical evaluation) and documented a comment only, no orders were placed. The DED stated the RME note was not a medical screening examination (MSE). The DED stated Patient 1 did not receive a MSE during while in the emergency department. During a concurrent interview and record review of the RME note, on [DATE] at 11:50 a.m., PA 1 stated she spoke to Patient 1 on [DATE] at 8:20 p.m. and documented a quick blurb (a short and descriptive account) in the medical record. PA stated she did not take Patient 1 history, nor, did she perform a physical exam. PA 1 stated she performed a rapid medical evaluation (RME), a quick evaluation to determine the severity of the patient. During an interview, on [DATE] at 11:59 a.m., the Medical Director for the Emergency Department (MDED) stated the RME was a rapid evaluation of the patient, it was only the beginning and only a small portion of the MSE. The MDED stated the RME did not fall under the definition of an MSE. The MDED stated the MSE was required to exclude a life-threatening emergency per EMTALA regulations. A review of the facility's policy and procedure titled, Standards of Practice or Care, dated [DATE], indicated the patient was evaluated based on triage levels. Urgent: indicates the patient presents with a condition that could progress to a serious problem requiring emergency intervention. Patient should have a medical screen within sixty (60) minutes of arrival. A review of the facility's policy and procedure titled, Screening & Stabilization (EMTALA), reviewed ,d+[DATE], indicated a hospital must provide an appropriate MSE within the capacity of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an emergency medical condition (EMC) exist; (i) to any individual, including a pregnant woman having contractions, who request such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. The Hospital must perform an MSE to determine if an EMC exist. It is not appropriate to merely log in or triage an individual with a medical condition and not provide an MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The individual must be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, or if he or she does, until he or she is stabilized or appropriately admitted or transferred. The MSE may vary depending on the individual's signs and symptoms: (i.) Depending on the individual's 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 involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory test, CT scans, and other diagnostic procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42937 Based on interview and record review, the facility failed to ensure the following: 1. Nursing staff to adhere to its policies and procedures on: a.) Policy and procedure titled (P&P) titled, Informed Consent Policy. No second personnel signature on 1 of 30 sampled patient consent form. b.) Policy and procedure titled (P&P) titled, Nova Stat Strip Glucose Meter Procedure. No open and discard date written on 3 of 3 Glucose Control Solution Bottle. 2. That nursing care staff personnel are adequately supervised and that their clinical activities are evaluated for one (1) of six (6) sampled licensed nursing staff (RN1). These deficient practices had the potential to: 1. Obtain a consent for a wrong treatment without the verification of a second witness. 2. Result in inaccuracies of blood glucose (sugar found in blood) values. 3. Affect the facility's ability to assure patient safety. Findings: 1. During a concurrent interview and record review on 8/25/22, at 10:22 a.m., with Registered Nurse 9 (RN 9), Patient 12's Authorization for and Consent to Surgery and Other Medical/ Therapeutic Procedures for an Extra Ventricular Drain (A temporary system that allows drainage of cerebral spinal fluid from the ventricles to an external closed system), dated 8/22/22, was reviewed. The Record indicates that a telephone consent obtained from patient's legal representative is missing a second witness signature. RN 9 stated, it is policy that when obtaining a telephone consent, (2) staff must verify consent from the patient's legal representative. The (2) staff who verifies the consent and witness must sign and date the consent form. During a review of the facility's policy and procedure (P&P), titled Informed Consent Policy, last revised on 04/2022, the P&P indicated, consent by telephone must have (2) hospital personnel verify that the patient's legal representative and physician have discussed the patient's condition and the recommended treatment and that the patient's representative has given consent. The hospital staff member who obtains and verifies the consent for medical treatment and the witness should both sign and date this record. 2. During a concurrent observation and interview, on 8/25/2022, at 3:30 p.m., It was observed that (3) Glucose Control Solution bottle in the 6 West Nurse Station has no written open and discard dates. The CNC (Clinical Nurse Coordinator) confirmed that the (3) Glucose Control Solution bottle has no written open and discard dates, and that it is policy that Glucose Control Solution bottle when opened, must have a written open and discard dates on the label. Discard date is 90 Days or 3 months after opening. A review of the facility's policy and procedure (P&P), titled Nova Stat Strip Glucose Meter Procedure, revised 4/2021, indicated Stat Strip Glucose Control Solution are stable for 3 months from date opened or until the printed expiration date. Always write date opened and discard date on the bottle. 46120 3. During an interview and concurrent nursing staff personnel record review on 8/25/2022, at 2:25 p.m., Human Resources Business Partner (HR1) stated that RN1 is missing a performance evaluation on file. HR1 stated evaluations are done annually for nursing staff however HR1 was not able to find any evaluations for RN1. Upon further inquiry, HR1 later submitted a performance evaluation for 2016-2017 appraisal period for RN1; graded as 3.71, a competent plus performer. HR1 then stated there was no other performance evaluation on file for RN1. A review of the hospital's policy and pocedure (P&P), titled Job Description for Registered Nurse - Emergency services, {No Date], provided by HR1, indicated staff members are required to maintain departmental policies and procedures, objective, performance improvement program, safety, environmental and infection control standards. It also indicates nursing staff are expected to participate in performance improvement activities. During an interview on 8/25/2022, at 2:25 p.m., with Director of Clinical Education ([DATE]), [DATE] stated nursing staff are required to participate in performance improvement activities including taking online classes and clinical skills validation with a preceptor or a charge nurse. Nurses are then evaluated on their skills and signed off if rated competent. During an interview on 8/26/2022, at 10:41 a.m., with [NAME] President of Human Resources (HR3), HR3 stated that nursing and auxiliary services personnel are union employees with periodic performance evaluations however the Union agreement does not specify the period range. A review of the SEIU-UHW United Healthcare Workers-West Collective Bargaining Agreement with the Hospital dated April 1,2020- March 31,2023, Article 23 indicated periodic performance evaluations reports are hospital records. And a review of SEIU Local 121RN and the hospital dated September 16,2020 -September 15, 2023, Article 17 indicated Annual performance evaluation reports are hospital records. During an interview on 8/26/2022, at 10:41 a.m., with HR3, upon review of document provided, HR3 explained that the facility's policy and procedure trumps the Union agreement and specifies that the performance evaluation is done annually for all nursing personnel. HR3 then clarified that RN1 is part of the nursing services personnel. Therefore, their (referring to nursing staff) performance evaluation is an annual requirement. HR3 stated that RN1's annual performance evaluation has been done for 2021-2022 appraisal period and submitted it. A review of RN1's performance evaluation for 2021-2022 appraisal period showed RN1 is graded as 3.71, a competent plus performer. During an interview on 8/26/2022, at 11:12 a.m., with the Director of Emergency Department (DED 1), DED1 stated a performance evaluation is done in the current year for the previous year's work. The performance evaluations are done by clinical nurse coordinators also known as charge nurses however DED1 is not sure why RN1 is missing performance evaluations for the period he was fully employed at the hospital. DED1 stated RN1 was on a leave of absence for an extended period of time, therefore, a performance evaluation was not done. During an interview and concurrent record review on 8/26/2022, at 11:49 a.m., HR3 stated RN1 was not working therefore a performance evaluation was not obtained for appraisal periods 2019-2020 and 2020-2021. A review of RN1's Claim Overview documents printed on 8/26/2022 and submitted by HR3, indicated that RN1 was out of work on a continuous leave of absence from 11/10/2020 through 2/8/2021 and again from 9/21/2021 through 2/17/2022. HR3 then confirmed that a performance evaluation is only missing for 2017-2018 appraisal year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42937 Based on interview and record review, the facility failed to reassess a level 3 patient every 60 minutes until seen by the ED (Emergency Department) MD (Medical Doctor) as per facility's Rapid Medical Evaluation Policy No. 2737. This deficiency resulted to a missed ongoing assessment for 1 of 30 sampled patients (Patient 1). Findings: On [DATE], at 2:20 p.m., during an interview with DED (Director of Emergency Department). DED stated that on [DATE], Patient 1 was brought to the ED via ambulance. Patient 1 was stable and Awake, alert and oriented x3 (oriented to person, place, and time). Patient 1 was Triaged a Level 3 (Urgent, not life-threatening condition). Patient 1 was transferred to the waiting room by the paramedics. The Paramedics dropped Patient 1 in the waiting room and left without giving report to the Emergency Department Technician 1 (EDT 1). EDT 1 was not aware of Patient 1 being in the waiting room. Patient 1 was found not breathing 2 hours after being dropped off by the paramedics. Facility initiated CPR (Cardiopulmonary Resuscitation-a life saving procedure performed when the heart stops beating) but was unsuccessful, Patient 1 expired. DED said that staff should have assessed Patient 1 every hour. No assessment was completed for more than 2 hours. There should have been a report or hand-off between staff. DED further added that facility will be initiating a new process in which moving a patient from ambulance triage to waiting room will require approval by emergency provider or physician. Charge Nurse must give report to ED technician to continue supervision of patient. A review of the facility's policy and procedure (P&P), titled Rapid Medical Evaluation - Policy No. 2737, indicated that level 3 patient in the waiting area must be reassessed every 60 minutes until seen by the ED MD or discharged . Reassessments of RME (Rapid Medical Evaluation) patients are the responsibility of the RME team.