The Jewish Hospital-Mercy Health

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28999 Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed the current facility policies related to pain management, nursing triage guidelines, and reassessment of the Emergency Department patient. This affected Patient #5. Findings include: Review of the medical record of Patient #5 revealed the patient arrived to the Emergency Department on 01/25/24 at 11:17 PM with an arrival complaint that stated “virus”. The patient care timeline revealed the patient was triaged by Staff S at 12:20 AM. At 12:22 AM, Patient #5’s vital signs included a blood pressure of 162/101 mmHg, heart rate of 117 beats per minute, respirations of 10 breaths per minute, temperature of 98 degrees Fahrenheit, and oxygen saturation of 97 percent. At 12:22 AM, the patient’s chief complaint was updated to include abdominal pain and back pain. The medical record lacked documentation the patient’s pain was assessed. The triage end time was 12:24 AM. The patient acuity or Emergency Severity Index level was a level 3/urgent. According to the timeline, the patient left without being seen at 4:11 AM. The medical record lacked documentation a reassessment was performed at any interval related to the patient’s acuity. The medical record lacked documentation a medical screening exam to determine if an emergency medical condition existed was conducted prior to the patient leaving. The medical record also lacked documentation staff explained the importance of staying for a Medical Screening Evaluation. Staff A and Staff B were interviewed on 02/14/24 at 3:26 PM. It was confirmed that the medical record lacked documentation of a pain assessment as required. Staff A and Staff B were interviewed on 02/14/24 at 2:40 PM. It was confirmed that the medical record lacked documentation of a nurse’s reassessment. Staff S was interviewed on 02/15/24 at 6:36 PM. Staff S stated there are basic protocol orders for patients with certain conditions that can be placed by the ED nurse. She stated that the expectation of ED registered nurses is to place these orders to identify early signs of distress and to try to stay on top of the flow of things in the ED. Staff S did not recall Patient #5 and could not speak to the reason orders for a patient with abdominal pain weren’t placed. Staff A was interviewed via phone on 02/16/24 at 11:10 AM. It was confirmed that the medical record lacked documentation the guidelines for ED Nursing Triage were followed as there were no orders placed. The facility policy titled “Emergency Severity Index Triage” effective 10/01/15, documented Emergency Severity Index (ESI) is based on the acuity of patients’ health care problems and the number of resources their care is anticipated to require. Five ESI levels were described. A level 3 or urgent level includes conditions that require prompt care but will not generally cause loss of life or permanent severe impairment if left untreated for several hours. The policy stated that ALL patients are to have a focused assessment by a registered nurse, patients are to be reassessed at times indicated by ESI levels, and reassessments are to include vital signs. According to the policy, an ESI level 3/urgent requires a vital sign/reassessment every 30-60 minutes. The facility policy titled Pain Management, effective 05/06/23, documented pain assessments must be completed during any emergency department visit, upon a patient’s initial complaint of pain, during an ambulatory or outpatient visit, upon arrival to a unit, and at a minimal of every 12 hours. The policy instructed healthcare providers to include the appropriate pain scale individualized to meet the patient’s needs. The pain assessment must include descriptors to identify how pain is affecting the patient’s passive and active activities. The policy further instructed staff that a pain assessment must include at least a pain score, pain location, and pain descriptors. If pain is present, healthcare providers are instructed to document the patient’s pain goal or what is considered tolerable by the patient. Review of the policy titled “ED Nursing Triage Guidelines”, dated 02/26/08, documented when a patient presents to the ED with complaints of abdominal pain/flank pain, an ED nurse may order a CBC with diff, CMP, Lipase, UA reflex to culture, and the patient made NPO in order to expedite patient care.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 28999 Based on observation, interview and policy review, the facility failed to post Emergency Medical Treatment and Labor Act (EMTALA) signage at ambulance entrances so that patients would likely see them. This had the potential to affect all patients entering the emergency departments through the ambulance entrance. Findings include: The 12-bed off-campus Dedicated Emergency Department was toured on 02/13/24 at 6:50 AM. A Patient Access staff member (Staff ) was observed sitting behind the registration desk as the facility was entered. An Emergency Medical Treatment and Active Labor Act (EMTALA) sign was conspicuously posted on the wall to the left of the registration desk. A Patient Rights sign listing the rights of patients was also posted on the wall at the entrance of the ED. The ED was entered through a locked double door. Three staff members, Staff A, Staff B, and Staff C, joined to tour the 12-bed unit for safety. The ambulance entrance was exited and re-entered as patients arriving by squad would enter. There was no EMTALA signage observed. The absence of the EMTALA signage was confirmed with Staff A, Staff B, and Staff C. Staff A was asked where the EMTALA signage was posted. He directed this Surveyor only to the sign posted next to the registration desk. It was confirmed that the EMTALA sign posted at the registration desk would not be visible to patients presenting through the ambulance entrance. The facility policy titled EMTALA, effective 10/01/19, was reviewed on 02/13/24 at. According to the policy, on and off-campus Emergency Departments and dedicated Emergency Departments must post signs informing individuals of their rights under EMTALA. The EMTALA signs must: 1. indicate whether the facility does or does not participate in the Medicaid program; 2. be clear and written in simple terms and languages that are understandable by the population served by by the hospital; 3. be posted in places likely to be noticed by individuals entering the Dedicated Emergency Department, as well as those individuals waiting for examination and treatment. Staff A and Staff B were interviewed during the tours of the Emergency Department. It was confirmed that EMTALA signage must be posted at ambulance entrances.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 28999 Based on surveyor observations made during tour, facility policy review, and staff interview, the facility failed to ensure staff removed soiled gloves. This had the potential to affect all patients receiving care in the ED. Findings include: The 28-bed Emergency Department, located on the main campus of the facility was toured on 02/13/24 at 8:45 AM. Staff L was observed walking down the hall of the ED wearing disposable gloves. She walked into Room #14 and was observed covering the patient with a blanket. Staff L was then observed leaving the room while still wearing the same disposable gloves. A second staff member, Staff M, was observed interviewing a patient in Room #1. She was typing on a computer on wheels. Staff L was observed walking out of the room and opening a door to a supply room while still wearing the same disposable gloves. Staff A and Staff B, present during the tour, verified both staff members left patient rooms without removing their soiled gloves. The facility policy titled “Isolation Precaution”, effective 04/17/01, documented that wearing gloves is not a substitute for hand washing. Gloves are single patient use. Clean nonsterile gloves are required to be changed between tasks/procedures on the same patient and after contact with material that may contain a high concentration of microorganisms. Staff members are further instructed to remove gloves after contact with a patient and/or surrounding environment using proper technique to prevent hand contamination.”