Based on observation, interview, and record review, the facility failed to ensure: 1. Patients with orders to be admitted to the intensive care unit (ICU), the progressive care unit (PCU), telemetry units, and medical surgical units were provided inpatient beds before accepting elective interfacility transfers from other hospitals (Refer to A1103); 2. Patients in the Emergency Department (ED) with orders to be admitted to telemetry were provided the same level of service/monitoring as patients on the telemetry units (Refer to A1103); 3. Emergency care for patients arriving by ambulance was started in a timely manner (Refer to A1103); and, 4. Adequate staffing was provided to meet the needs of the patients in the ED (Refer to A1112). The cumulative effect of these systemic problems resulted in failure to ensure emergency services were provided in a safe and effective manner.

Based on observation, interview, and record review, the facility failed to ensure the full extent of it's patient care resources was made available to Emergency Department (ED) patients when: 1. Patients with orders to be admitted to the intensive care unit (ICU), the progressive care unit (PCU), telemetry units, and medical surgical units were not provided inpatient beds before accepting elective interfacility transfers from other hospitals; 2. Nine patients in the ED with orders to be admitted to telemetry were not provided the same level of service/monitoring as patients on the telemetry units (Patients 23, 24, 25, 27, 28, 32, 33, 41, and 105); and, 3. 10 of 21 patients arriving to the ED by ambulance (Patients 78, 87, 88, 89, 91, 92, 93, 94, 95, and 96) remained on ambulance gurneys for prolonged periods of time before being assigned an ED bed. These failed practices resulted in delays in care to ED patients, the potential for cardiac arrhythmias (abnormal heart rhythms) to go unnoticed and untreated, delays in releasing ambulances so they could continue to respond to community needs, and the potential for harm or death in ED patients, admitted patients, and patients in the community. Findings: 1a. During an interview with ED Charge Nurse (CN) 1 on April 8, 2019, at 10:50 a.m., EDCN 1 stated they had 35 beds in the ED, and currently had 83 patients receiving treatment, 36 of them with orders to be admitted to the hospital. The facility document titled, "Accepted Transfers In (Direct Admits and ER Transfers)," was reviewed. The document indicated the facility accepted 33 transfers in from other facilities in the previous three days (April 5 through 8, 2019). b. During a tour of the ED on April 8, 2019, at 7:55 p.m., accompanied by the Clinical Supervisor (CS), the CS stated they had 117 patients in the ED, 47 of them with orders to be admitted to the hospital. The CS stated the facility was still open to accept transfers in from other hospitals. c. During a tour of the ED on April 9, 2019, at 9:50 a.m., accompanied by the Assistant Chief Nursing Officer (ACNO), the following was observed: - Five gurneys were lining the hallway at the back entrance to the ED. One of the patients was yelling, "Turn off the lights;" - Four ambulance gurneys were waiting for beds at the ambulance entrance; and, - The tracking board showed 43 patients had orders to be admitted to the hospital and were waiting to be assigned to inpatient beds. In a concurrent interview with ED charge nurse (EDCN) 2, EDCN 2 stated there were 128 patients in the ED, 48 of them with orders to be admitted to the hospital (two for the ICU, 15 for the PCU, and 31 for the medical surgical/telemetry units). A review of the transfers in indicated six transfers were accepted from other hospitals during the previous (night) shift. d. During a tour of the ED on April 9, 2019, at 11:50 a.m., accompanied by the ACNO, six ambulance gurneys were waiting for beds at the ambulance entrance. The tracking board showed 43 patients had orders to be admitted to the hospital and were waiting to be assigned to inpatient beds. In a concurrent interview, EDCN 2 stated there were 132 patients in the ED, 46 of them with orders to be admitted to the hospital (two for the ICU, 10 for the PCU, and 34 for the medical surgical/telemetry units). e. On April 9, 2019, at 12:30 p.m., Patient 66 was observed on an ambulance gurney at the ambulance entrance. The head of the gurney was raised, and the patient had a non-rebreather mask on (to deliver a high level of oxygen). The patient's blood pressure was 80/51 (normal 120/80), and his pulse oximeter (level of oxygen in the blood) was 88% (normal 96-100%). The paramedic was observed changing the oxygen tank to a new one. In a concurrent interview, the paramedic stated they had been there (waiting for an ED bed) since 11:20 a.m. (one hour and 10 minutes), and the oxygen tank ran out of oxygen, so Patient 66's oxygen level dropped. The ED physician approached the ambulance gurney and stated Patient 66 needed to be placed on Bi-PAP (positive air pressure delivered through the nostrils to help the patient maintain an adequate oxygen level), but they could not put him on Bi-PAP until there was an available ED bed. Anonymous interviews were conducted with medical and nursing staff on April 8 and 9, 2019. The following was stated: - The facility remained open to transfers of any kind. They had been told to accept transfers no matter how many patients were being held in the ED. There was no place to examine or treat the ED patients, and it was not good for their patients or the community; - The administration was overriding any physician who denied a transfer, and it was not safe. Patients were being transferred to radiology by paramedics due to no staff available to take them; - Staff was being told to accept transfers no matter what. Patients leaving against medical advice were increasing over the past few months; - The staff was accepting transfers even when they were holding multiple patients in the ED with orders to be admitted . Staff would spend 20-30 minutes explaining to administration why they should not accept a transfer, and they were told they had to anyway. Staff could have spent that time caring for ED patients. Eventually staff just stopped fighting and did what they were told, "at our patient's expense"; - It was difficult to take care of ED patients when staff was taking care of patients who should have been taken care of in another hospital. Staff should be able to focus on the patients who were already there (in the ED). The facility document titled, "ED Log - AMA Patients," was reviewed on April 9, 2019. The document indicated for the first eight days in April 2019 (April 1 through 8), 77 patients eloped from the ED (left without notice), or left the ED against medical advice. On April 9, 2019, at 3 p.m., the Chief Executive Officer, Chief Nursing Officer, Assistant Chief Nursing Officer, Vice President of Quality and Patient Safety, Chief Financial Officer, Assistant Chief Financial Officer, and the Vice President of Operations were notified an Immediate Jeopardy to the health and safety of the patients presenting for care in the Emergency Department was identified. The immediate jeopardy was identified due to failure to ensure integration of services and availability of resources required to meet the needs of the ED patients. The facility implemented and maintained a practice of consistently holding admitted patients in the ED while continuing to accept transfers from other hospitals, although they did not have the capability to care for them. This resulted in delays in care for ED patients, lack of appropriate monitoring of patients, delays in patients arriving by ambulance and being put into ED beds, and an increase in ED patients leaving without treatment. On April 9, 2019, at 5:15 p.m., the facility implemented an initial plan of correction, and closed to transfers from other hospitals and increased staffing in the ED to accommodate the needs of the ED patients. On April 11, 2019, at 2:05 p.m., the facility presented a plan of correction that included, as they approach their licensed bed capacity for each hospital bed type, including admitted patients holding in the ED, they would continually evaluate their ability to continue to accept transfers from other hospitals based on their operational status, acuity and patient needs, and availability of resources at that time. If the facility made the determination to close to transfers from other hospitals, they would remain open to transfers for ST elevation myocardial infarctions (STEMI - a heart attack requiring immediate specialized treatment - the hospital was a STEMI center), strokes (the hospital was a stroke center), and traumas (the hospital was a trauma center). Additionally, the facility will make all appropriate efforts and adjustments to maintain a 1:4 nurse to patient ratio for all ED patients. During an interview with the Vice President of Quality and Patient Safety (VPQPS) on April 11, 2019, at 2:20 p.m., the VPQPS stated it was the intent of the facility to remain within their licensed bed capacity for each bed type. The VPQPS stated rationale for accepting transfers from other hospitals would be documented through their transfer center. On April 11, 2019, at 2:30 p.m., the VPQPS was notified the facility plan of correction was accepted and the Immediate Jeopardy was lifted. 2. A review of the facility policy titled, "Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child) (approved by: Board of Trustees Date: 3/18)," indicated if a patient was on telemetry: "Monitor EKG (electrocardiogram) continuously. Print rhythm strip Q4h (every four hours)...and with change of heart rate/rhythm. Notify physician of rhythm changes..." a. During a tour of the ED on April 8, 2019, at 11:10 a.m., Patient 33 was observed in the, "X area," of the ED, sitting in a recliner chair with no shirt on. His color was pale, he did not have any cardiac monitoring/telemetry patches on, and there was no cardiac monitor visible. In a concurrent interview with the primary nurse ED Registered Nurse (D), (EDRN D) stated Patient 33, with an, "extensive cardiac history," presented on April 8, 2019, with complaints of chest pain and an abnormal EKG. EDRN D stated Patient 33 had orders to be admitted to the telemetry unit, but there were no beds available so he was holding the patient in the ED. EDRN D stated he was, "working on," getting a portable cardiac monitor, but they, "often," exhausted their resources and had difficulty getting monitors for cardiac patients. b. During a tour of the ED holding area on April 8, 2019, at 11:25 a.m., the following patients were observed with orders to admit to the telemetry unit: - Patient 23, an [AGE] year old male with confusion and a recent fall; - Patient 24, a [AGE] year old female with chest pain; - Patient 25, a [AGE] year old male with chest pain; - Patient 27, a [AGE] year old male with a diagnosis of [DIAGNOSES REDACTED] - Patient 28, a [AGE] year old male with chest pain and a history of a heart attack; - Patient 32, an [AGE] year old female with diagnoses that included [DIAGNOSES REDACTED] - Patient 105, a [AGE] year old female with an altered level of consciousness and a recent fall. All of the patients were on portable monitors at the bedside, and all of them had their privacy curtains pulled. Cardiac rhythms could not be observed without walking to the bedside of each patient. During an interview with telemetry (T) RN 1 on April 8, 2019, at 11:30 a.m., TRN 1 stated the cardiac monitors could not be seen from the nurse's station, so they had to, "go check every now and then," to know what rhythms the patients had. During an interview with TRN 2 on April 8, 2019, at 11:35 a.m., TRN 2 stated with portable monitors she was not able to do continuous monitoring of the patients, so she did, "frequent rounds." During an interview with TRN 3 on April 8, 2019, at 11:50 a.m., TRN 3 stated they did not have a central station (location where rhythms could be visually monitored at all times) in the holding area. TRN 3 stated she could not look back and see the history of the patient's rhythm (to determine if there had been any abnormal rhythms) like they could on the telemetry unit. c. During a tour of the ED on April 8, 2019, at 8:15 p.m., multiple patients were observed sitting in chairs, lined up in the hallway, inside the ED. No cardiac monitors were observed in the area. In a concurrent interview with EDRN B (the nurse responsible for the patients in the hallway chairs), EDRN B stated there were 18 patients, and one of them had orders to admit to the telemetry unit. EDRN B stated she did not have a cardiac monitor for the patient. d. During a tour and observation of the ED on April 10, 2019, at 8:22 a.m., Patient 41 was observed asleep in a recliner chair in the ED hallway. A review of Patient 41's record reflected the patient presented on April 8, 2019, at 8:32 p.m., with a chief complaint of chest pain and gastrointestinal bleeding. The patient's history included high blood pressure and coronary artery disease. Further record review indicated Patient 41 was triaged at 8:39 p.m., on April 8, 2019, and had a blood pressure of 185/90 (average blood pressure is 120/80). The patient was assigned a triage acuity level 3 (urgent). The second blood pressure Patient 41 had was on April 8, 2019, at 11:21 p.m., two hours and 24 minutes after her first blood pressure was taken. The record indicated at 8:43 p.m., on April 8, 2019, Patient 41 was placed in a chair in the ED hallway until 9 p.m., when she was then moved to a recliner chair, where the patient was observed 39 hours and 22 minutes later. An interview was conducted with EDRN E on April 10, 2018, at 9 a.m., who stated Patient 41 had orders written to be admitted to the telemetry unit at 4 a.m. that morning, but there were no beds available. Patient 41 had a telemetry monitor on, however it was not connected to the central telemetry monitoring area, so telemetry strips were unable to be obtained for evaluation. 3. A review of the time frames when patients were brought to the ED by a paramedic ambulance (BIBA), to the time the patients were removed from the ambulance gurney, and care was transferred from the paramedic to the nursing and medical staff, was calculated with the ED Clinical Manager (EDCM) on April 11, 2019, at 10 a.m. - The following record reflected the ED wait time which occurred on April 7, 2019: a. Patient 78 was brought in via ambulance, at 12:21 p.m., with the chief complaint of suicidal ideation. The, "Rapid Initial Assessment," dated April 7, 2019, at 12:22 p.m., indicated Patient 78 was brought to the facility after walking on the freeway and stating he had plans to walk into traffic; the patient wanted to be placed on a 5150 (a psychiatric hold) and transferred to a locked psychiatric unit; and was assigned a triage acuity level 2 (emergent). Vital signs were not done. The, "Emergency Provider Report," dated April 7, 2019, at 2:35 p.m., indicated Patient 78 was initially greeted by the physician at 12:41 p.m.; psychiatric screening laboratory tests were ordered and resulted a potassium of 5.2 mmol/L (millimoles per liter - normal range 3.5 to 5.1) and a white blood cell count of 11.1 K/mm3 (thousands per cubic milliliter - normal range 4.8 to 10.8); and the physician planned to have a telemedicine psychiatrist evaluate the patient. Patient 78 was never removed from the ambulance gurney, and remained in the ambulance bay. On April 7, 2019, at 2:25 p.m. (two hours and three minutes after arrival to the facility ED), Patient 78, "ripped off his arm band," got off of the ambulance gurney, and walked out of the facility through the ambulance ED entrance as reported by the ambulance paramedic. Patient 78 was removed from the ED census on April 7, 2019, at 2:30 p.m., as a psychiatric elopement. During an interview with the ED Operations Manager (EDOM) on April 9, 2019, at 2 p.m., the EDOM stated Patient 78 was an ED hallway chair patient, but remained in the ambulance bay with the paramedics, and was never off loaded from the ambulance gurney when he eloped from the ED. - The following records reflected ED wait times which occurred on April 8, 2019: a. Patient 87 was BIBA at 11:20 p.m., with a chief complaint (CC) of a breathing problem. The patient's care was transferred (to nursing/medical staff) at 1:15 a.m., one hour and 55 minutes later; b. Patient 88 was BIBA at 10:22 p.m., with a CC of a breathing problem. The patient's care was transferred at 11:31 p.m., 50 minutes later; c. Patient 89 was BIBA at 8:58 p.m., with a CC of left foot pain. The patient's care was transferred at 11:09 p.m., two hours and seven minutes later; d. Patient 91 was BIBA at 8:10 p.m., with a CC of fall. The patient's care was transferred at 8:48 p.m., 38 minutes later; e. Patient 92 was BIBA at 7:45 p.m., with a CC of weakness, nausea and vomiting. The patient's care was transferred at 8:28 p.m., 43 minutes later; f. Patient 93 was BIBA at 7:25 p.m., with a CC of chest pain and heart problems. The patient's care was transferred at 8:13 p.m., 48 minutes later; and, g. Patient 94 was BIBA at 7:26 p.m., with a CC of mechanical fall. The patient's care was transferred at 10:32 p.m., three hours and six minutes later. - The following records reflected ED wait times which occurred on April 9, 2019: a. Patient 95 was BIBA at 1:42 p.m., with a CC of seizures. The patient's care was transferred at 4:50 p.m., three hours and eight minutes later; and, b. Patient 96 was BIBA at 11:19 a.m. with a CC of breathing problems. The patient's care was transferred at 12:50 p.m., one hour and 31 minutes later. An interview was conducted with the EDCM on April 11, 2019, at 12 noon, who stated ED patients BIBA should be transferred from the paramedic's care to the nursing/medical staff's care as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to meet the needs of the patients in the Emergency Department (ED), when: 1. Two nurses were each assigned 11 patients, who were identified as having urgent or emergent needs, on the morning of April 8, 2019; 2. One nurse was assigned 18 patients, who were identified as having urgent or emergent needs, on the night of April 8, 2019; 3. Three nurses were assigned to an area with seventeen patients, identified as having urgent or emergent needs, on the morning of April 9, 2019; and, 4. Two nurses were each assigned 11 patients, identified as having urgent or emergent needs, on the afternoon of April 9, 2019. This failed practice resulted in failure to provide adequate monitoring, assessments/reassessments, pain management, and treatment. Findings: [According to the Canadian Triage and Acuity Scale (the scale used by the ED); - Level 2 patients are, "Emergent," patients with conditions that are a potential threat to life, limb, or function, requiring rapid medical intervention. These patients should be reassessed every 15 minutes; and, - Level 3 patients are, "Urgent," with conditions that could potentially progress to a serious problem requiring emergency intervention. These patients should be reassessed every 30 minutes] 1. During a tour of the ED on April 8, 2019, at 10:20 a.m., accompanied by the Vice President of Quality and Patient Safety (VPQPS), the Associate Director of the ED (ADED), and the ED Clinical Manager (EDCM), the EDCM stated after patients were triaged, if there were no beds available, the patients were sent to one of two waiting areas to wait for care, depending on their level of acuity. The EDCM stated level 2 and 3 patients were sent to the chairs in the hallway, inside of the ED. During the tour, multiple patients were observed lined up in chairs against the wall, in the hallway inside the ED. During an interview with ED registered nurse (RN) A, on April 8, 2019, at 10:30 a.m., EDRN A stated there were 22 patients sitting along the wall in the hallway, and there were two nurses assigned to care for the 22 patients. EDRN A stated the, "chairs," usually had one nurse assigned to care for the patients who were there waiting for treatment, a disposition, or a bed. EDRN A stated the nurses assigned to the, "chairs," were responsible for treatments that were ordered, and discharged some patients from the area if they did not get into a bed before their treatment was completed. EDRN A stated five of the patients were currently receiving treatment as follows: - One patient (Patient 97) had chest pain with a high heart rate, had an IV started for a Computerized Axial Tomography (CAT) scan of his abdomen, and was receiving IV fluids. - One patient (Patient 99) was medicated for dizziness; - One patient (Patient 100) was receiving a breathing treatment due to shortness of breath; - One patient (Patient 101) was receiving intravenous (IV - directly into the vein) fluids, and had been medicated for abdominal pain and vomiting; and, - One patient (Patient 102) had been given an injection for pain. During the interview, EDRNA received a call from the laboratory with a panic value (Sodium level of 118 - normal 135-145) for one patient (Patient 103). The list of patients admitted to the chairs since the beginning of EDRN A's shift was reviewed. The list indicated the following patients had eloped from the ED (left without notice) since 7 a.m.: - One patient with chest pain who had been treated with aspirin (to dissolve a possible clot in the coronary artery) and nitroglycerine (to dilate the vessels and increase the blood flow and oxygenation to the heart); - One patient with chest pain and shortness of breath after cocaine ingestion; and, - One patient with chest pain, shortness of breath, and throat swelling. Records for five of the 22 patients were reviewed and indicated the following: a. Patient 97, a [AGE] year old male, presented on April 8, 2019, at 5:40 a.m. (after being admitted for alcohol withdrawals and leaving against medical advice the day prior), with complaints of chest pain. Patient 97 had a heart rate of 135 (normal 60-100), and was assigned an acuity level 2 (emergent) and placed in a chair in the hallway. The record indicated Patient 97 had an IV inserted and received one liter of IV fluids and an abdominal CAT scan. No further vital signs were checked. Patient 97 eloped from the ED at 11:47 a.m. (six hours and seven minutes after arriving), with an IV still in place. b. Patient 104, a [AGE] year old male, presented on April 8, 2019, at 8:41 a.m., with a history of liver disease and an acute change in his mental status and level of orientation. The record indicated Patient 104 was assigned an acuity level 2 (emergent) and placed in a chair in the hallway after his vital signs were taken at 8:50 a.m. "Critical," laboratory results were called to the ED nurse at 10:40 a.m., with a sodium level of 118, while Patient 104 was waiting in the chair (low sodium levels potentially lead to brain swelling, confusion, and brain damage). The record indicated vital signs were not rechecked until 12:19 p.m. (three hours and 29 minutes after the initial vital signs were checked). c. Patient 36 presented on April 8, 2019, at 8:56 a.m., with a chief complaint of testicular pain and swelling. The patient was triaged at 9:06 a.m., and placed in a chair in the ED hallway at 9:55 a.m. The patient was assigned an acuity level 3 (urgent). Patient 36's vital signs were taken at the time he was triaged on April 8, 2019, at 8:56 a.m., and not again until 2:28 p.m.,upon discharge (five hours and 32 minutes later). An interview was conducted with the ED Clinical Manager on April 10, 2019, at 10:30 a.m., who stated the patient's vital signs were delayed. d. Patient 49, a [AGE] year old male, presented on April 8, 2019, at 9:16 a.m., with complaints of abdominal distension (swelling), shortness of breath for one week, a history renal (kidney) insufficiency, and hyperglycemia (high blood sugar). Patient 49 was triaged at 9:23 a.m., assigned an acuity level 2 (emergent) and placed in a chair. Vital signs showed a blood pressure of 160/122 (normal 120/80), and a heart rate of 101 (normal 60-100). At 2:21 p.m., Patient 49 had a paracentesis (drainage of a large volume of fluid from the abdomen) with 2500 ml (milliliters) removed. At 3:55 p.m. (six hours and 32 minutes after the first set of vital signs), the second (and final) blood pressure taken on Patient 49 was 153/100, and his heart rate was 98. e. Patient 50, a [AGE] year old female, presented to the ED at 7:20 a.m. on April 8, 2019, with complaints of dizziness, nausea, and headache. Triage vital signs at 7:27 a.m., showed a blood pressure of 144/90, a heart rate of 106, and a pain level of 7 (very intense) on a 1-10 scale. Patient 50 was assigned an acuity level 3 (urgent), and placed in a chair. At 8:53 a.m., Meclizine (a medication to treat motion sickness and dizziness) 25 mg (milligrams) was administered orally. No other vital signs were taken during the remainder of the ED stay. 2. During a tour of the ED on April 8, 2019, at 8:15 p.m., accompanied by the ED Clinical Supervisor (CS), multiple patients were observed lined up in chairs against the wall, in the hallway inside the ED. In a concurrent interview, EDRN B stated she was the only nurse assigned to the chairs, and she currently had 18 patients she was responsible for, one of those with orders to admit to the telemetry unit. EDRN B stated it was, "very frustrating," when they could not get ED beds or inpatient beds for their own ED patients, because they were accepting interfacility transfers and holding them in the ED for hours. EDRN B stated it would be OK if all of the patients in the ED were actually ED patients, because they would all come in, get treated, then go on to their disposition. EDRN B stated they could manage the flow that way, and they wouldn't have all of those patients in chairs, but there was no flow when, "this is happening." Records for four of the 18 patients were reviewed and indicated the following: a. Patient 74 presented to the ED, on April 8, 2019, at 6:13 p.m., with complaints of asthma, chronic obstructive pulmonary disease (COPD - progressive lung disease), and swelling in both lower legs. Patient 74 was triaged at 6:18 p.m., vital signs were obtained to include an oxygen saturation on room air of 92% (normal range 95 to 100%) and a heart rate of 115 (normal 60 to 100); pain level was a 6 on a scale of 1-10. Patient 74 was assigned an acuity level 2 (emergent). Patient 74 was placed in a chair in the ED hallway, oxygen via a nasal cannula was applied at 2 liters per minute, a saline lock intravenous line was started, and a breathing treatment was done by the respiratory therapist. On April 8, 2019, at 9:30 p.m., Methylprednisolone (a steroid) 125 mg IV (intravenous - directly into a vein) was ordered, and it was given at 10:42 a.m. (greater than one hour after being ordered). The next nursing assessment was done at 11:19 p.m. (5 hours after the triage assessment), and vital signs were done at 11:26 p.m. (five hours and eight minutes after the triage vital signs) The vital signs showed a heart rate of 111. At 11:48 p.m., Patient 74 was moved from the chairs in the ED hallway to a room in the ED, and was subsequently admitted to the facility. During an interview with the ED Operations Manager (EDOM), on April 9, 2019, at 12:45 p.m., she stated vital signs and a reassessment of the chief complaint should be done at least every two hours, and more frequently based on the patient's condition. b. Patient 75 presented on April 8, 2019, at 6:09 p.m., with complaints of chest pain, left arm pain, bilateral swelling of both lower legs, and high blood pressure. Patient 75 was triaged at 6:20 p.m., vital signs were obtained and showed a blood pressure of 183/98 on the right arm (normal 120/80), a blood pressure of and 183/114 on the left arm, and a pain level of 6. Patient 75 was assigned an acuity level 2 (emergent). Patient 75 was placed in a chair in the ED hallway, an EKG was done and laboratory tests were drawn. On April 8, 2019, at 8:50 p.m. (two hours and 30 minutes after the patient's vital signs were obtained) Losartan Potassium (medication used to treat high blood pressure) 50 mg by mouth was ordered, and it was given at 9:12 p.m. The physician wrote a discharge order for Patient 75 to go home on April 8, 2019, at 8:51 p.m. (before the blood pressure was rechecked to see if the medication was effective). At 9:15 p.m., Patient 75's blood pressure was 175/112 (2 hours and 55 minutes after the initial of vital signs were taken). At 9:24 p.m., Patient 75 was provided discharge instructions and, "did not want to wait for a BP (blood pressure) re-check." There was no documented indication the physician was informed Patient 75's blood pressure remained elevated at the time of discharge from the facility. During an interview with the EDOM, on April 9, 2019, at 12:50 p.m., she stated Patient 75's vital signs should have been done at least every hour. c. Patient 77 presented on April 8, 2019, at 3:58 p.m., eight days after delivering a baby, with complaints of fever for three days, vaginal bleeding, and foul smelling vaginal discharge. Patient 77 was triaged at 5:30 p.m., vital signs were obtained and showed a temperature of 102.8°F (normal 97.7 to 99.5°F), a heart rate of 122 (normal 60-100), and a pain level of 6. Patient 77 was assigned an acuity level 2 (emergent). A nursing assessment was done at 5:35 p.m. At 9:57 p.m., Patient 77's vital signs were reassessed (4 hours and 27 minutes after the initial set of vital signs was taken). On April 9, 2019, at 8 a.m., a nursing assessment/reassessment was completed (14 hours and 30 minutes after the initial triage assessment). On April 9, 2019, at 11:35 a.m., Patient 77 was still being held in the ED awaiting an inpatient bed, with a diagnosis of endometritis (an inflammatory condition of the lining of the uterus, usually due to an infection). During an interview with the ED Clinical Manager (EDCM) on April 9, 2019, at 1:30 p.m., he stated the vital signs for Patient 77 were delayed, and there should have been an initial nursing assessment followed by reassessments every four hours. d. Patient 52, a [AGE] year old female, presented on April 8, 2019, at 7:54 p.m., with complaints of chest pain and bilateral calf pain after a six hour airplane flight. Patient 52 was assigned an acuity level 3 (urgent), and placed in a chair. At 8 p.m., Patient 52 had an EKG, with the results showing sinus tachycardia (rapid rate in the heart) with no signs of a myocardial infarction (MI-heart attack). At 8:02 p.m., Patient 52's vital signs were taken and showed a blood pressure of 142/92 and a heart rate of 93. The next vital signs were not taken until 11:50 p.m., 3 hours and 50 minutes later. 3. During a tour of the ED on April 9, 2019, at 10:25 a.m., accompanied by the Assistant Chief Nursing Officer (ACNO), multiple patients were observed lined up in chairs against the wall, in the hallway inside the ED. In a concurrent interview, EDRN C stated there were three nurses assigned to care for patients in the chairs, and they currently had 17 patients they were responsible for in the chairs, plus one patient with a bowel obstruction, "around the corner," with a nasogastric tube (a tube inserted through the nose and into the stomach) hooked up to suction. EDRN C stated, "most," of the patients had received medications, and, "quite a few," had IVs inserted. EDRN C stated pain management was a problem for the patients in the chairs. EDRN C stated they could not administer narcotic pain medications to patients who needed them, because they could not monitor for respiratory depression (decrease in respirations - a potential side effect of narcotic pain medication). EDRN C further stated IV medications that needed to run through a pump were, "difficult," to administer, because they did not have a place to plug in the pumps. EDRN C stated they were not able to monitor any of the patients in chairs as closely as they should be monitored. EDRN C stated she felt, "bad," for the patients, and it was, "very frustrating," that the facility was accepting interfacility transfers who were admitted to inpatient beds, so the ED patients did not have beds to go to. EDRN C stated if the interfacility transfers were not being transferred in, the ED patients would not have to be lined up in the chairs. The record for one of the 17 patients was reviewed and indicated the following: Patient 63, a [AGE] year old male, presented on April 9, 2019, at 6:04 a.m., with complaints of chest pain, shortness of breath, and leg swelling. Initial vital signs at triage showed a blood pressure of 168/81 (normal 120/80) and a heart rate of 101 (normal 60-100). Patient 63 was assigned a level 3 acuity, and placed in a chair in the hallway. The physician assessment indicated Patient 63 was, "mildly tachypneic," (breathing too fast) and had decreased breath sounds. The EKG showed a heart rate of 109. The record indicated at 8:41 a.m., the physician ordered a CAT scan angiogram to rule out a pulmonary embolus (a blood clot in the lung), a breathing treatment, and IV morphine (a narcotic medication that decreases pain, eases the work of breathing, increases the capacity of the blood vessels, and decreases the workload of the heart). There was no evidence the morphine had been administered as of 11:25 a.m. (two hours and 44 minutes after the medication was ordered). 4. During a tour of the ED on April 9, 2019, at 12:40 p.m., accompanied by the ACNO, multiple patients were observed lined up in chairs against the wall, in the hallway inside the ED. In a concurrent interview, EDRN C stated there were two nurses assigned to care for patients in the chairs (as one nurse got pulled to triage), and they currently had 22 patients they were responsible for. The record for one of the 22 patients was reviewed and indicated the following: Patient 67, a [AGE] year old female, presented on April 9, 2019, with complaints of fever, body aches, and a cough for two weeks. The triage vital signs at 11:28 a.m., showed a blood pressure of 80/53 (normal 120/80) and a heart rate of 122 (normal 60-100). Patient 67 was assigned an acuity level 2, had a mask put on, and was placed in a chair in the hallway. The physician ordered a cardiac monitor, hemodynamic monitoring with pulse oximetry (blood pressure and oxygen level continuously), and an IV antibiotic. Patient 67 was placed in a bed at 12:23 p.m. (55 minutes after being placed in the chair). There was no evidence Patient 67 was placed on a cardiac monitor, had hemodynamic monitoring, or received antibiotics prior to being placed in a bed. 5. A review of Patient 42's record was conducted on April 10, 2019, at 10:20 a.m. Patient 42 was admitted to the facility on on [DATE], at 5:23 p.m., with a chief complaint of heaviness to the chest radiating to the left arm. The patient was triaged, vital signs were done, and an acuity level 2 was assigned (Emergent). Patient 42 was placed on outpatient observation status at 7:46 p.m., with a diagnosis of possible sepsis (a severe infection), and an elevated troponin level, (proteins which are released when the heart muscle has been damaged, such as occurs with a heart attack). The record indicated after the patient's vital signs were taken at the time the patient was triaged, vital signs were not rechecked until 10:47 p.m. (five hours and 27 minutes later). On March 27, 2019, at 10:47 p.m., Patient 42 complained of a headache, with pain at a level 10 out of 10 (indicating the highest pain level). The record failed to show a follow up pain assessment after the patient was given Tylenol (pain medication), at 12:51 a.m. An interview was conducted with the ED Clinical Manager (EDCM), on April 10, 2019, at 11:30 a.m., who stated the reassessment of Patient 42's vital signs were delayed, and a reassessment of the patient's pain was not done following the administration of pain medication. The facility policy titled, "Admission/Discharge of the Patient to the Emergency Department," was reviewed on April 8, 2019. The policy indicated the following: A. The triage nurse would assign each patient a priority category based on the Canadian Triage and Acuity Scale; B. Category 2 patients were, "Emergent," with serious injuries or illnesses who might deteriorate or suffer long term problems if they did not receive very urgent treatment; and, C. Category 3 patients were, "Urgent," and would require two or more ED resources for a disposition to be reached. The facility policy titled, "Standards of Care, Practice Guidelines and Assessment for the Adult Patient," was reviewed on April 10, 2019. The policy indicated the following: a. ED patients triaged as a level 2 acuity would have vital signs, oxygen saturation level, and pain level monitored every 30 minutes and as needed; b. Patients triaged as a level 3 acuity would have vital signs, oxygen saturation level, and pain level monitored every 60 minutes and as needed; and, c. A follow-up pain assessment was to be done within one hour of treatment for pain. The nursing staffing policy was reviewed on April 10, 2019. The policy indicated the following: A. It was the responsibility of the unit directors, managers, and charge nurses to ensure there were adequate levels of appropriate staff in sufficient quantities to staff their individual units on an ongoing basis; and, B. In the ED, the minimum staffing ratio would be one nurse for every four patients. The facility policy titled, Bed Management Plan," was reviewed on April 10, 2019. The plan indicated the following: a. The purpose was to facilitate efficient patient flow, minimize ED holding time, and maximize utilization of facility resources; b. The definition of, "Bed Level III Orange - Inadequate Beds," included beds at capacity and volume of emergency patients exceeded the available clinical resources, increase in ambulance traffic and ED was at full capacity, 15 or more patients were in the ED waiting for inpatient beds, and/or time to treatment goals were not being met; and, c. When Level III occurred, the Liaison (nursing supervisor) would delay non-emergent outside transfers.