ER Inspector WILKES-BARRE GENERAL HOSPITALWILKES-BARRE GENERAL HOSPITAL

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Updated September 19, 2019

This database was last updated in September 2019. It should only be used as a historical snapshot.Researchers can find more recent data on timely and effective care in the Centers for Medicare and Medicaid Services’ hospitals datasets and guidance about hospital regulations.

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ER Inspector » Pennsylvania » WILKES-BARRE GENERAL HOSPITAL

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WILKES-BARRE GENERAL HOSPITAL

575 north river street, wilkes-barre, Pa. 18764

(570) 829-8111

61% of Patients Would "Definitely Recommend" this Hospital
(Pa. Avg: 70%)

4 violations related to ER care since 2015

Hospital Type

Acute Care Hospitals

Hospital Owner

Voluntary non-profit - Private

ER Volume

High (40K - 60K patients a year)

See this hospital's CMS profile page or inspection reports.

Patient Pathways Through This ER

After a patient arrives at the emergency room, they are typically seen by a doctor or medical practitioner and then either sent home or admitted to the hospital and taken to a room. A small percentage of patients leave without being seen. The chart below shows on average how long each of these pathways take. Lower numbers are better, and all times refer to the average length of time people waited.

Arrives at ER
2% of patients leave without being seen
6hrs 9min Admitted to hospital
8hrs 55min Taken to room
2hrs 46min Sent home

All wait times are average.

Detailed Quality Measures

Here is a more in depth look at each quality measure, compared to state and national averages for hospitals with high ER volumes. Experts caution that very small differences between hospitals for a given measure are unlikely to correspond to noticeable differences in the real world.

Measure
Average for this Hospital
How this Hospital Compares

(to other hospitals with similar
ER volumes, when available)

Discharged Patients
Time Until Sent Home

Average time patients spent in the emergency room before being sent home (if not admitted).

2hrs 46min
National Avg.
2hrs 42min
Pa. Avg.
2hrs 56min
This Hospital
2hrs 46min
Impatient Patients
Left Without
Being Seen

Percentage of patients who left the emergency room without being seen by a doctor or medical practitioner.

2%
Avg. U.S. Hospital
2%
Avg. Pa. Hospital
2%
This Hospital
2%
Admitted Patients
Time Before Admission

Average time patients spent in the emergency room before being admitted to the hospital.

6hrs 9min

Data submitted were based on a sample of cases/patients.

National Avg.
5hrs 4min
Pa. Avg.
5hrs 16min
This Hospital
6hrs 9min
Admitted Patients
Transfer Time

Among patients admitted, additional time they spent waiting before being taken to their room (sometimes referred to as "boarding time.")

2hrs 46min

Data submitted were based on a sample of cases/patients.

National Avg.
2hrs 2min
Pa. Avg.
2hrs 19min
This Hospital
2hrs 46min
Special Patients
CT Scan

Percentage of patients who arrived with stroke symptoms and did not receive brain scan results within 45 mins.

8%
National Avg.
27%
Pa. Avg.
22%
This Hospital
8%

Violations Related to ER Care

Problems found in emergency rooms at this hospital since 2015, as identified during the investigation of a complaint. About This Data →

Violation
Full Text
EMERGENCY SERVICES

Sep 14, 2018

Based on the systemic nature of the standard-level deficiencies related to emergency services, the facility staff failed to substantially comply with this condition.

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Based on the systemic nature of the standard-level deficiencies related to emergency services, the facility staff failed to substantially comply with this condition. The findings were: These following standards were cited and show a systemic nature of non-compliance with regards to emergency services as follows: (482.55 Tag-1103) The information reviewed during the survey provided evidence that the facility failed to coordinate and communicate with other hospital departments by failing to have adequate numbers of Security staff to check closely and remove all potentially harmful items from suicidal patient's belongings and by failing to have adequate numbers of registered nurses trained to respond to Trauma Alert Activation in the ED without pulling nurses from other units. (482.55 Tag-1104) The information reviewed during the survey provided evidence that the facility failed to ensure a patient presenting to the Emergency Department (ED) was assessed for concealed metal items for one of one medical record reviewed (MR1). (482.55 Tag-1112) The information reviewed during the survey provided evidence that the facility failed to provide qualified staff in adequate numbers to prevent suicidal patients from self-harm for two of two medical records reviewed (MR1 and MR2). Cross Reference: 482.13 Patient Rights 482.23 Nursing Services

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INTEGRATION OF EMERGENCY SERVICES

Sep 14, 2018

Based on review of facility documents and staff interview (EMP), it was determined the facility to coordinate and communicate with other hospital departments by failing to have adequate numbers of Security staff to provide safety checks on suicidal patients and by failing to have adequate numbers of registered nurses trained to respond to Trauma Alert Activation in the ED without pulling nurses from other units. Findings include: Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital.

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Based on review of facility documents and staff interview (EMP), it was determined the facility to coordinate and communicate with other hospital departments by failing to have adequate numbers of Security staff to provide safety checks on suicidal patients and by failing to have adequate numbers of registered nurses trained to respond to Trauma Alert Activation in the ED without pulling nurses from other units. Findings include: Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital. Scope: This policy applies to any member of the trauma team but is most likely to be initiated by the Emergency Department (ED) attending physician or nurse. Definitions: Trauma Alert (Level I, II, and III): For all patients greater than fourteen (14) years of age. ... Pediatric Trauma Alert: For all patients fourteen (14) years of age or less Trauma Alert - OB: For all patients greater than or equal to 20 weeks gestation Resuscitation: This intense period of patient assessment and medical care to save life or limb Trauma Team: A group of health care professionals organized to provide care and monitor the trauma patient in coordinated and timely fashion Trauma Resuscitation Area: A space used for trauma resuscitation. It must be of adequate size to accommodate for full trauma resuscitation, and equipment. Trauma Resuscitation Team: Major trauma resuscitations require a multidisciplinary team of health care providers who work in synergy to rapidly assess and treat the patient. The trauma attending or appropriate designee must lead the team. ... Procedure: The Trauma Alert response will be determined prior, if at all possible, to the patient's arrival by the Emergency Department physician and /or ED RN or Trauma surgeon. All level I and II trauma alerts will be taken to the trauma resuscitation rooms upon pre-hospital arrival. The Emergency Department physician and /or ED RN or the Trauma Surgeon will initiate a Trauma Alert prior to the arrival of the patient if prior information is available. If no prior notification is obtained, then the Trauma Alert will be called on the patient's arrival in the Emergency Department. The ED physician will give medical commend to ALS/BLS units. The designated Trauma Nurse will notify the switchboard of the classification of Trauma Alert and the estimated time of arrival. ... The ED nurse at the direction of the ED physician activates Trauma Alert Level II. The switchboard will notify the response team to be present upon patient arrival. Trauma Team that will respond will include the following: ... 3. Designated emergency Department trauma nurse ... The ED nurse at the direction of the ED physician activates Trauma Alert Level III. The Trauma surgeon will be paged by the ED physician or Nurse. 1. Emergency Department physician 2. Trauma Surgeon 3. Designated emergency Department trauma nurse. ..." Review on September 11, 2018, of the facility's "Staffing the Emergency Department" policy, effective June 2015, revealed "Purpose: The purpose of this policy is to explain the methodology for properly staffing the Emergency Department. Policy: Patients presenting to the emergency department are seen as quickly as possible. Staffing must be appropriate for this to occur. ... Procedure: ... 2. Scheduling a. In accordance with the CBA [Collective Bargaining Agreement] and Hospital Policy, emergency Department Leadership issues a six-week schedule in the electronic scheduling program with the maximum number of staff members in each title that would be required at a given hour of the day. ..." Interview with EMP29, EMP30 and EMP31 on September 10, 2018, revealed there is not always a Flow/Trauma Nurse always assigned to cover this position. These employees revealed when a trauma patient presents to the ED, and there is no Flow/Trauma Nurse coverage, a RN is pulled from their patient assignment to cover the trauma. Review on September 11, 2018, of the ED staffing sheets for August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018, revealed no designated Flow/Trauma Nurse coverage. Review on September 11, 2018, of the ED trauma list for August 2018, revealed the following trauma patients presented to the ED: August 8, 2018: 2 - Level II trauma patients August 13, 2018: 1 - Level 2 trauma patients August 20, 2018: 1 - Level I trauma patient August 21, 2018: 1 - Level I trauma patients August 25, 2018: 1 - Level I trauma patient; 3 - Level II trauma patients and 1 - Level III trauma patient August 26, 2018: 1 - Level I trauma patient and 1 - Level III trauma patient August 29, 2018: 1 - Level I trauma patient Interview with EMP3 and EMP7 on September 11, 2018, at approximately 10:45 AM confirmed there was no designated Flow/Trauma Nurse coverage on August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma. Review on September 11,2 018, of the ED staffing sheets for September 4, 5, 6, 7 and 9, 2018, revealed no designated Flow/Trauma Nurse coverage. Review on September 11, 2018, of the ED trauma list for September 2018, revealed the following trauma patients presented to the ED: September 4, 2018: 3 - Level I trauma patients and 1 - Level II trauma patient September 5, 2018: 1 - Level 2 trauma patients September 6, 2018: 1 - Level I trauma patients; 2 - Level II trauma patients and 1 - Level III trauma patient September 7, 2018: 2 - Level II trauma patients Interview with EMP3 and EMP7 on September 11, 2018, at approximately 12:00 PM confirmed there was no designated Flow/Trauma Nurse coverage on September 4, 5, 6, 7 and 9, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma. Review on September 10, 2018, of the facility provided the "Emergency Department Staffing Grid " dated June 16, 2018, revealed the required staffing at 7 AM is 10 Registered Nurses (RN's), 1 RN for Crisis, 2 Techs; 1 Nurse Assistant (NA) and 1 Unit Secretary (US); at 9 AM the required staffing is 12 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; at 11 AM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 3 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 7 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 11 PM the required staffing is 14 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; and at 3 AM the required staffing is 8 RN's, 1 RN for Crisis, 2 Techs; 1 NA and 1 US." Interview with EMP3 on September 10, 2018, at approximately 8:00 PM revealed the time from 11:00 AM to 7:00 PM are the busiest times with more patient visits in the ED. EMP3 revealed staffing numbers are increased during this time due to the increase in patient visits. Interview with EMP29, EMP30, EMP31, EMP32, EMP33, EMP34, EMP35, EMP36, EMP37 and EMP38 on September 10, 2018, revealed there is inadequate staffing of Registered Nurses (RN), Techs, Nursing Assistants (NA's) and Unit Secretary's (US) in the ED. On September 10, 2018, a random sample of the ED staffing sheets for August 2018 and September 2018 were selected for review. Review on September 11, 2018, of the staffing sheets for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED. Interview with EMP3 on September 11, 2018, at approximately 10:15 AM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018. Review on September 11, 2018, of the staffing sheets for September 2, 4, 5, 6, and 9, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED. Interview with EMP3 on September 11, 2018, at approximately 12:00 PM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for September 2, 4, 5, 6, and 9, 2018.

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EMERGENCY SERVICES POLICIES

Sep 14, 2018

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to follow their policy related to metal detector use for patients presenting to the Emergency Department Crisis (ED) for one of one medical record reviewed (MR1).

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Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to follow their policy related to metal detector use for patients presenting to the Emergency Department Crisis (ED) for one of one medical record reviewed (MR1). Findings include: Review on September 12, 2018, of the facility provided Metal Detector user manual revealed "... The [name of metal detector] with both audible and silent vibrating alarms offers outstanding performance as well as operating features not found in any other hand-held detector, with state of the art circuitry that allows instant operation, which provides the optimum setting with no operator adjustment. With full 360 (degree) plus detection coverage - even at its tip - the [name of metal detector] is very effective in easily detecting even the smallest of metallic objects. ... Recommended Body Scanning Procedure The illustrations indicate scanning beginning at the head then going to one arm and leg, then the other arms and leg and finally down the trunk on the front and back of the body. ..." Review on September 12, 2 018, of the facility's "Crisis Room: Security Metal Detector Use" policy, effective February 21, 2015, revealed "1.0 Purpose: The purpose of this policy is to provide the approved plan to be followed when patients are admitted to the Crisis Room for evaluation. 2.0 Policy: When any patient is admitted to the Crisis Room for the purpose of having an evaluation by the Crisis Caseworker, it will be the responsibility of the Security Officers assigned to the areas to: ... 2.3 All clients/visitors who enter the Crisis Room will be asked by the Mental Health worker Or the Security Office if they have pacemakers, implantable cardioverter/defibrillators or spinal cord stimulators prior to being screened through the [name of metal detector] or with the hand held metal detector. If so, those clients/visitors will not be allowed to pass through the [name of metal detector] but will undergo the hand-held scanner after Security personnel consult with emergency room Personnel as to their ability to do so in a safe manner. The "hand held scanner" should not be held near the medical device no longer then is absolutely necessary. If clients/visitors do not have medical devices on or within their person, the following procedure (2.3) will be followed. 2.4 All clients and/or visitors who enter the Crisis Room will be required to pass through the [name of metal detector], if physically able, or be screened. ..." Interview with EMP60 and EMP61 on September 12, 2018, at approximately 9:45 AM revealed the facility purchased a [name of metal detector] approximately seven years ago and this metal detector was put into storage and never utilized in the Emergency Department due to not having enough staff in the security department to use and man this piece of equipment. Interview with EMP60 and EMP61 on September 12, 2018, at approximately 9:50 AM revealed this [name of metal detector] scans the persons entire body from the head to the feet. Review of MR1 on September 12, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self. Review of MR1 on September 12, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards. Review of MR1 on September 12, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds. Review of MR1 on September 12, 2018, revealed nursing documentation dated August 11, 2018, at 8:30 PM a call was received from a friend of MR1's indicating MR1 had a razor blade in the mouth. Review of MR1 on September 12, 2018, revealed nursing documentation this patient was cooperative with a mouth search; handed ED staff a razor blade from the mouth and that MR1 indicated this patient keeps it there all the time. Interview with EMP1, EMP3 and EMP7 September 12, 2018, at approximately 10:15 AM confirmed MR1 was wanded by security and no concealed metal items or safety hazards were found. EMP1, EMP3 and EMP7 confirmed that MR1 produced a razor blade they had in their mouth. Interview with EMP60 and EMP61 on September 12, 2018, at approximately 10:20 AM confirmed security wanded MR1 and that no concealed metal items or safety hazards were found. EMP60 and EMP61 revealed security does not wand the head or mouth area of a patient for concealed metal items.

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QUALIFIED EMERGENCY SERVICES PERSONNEL

Sep 14, 2018

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patients presenting to the Emergency Department (ED) with suicidal thoughts were provided adequate monitoring to prevent self-harm for two of two medical records reviewed (MR1 and MR2); the facility failed to provide physician ordered 1:1 observation monitoring for patients presenting with suicidal thoughts for four of four medical records reviewed (MR3, MR4, MR5 and MR6); and failed to follow the established staffing policy to ensure consistent categories of nursing personnel based on the facility's staffing grid and schedules in the Emergency Department.

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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patients presenting to the Emergency Department (ED) with suicidal thoughts were provided adequate monitoring to prevent self-harm for two of two medical records reviewed (MR1 and MR2); the facility failed to provide physician ordered 1:1 observation monitoring for patients presenting with suicidal thoughts for four of four medical records reviewed (MR3, MR4, MR5 and MR6); and failed to follow the established staffing policy to ensure consistent categories of nursing personnel based on the facility's staffing grid and schedules in the Emergency Department. Findings include: Review on September 12, 2018, of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy, last revised August 2017, revealed "Policy: All patients who are admitted for care and services will be assessed for suicide ideation and /or suicide risk factors during initial intake/admission assessment process. In addition, patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will be assessed for suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients form inflicting harm to self or others. Purpose: To identify patients at risk for suicide and provide safety interventions. ... Definitions: ... Suicidal Ideation: Thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan. Suicide Attempt: A non-fatal, self-inflicted destructive act with explicit of inferred intent to die. ... Level of Supervision A. Continuous visual surveillance (Level 1) - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately. De-escalation techniques will be used as appropriate. B. Continuous visual surveillance (Level 2). Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight of patient. If de-escalation techniques are ineffective, patient will be escalated to Activity Level 1. C. Close observation (Level 3): Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals at a maximum of 15-minute intervals. Supportive family/friend must receive education from staff on expected responsibilities and be willing to sign a contract to stay with the patient at all times or know and agree to communicate with/seek staff assistance if chooses to leave for any concerns. In absence of reliable support person, patient will be escalated to Activity Level 2. D. Intermittent observation (Level 4): Observation at a maximum of 30-minute intervals by clinical staff. E. General observation (Level 5): Routine check by clinical staff at a maximum of one-hour intervals. ..." Review on September 12, 2018, of the facility's "Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting" form, last reviewed April 12, 2018, revealed "Level 1 Definition Requires immediate life-saving intervention. Immediate danger to self or others. Observed Violent Behavior Possession of weapon Self-Destructive act that resulted in physical harm Reported Verbal commands to do harm to self or others (command hallucinations) violent/self-destructive behavior Behavior that has resulted in harm to self or others, including actual suicide attempt Interventions Continuous visual surveillance 1:1 ratio: direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. Level 2 High-risk situation Risk of danger to self or others and/or Severe behavioral disturbance Observed Extreme agitation Physically/verbally/aggressive Uncooperative hallucinations/delusions/paranoia distorted perception of reality May or has require(d) restraint/seclusion Words or behavior reflect high risk of elopement (pacing, hovering near doorway) signs of severe depression (Activities of Daily Living impacted) Reported threat to harm self or others Suicidal ideation (thoughts of suicide) with or without a plan acute drug or alcohol intoxication with history of suicide attempt or ideation Psychotic symptoms: Hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior Overwhelming symptoms of depression Interventions Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. ..." Review on September 12, 2018, of the facility's "Suicide Precautions" policy, last revised November 2017, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. 4. The nurse will inform the patient that he/she is being placed on suicide precautions and explain the rational. 5. The patient on suicide precautions should be assigned the bed near the door in a semi-private room. 6. An environmental safety check of the patient's room will be performed. 7. Patient belongings will be checked closely and all potentially harmful items will be removed, labeled and secured in the designated area on each department. ... 13. The patient monitor is to be seated at the foot of the patient's bed (beyond arms length but in direct proximity of the patient). 10. (sic) The patient monitor will report any potentially unsafe behaviors to the assigned nurse. ..." Review on September 12, 2018, of the facility's "Prevention/Alternatives and Use of Restraints/Protective Devices" policy, last revised December 2016, revealed "Philosophy: The patient has the right to be free from restraints of any form that are not absolutely medically or behaviorally necessary. Our approach to restrain will protect the patient's health and safety and maintain the patient's dignity. ... Policy: ... 5. The use of restraint must be implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with State law. ..." Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital. Scope: This policy applies to any member of the trauma team but is most likely to be initiated by the Emergency Department (ED) attending physician or nurse. Definitions: Trauma Alert (Level I, II, and III): For all patients greater than fourteen (14) years of age. ... Pediatric Trauma Alert: For all patients fourteen (14) years of age or less Trauma Alert - OB: For all patients greater than or equal to 20 weeks gestation Resuscitation: This intense period of patient assessment and medical care to save life or limb Trauma Team: A group of health care professionals organized to provide care and monitor the trauma patient in coordinated and timely fashion Trauma Resuscitation Area: A space used for trauma resuscitation. It must be of adequate size to accommodate for full trauma resuscitation, and equipment. Trauma Resuscitation Team: Major trauma resuscitations require a multidisciplinary team of health care providers who work in synergy to rapidly assess and treat the patient. The trauma attending or appropriate designee must lead the team. ... Procedure: The Trauma Alert response will be determined prior, if at all possible, to the patient's arrival by the Emergency Department physician and /or ED RN or Trauma surgeon. All level I and II trauma alerts will be taken to the trauma resuscitation rooms upon pre-hospital arrival. The Emergency Department physician and /or ED RN or the Trauma Surgeon will initiate a Trauma Alert prior to the arrival of the patient if prior information is available. If no prior notification is obtained, then the Trauma Alert will be called on the patient's arrival in the Emergency Department. The ED physician will give medical commend to ALS/BLS units. The designated Trauma Nurse will notify the switchboard of the classification of Trauma Alert and the estimated time of arrival. ... The ED nurse at the direction of the ED physician activates Trauma Alert Level II. The switchboard will notify the response team to be present upon patient arrival. Trauma Team that will respond will include the following: ... 3. Designated emergency Department trauma nurse ... The ED nurse at the direction of the ED physician activates Trauma Alert Level III. The Trauma surgeon will be paged by the ED physician or Nurse. 1. Emergency Department physician 2. Trauma Surgeon 3. Designated emergency Department trauma nurse. ..." Review on September 11, 2018, of the facility's "Staffing the Emergency Department" policy, effective June 2015, revealed "Purpose: The purpose of this policy is to explain the methodology for properly staffing the Emergency Department. Policy: Patients presenting to the emergency department are seen as quickly as possible. Staffing must be appropriate for this to occur. ... Procedure: ... 2. Scheduling a. In accordance with the CBA [Collective Bargaining Agreement] and Hospital Policy, emergency Department Leadership issues a six-week schedule in the electronic scheduling program with the maximum number of staff members in each title that would be required at a given hour of the day. ..." Review of MR1 on September 11, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self. The ED physician ordered 1:1 sitter at the bedside for constant observation at all times on August 11, 2018, on admission to the ED. Review on September 11, 2018, of MR1's Suicide Risk/Behavioral Disorder assessment dated [DATE], at 2:15 PM revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. Must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards. Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:20 PM there was no sitter at the bedside because no sitter was available. Review of MR1 on September 11, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds. Interview with EMP1, EMP3 and EMP7 September 11, 2018, at approximately 9:15 AM confirmed MR1 was admitted to the ED for evaluation and treatment of suicidal ideations and major depression; the ED physician ordered 1:1 sitter at the bedside for constant observation at all times; MR1 was wanded by security; that no concealed metal items or safety hazards were found and MR1's nursing documentation revealed there was no sitter at the bedside because no sitter available. EMP1, EMP3 and EMP7 confirmed MR1's nursing documentation this patient had multiple open lacerations on the arms and front of the neck and this patient's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds. Review of MR2 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, at 1:18 AM for evaluation and treatment of a suicidal attempt. Review on September 13, 2018, of MR2's admission Suicide Risk/Behavioral Disorder assessment dated July 29, 2018, revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. The ED physician ordered Continuous visual surveillance 1:1 direct observation on this patient. Review on September 13, 2018, of MR2's Physician's Restraint/Seclusion Orders Violent - Self Destructive order sheet dated July 29, 2018, at 1:10 AM revealed a physician order instructing nursing staff to apply four-point leather restraints. ED nursing staff applied leather restraints to MR2's both wrists and both ankles. Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 1:30 AM this patient was being obstructive to self and others by kicking and screaming to staff, thrushing (sic) around in bed, and trying to bite staff. At 1:35 AM on July 29, 2108, nursing documented this patient was able to strangle self with the gown strings. Oxygen was applied to the patient; the patient was hypoxic (inadequate oxygenation of the blood related to suffocation) and the doctor was made aware. Review of MR2 on September 13, 2018, revealed physician documentation that MR2 was cyanotic (blue discoloration of the skin due to having low oxygen in the blood) and initially not responsive. MR2 was bagged for a few seconds and became awake. Review of MR2 on September 13, 2018, revealed no documentation this patient was provided a sitter for 1:1 direct observation. Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 9:52 AM, 11:03 AM and 3:00 PM that this patient was ordered Level 1 (Continuous visual surveillance). Nursing documentation revealed there was no sitter at the bedside due to the lack of staffing. Interview with EMP1, EMP3 and EMP7 September 13, 2018, at approximately 9:20 AM confirmed MR2 was admitted to the ED for evaluation and treatment of a suicidal attempt: the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio and that MR2 was placed in four-point leather restraints. EMP1, EMP3 and EMP7 confirmed nursing documented this patient was able to strangle self with the gown strings and MR2 became hypoxic requiring oxygen administration. EMP1 and EMP3 confirmed there was no documentation this patient was provided a sitter for 1:1 direct observation and that nursing documented there was no sitter at the bedside due to the lack of staffing. Review of MR3 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self. Review on September 13, 2018, of MR3's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. There was no documentation in MR3 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight. Review of MR4 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self. Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. There was no documentation in MR4 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight. Review of MR5 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self. Review on September 13, 2018, of MR5's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. There was no documentation in MR5 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight. Review of MR6 on September 13, 2018, revealed this patient was admitted to the ED on July 28, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self. Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 28, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. There was no documentation in MR6 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight. Interview with EMP3 on September 13, 2018, at approximately 2:45 PM confirmed MR3, MR4, MR5 and MR6 were admitted to the ED for evaluation and treatment of suicidal thoughts with a plan to injure self and the ED physician ordered these patients on Level 2 Continuous visual surveillance 1:1 ratio for observation at all times by designated staff with direct line of sight. EMP3 confirmed there was no documentation in MR3, MR4, MR5 and MR6 indicating these patients were on a Level 2 Continuous visual surveillance 1:1 ratio with observation at all times by designated staff with direct line of sight. Interview with EMP29, EMP30 and EMP31 on September 10, 2018, revealed there is not always a Flow/Trauma Nurse always assigned to cover this position. These employees revealed when a trauma patient presents to the ED, and there is no Flow/Trauma Nurse coverage, a RN is pulled from their patient assignment to cover the trauma. Review on September 11, 2018, of the ED staffing sheets for August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018, revealed no designated Flow/Trauma Nurse coverage. Review on September 11, 2018, of the ED trauma list for August 2018, revealed the following trauma patients presented to the ED: August 8, 2018: 2 - Level II trauma patients August 13, 2018: 1 - Level 2 trauma patients August 20, 2018: 1 - Level I trauma patient August 21, 2018: 1 - Level I trauma patients August 25, 2018: 1 - Level I trauma patient; 3 - Level II trauma patients and 1 - Level III trauma patient August 26, 2018: 1 - Level I trauma patient and 1 - Level III trauma patient August 29, 2018: 1 - Level I trauma patient Interview with EMP3 and EMP7 on September 11, 2018, at approximately 10:45 AM confirmed there was no designated Flow/Trauma Nurse coverage on August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma. Review on September 11,2 018, of the ED staffing sheets for September 4, 5, 6, 7 and 9, 2018, revealed no designated Flow/Trauma Nurse coverage. Review on September 11, 2018, of the ED trauma list for September 2018, revealed the following trauma patients presented to the ED: September 4, 2018: 3 - Level I trauma patients and 1 - Level II trauma patient September 5, 2018: 1 - Level 2 trauma patients September 6, 2018: 1 - Level I trauma patients; 2 - Level II trauma patients and 1 - Level III trauma patient September 7, 2018: 2 - Level II trauma patients Interview with EMP3 and EMP7 on September 11, 2018, at approximately 12:00 PM confirmed there was no designated Flow/Trauma Nurse coverage on September 4, 5, 6, 7 and 9, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma. Review on September 10, 2018, of the facility provided the "Emergency Department Staffing Grid " dated June 16, 2018, revealed the required staffing at 7 AM is 10 Registered Nurses (RN's), 1 RN for Crisis, 2 Techs; 1 Nurse Assistant (NA) and 1 Unit Secretary (US); at 9 AM the required staffing is 12 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; at 11 AM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 3 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 7 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 11 PM the required staffing is 14 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; and at 3 AM the required staffing is 8 RN's, 1 RN for Crisis, 2 Techs; 1 NA and 1 US." Interview with EMP3 on September 10, 2018, at approximately 8:00 PM revealed the time from 11:00 AM to 7:00 PM are the busiest times with more patient visits in the ED. EMP3 revealed staffing numbers are increased during this time due to the increase in patient visits. Interview with EMP29, EMP30, EMP31, EMP32, EMP33, EMP34, EMP35, EMP36, EMP37 and EMP38 on September 10, 2018, revealed there is inadequate staffing of Registered Nurses (RN), Techs, Nursing Assistants (NA's) and Unit Secretary's (US) in the ED. On September 10, 2018, a random sample of the ED staffing sheets for August 2018 and September 2018 were selected for review. Review on September 11, 2018, of the staffing sheets for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED. Interview with EMP3 on September 11, 2018, at approximately 10:15 AM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018. Review on September 11, 2018, of the staffing sheets for September 2, 4, 5, 6, and 9, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED. Interview with EMP3 on September 11, 2018, at approximately 12:00 PM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for September 2, 4, 5, 6, and 9, 2018.

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Notes

“Average time” refers to the median wait time (the midpoint of all patients' wait times). References to “doctor or medical practitioner” indicate a doctor, nurse practitioner or physician's assistant. CMS reports the CT scan quality measure as the percentage of patients who received a scan within 45 minutes. We have reversed that measure so that all measures follow a “lower is better” pattern.

Additional design and development by Mike Tigas and Sisi Wei.

Sources

All data comes from the Centers for Medicare and Medicaid Services. Detailed quality measures at the hospital, state and national level were last updated September 2019. Most data was collected between October 2017 and October 2018. Data on ER-related violations is from January 2015 to June 2019.

Additional Info

How We've Updated ER Inspector | Download ProPublica's Emergency Room Planning Toolkit | About This Data

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