Based on observation, interview, and record review, the facility failed to ensure the delivery of emergency services were provided to four (4) of 30 sampled patients (Patients 11, 13, 15 and 16) in accordance with the facility's policy and procedures as follows:
1. For Patient 11, License staff failed to monitor the patient's location and to provide care to the patient while in the emergency department.
2. For Patient 11, 15, and 16, the facility failed to follow their policy on reassessment determined by the patient's clinical condition or at a minimum of every two (2) hours or sooner if needed. This failure created the potential for harm if the patient's clinical conditions deteriorated.
3. Emergency Department licensed staff, failed to accurately assess a patient's "Emergency Severity Index" based on the acuity of the patient's health care problems and the number of resources their care is anticipated to require.
4. For Patient 13, the facility failed to ensure physician ordered life-saving equipment was applied to a patient in a timely manner. This failure created the potential for undetected abnormal life threatening cardiac arrhythmia's to be detected placing the patient at risk for possible death.
Findings:
1. Record review conducted on January 3, 2018, revealed Patient 11, a [AGE] year old male who presented to the Emergency Department (ED) on December 30, 2017 at 11:35 AM, with complaints of bilateral (left and right side) leg swelling and throat pain.
Further review of the patients ED record revealed the patient was seen by Physician Assistant 1 (PA) at 11:39 AM. PA 1 documented the patient had a history of a left nephrectomy (kidney removal), left [DIAGNOSES REDACTED] and recently (two days prior) had a biopsy of his right kidney.
At approximately 11:43 AM, the ED Triage Nurse 1 (EDTN) obtained a blood pressure of 76/47 mmHg, the EDTN further documented the patient was experiencing a pain intensity level of eight (8). The EDTN 1 assigned the patient as an "Emergency Severity Index" level four (4) based on a level one (1-requiring life-saving interventions) to a level five (5-patients likely to require no resources) scale.
On January 4, 2018, at 9:35 AM, an interview was conducted with EDTN 1. During the interview EDTN 1 stated she had difficulty obtaining the patient's blood pressure, "I checked both arms and changed the cuff, when I got it, it (blood pressure) was low."
According to the ED Physician Notes under the "Impression and Plan" in the "Disposition" section, documentation revealed "Patient care transitioned to: Time 12/30/17 11:49 AM, patient transferred to main (treatment area)."
On January 4, 2018 at 1:35 PM, an interview was conducted with the ED Manager (EDM) and the Director of the ED (DED). During the interview the EDM was asked after the patient left the triage area, who was assigned to care for the patient, the EDM stated, "It is unknown where the patient was taken to."
The EDM further stated we are currently investigating the situation, we know that the patient was taken to triage room 2 upon arrival and they were having a hard time taking his blood pressure, we think the patient was then taken to the fast track area, the "assumption was that was the only open area."
The DED stated the fast track area consisted of 3 rooms and patients could also be placed in the RAP (results are pending-a room consisting of approximately eight to 10 chairs used for patients receiving intravenous {in vein} fluids, awaiting lab results) room. The DED further stated patients from "Main" are also placed in the RAP room.
The DED and the EDM were asked who the patients in the RAP room were assigned to, the EDM stated, if they were a fast track patient then a fast track nurse would take care of them, if they were a main patient then a main nurse would take care of them.
As the interview continued the EDM was asked when a patient is placed in the RAP room either as a fast track patient or as a main patient if a specific licensed staff member is assigned to provide the care to the patient, the EDM stated, "No."
A review of Patient 11's ED record revealed blood work (labs) were obtained from the patient at 12:09 PM. At 12:30 PM documentation revealed ED Registered Nurse 1 (EDRN), assigned to the fast track area on December 30, 2017 inserted an IV into the patient's mid-right forearm.
On January 4, 2018 at 3:15 PM, an interview was conducted with EDRN 1. During the interview EDRN 1 stated he did not recall the patient or recall placing an IV into the patient.
Further review of the patient's ED record revealed at approximately 12:40 PM, a "SEPSIS Alert" was computer generated regarding Patient 11. The alert stated, "This patient has met criteria that predict high likelihood of SEVERE SEPSIS. Call the provider immediately to report these results and suggest orders according to the sepsis bundle."
On January 4, 2018 at 1:35 PM, during the interview with the EDM, the EDM was asked who is made aware of a "SEPSIS Alert," the EDM stated, "Whoever opens up the chart will see the notation of "SEPSIS Alert" in any section of the chart (nursing or physician). The EDM was asked if it anyone responded to the "SEPSIS Alert" the EDM stated, "It doesn't look like anyone was logging into the patient's chart." The EDM was asked if it was safe to say that the sepsis protocol was not put into effect, the EDM replied, "You are right."
On January 4, 2018 at 2:45 PM, an interview was conducted with the ED Fast Track Charge Nurse (EDFTCN). The EDFTCN was asked if she recalled Patient 11, the EDFTCN stated the patient was brought to fast track by the PA, I heard someone say I'll get the work up but I don't recall who it was, further stating she didn't recall anything more about the patient.
The EDFTCN stated around the time of the patient's arrival, they had 40 patients on the tracker, patients in the 3 fast track rooms, about 11-12 patients in the RAP room and patients in IWA (internal waiting room).
On January 4, 2018 at 3 PM, another interview was conducted with the EDM, the EDM stated we are looking at the December 30, 2017 video as well as security to try to locate the patient, we've only been able to locate him when he first arrived.
The EDM was asked if the RAP room was an appropriate area for Patient 11 to be placed in after the PA identified that the patient was not a fast track patient and needed more resources, the EDM stated, "This day we were not going to find a bed."
No documented evidence could be located in the ED record to indicate where Patient 11 was placed within the ED after the PA documented "Patient care transitioned to: Time 12/30/17 11:49 AM, patient transferred to main (treatment area). In addition, no documented evidence could be located in the ED record to indicate who was providing care to the patient until EDRN 2 assumed care at 8 PM.
2a. Record review conducted on January 3, 2018, revealed Patient 11, a [AGE] year old male, presented to the Emergency Department (ED) on December 30, 2017 at 11:35 AM, with complaints of bilateral (left and right side) leg swelling and throat pain.
A review of the ED Physician Notes dated December 30, 2017, revealed documentation that the patient was seen by Physician Assistant 1 (PA) at 11:39 AM. PA 1 documented the patient had a history of a left nephrectomy (kidney removal), left [DIAGNOSES REDACTED] and recently (two days prior) had a biopsy of his right kidney.
At 11:43 AM, ED Triage Nurse 1 (EDTN) obtained the patient's vital signs which revealed a blood pressure of 76/47 mmHg (millimeters of mercury) with a pain intensity level of eight (8). EDTN 1 assigned the patient as an "Emergency Severity Index" (ESI-a one to five level triage instrument {1: requiring life-saving interventions to 5: Patients that are likely to require no resources} that categorizes emergency department patients based on the acuity of their health care problems and the number of resources their care is anticipated to require) level four (4): Patients who are likely to require one resource.
According to the ED Physician Notes under the "Impression and Plan" in the "Disposition" section, documentation revealed "Patient care transitioned to: Time 12/30/17 11:49 AM, patient transferred to main (treatment area)."
Further review of the patient's medical record revealed no reassessment or vital signs were obtained from the patient until December 30, 2017 at 8 PM, approximately 8 hours and 17 minutes after the initial assessment and vital signs were obtained from the patient.
A review of the Emergency Department's Patient Care Services Policy and Procedure titled "Patient Assessment and Reassessment" last approved date August 3, 2016, under the "PURPOSE" section documentation revealed the following:
"1.2 Reassessments are based on individual patient acuity, which is specific to clinical condition, changes in clinical status or diagnosis, or physician's order. However, guidelines are as follows:
ESI level 1 = every 15 minutes or sooner if needed
ESI level 2 = every 30-60 minutes or sooner if needed
ESI level 3 = every 2 hours or sooner if needed
ESI level 4 = every 2-4 hours or sooner if needed
ESI level 5 = upon discharge or sooner if needed"
On January 4, 2018 at 1:35 PM, an interview was conducted with the ED Manager (EDM) and the Director of the ED (DED). During the interview the EDM and the DED were shown the patient's ED record, the EDM was asked if he could provide documentation that a reassessment and additional vital signs were completed, the EDM stated, "No, they were not done again until 2000 (8 PM)." The EDM further stated, "That's not our policy." The EDM further stated, "The expectation is for nurses to triage patients, follow policy's and protocols and provide patient care."
b. Record review conducted on January 5, 2018, revealed Patient 15 presented on December 30, 2017 at 1:35 PM, with a right arm injury. A review of the December 30, 2017 ED flowsheet revealed the patient was categorized as an ESI level 4. At 1:37 PM, vital signs were obtained and an initial assessment was performed on the patient.
Further review of the December 30, 2017 ED flowsheet, revealed vital signs were not obtained or a reassessment completed until 8 PM, approximately 6 hours and 23 minutes after the initial reassessment and vital signs were obtained.
On January 8, 2018 at 12:15 PM, an interview was conducted with the ED Medical Director (EDMD). The EDMD stated vital signs and reassessments should be completed according to facility policy and procedure further stating this is not standard practice.
c. Record review conducted on January 5, 2018, revealed Patient 16 presented on December 30, 2017 at 11:13 AM for fever lasting 3 days. A review of the December 30, 2017 ED flowsheet revealed the patient was categorized as an ESI level 4. At 11:33 AM, initial vital signs were obtained.
Further review of the December 30, 2017 ED flowsheet, revealed vital signs were not obtained until 7 PM, approximately 7 hours and 27 minutes after the initial set of vital signs were obtained.
On January 8, 2018 at 12:15 PM, an interview was conducted with the ED Medical Director (EDMD). The EDMD stated vital signs and reassessments should be completed according to facility policy and procedure and this is not standard practice.
3. On December 30, 2017, at 11:35 AM, a [AGE] year old (Patient 11) presented to the ED with complaints of bilateral leg swelling. A review of the ED Physician Notes dated December 30, 2017, revealed documentation that the patient was seen by Physician Assistant 1 (PA) at 11:39 AM.
At 11:43 AM, ED Triage Nurse 1 (EDTN) obtained the patient's vital signs which revealed a blood pressure of 76/47 mmHg (millimeters of mercury) with a pain intensity level of eight (8). EDTN 1 assigned the patient as an "Emergency Severity Index" level four (4): Patients who are likely to require one resource.
On January 4, 2018, at 1:35 PM, an interview was conducted with the ED Manager (EDM). The EDM was asked based on the patient's initial symptom's (BP 76/47 and pain intensity level of 8) if the ESI level four (4) was appropriate, the EDM replied, the patient "should not have been a 4, perhaps a 3 or even a 2."
On January 4, 2018, at 9:35 AM, an interview was conducted with EDTN 1. During the interview EDTN 1 stated she had difficulty obtaining a blood pressure on the patient, "I checked both arms and changed the cuff, then I got it, it was low."
As the interview continued, EDTN 1 was asked what the patient's ESI level was, EDTN stated, "A three (3)." EDTN 1 was shown her documentation dated December 30, 2017 at 11:43 AM, which indicated she determined the patient's "Tracking Acuity" level was a four (4-Non-Urgent). EDTN stated, "I was probably rushing."
On January 8, 2018 at 12:15 PM, an interview was conducted with the ED Medical Director (EDMD). During the interview, the EDMD confirmed the patient's ESI level was not accurate and should have been at a minimum an ESI level three and possibly an ESI level two.
4. On January 5, 2018 at 12:50 PM, observation of the ED tracker revealed Patient 13, presented to the Emergency Department at 9:33 AM, following a motor vehicle accident status post seizure. Further observation of the ED tracker revealed "Needs Cardiac Monitor."
At 12:55 PM, an interview was conducted with the EDFTCN, the EDFTCN stated the ED physician wanted the patient in the back (main ED treatment area) and not in the waiting room because he had a seizure. The EDFTCN was asked to point out the patient, the patient was observed sitting in a chair outside the fast track area without a cardiac monitor. The EDFTCN was observed to walk to the nurse's station in the main ED and speak with the physician. Upon the EDFTCN return she stated the physician still wanted the patient on a cardiac monitor.
The EDFTCN was asked why a cardiac monitor had not been placed on the patient, the EDFTCN stated, "There are none available."
On January 5, 2018 at 1 PM, an interview was conducted with the Director of the ED. The DED was asked what they needed to do when they are short on equipment, the DED stated, "We need to locate some."
On January 5, 2018 at 1:55 PM, the DED was asked if he was aware that Patient 13 had an ordered for a cardiac monitor however none were available, the DED stated he did not know.
On January 5, 2018 at 1:57 PM, observation of Patient 13 revealed a cardiac monitor had yet to be applied on to the patient. At 2 PM, an interview was conducted with EDMCN 2, the EDMCN confirmed they were out of cardiac monitors and further stated he was aware that the patient needed a cardiac monitor further stating that the patient hadn't had a seizure in two (2) years and that he assessed the situation and felt the patient was not in need of a cardiac monitor. The EDMCN confirmed he had not elevated the need for a cardiac monitor to ED management.
On January 5, 2018 at 3:41 PM, a review of Patient 13's ED orders revealed the ED physician wrote the order for the cardiac monitor at 10:39 AM and had yet to be applied to the patient until after this surveyor intervened.
On January 8, 2018 at 9 AM, an interview was conducted with the EDM. The EDM stated he was not made aware of the need for a cardiac monitor for Patient 13 until after the fact, the EDM further stated they were able to locate an additional 7 telemetry monitors from the hospital floors. In addition, the EDM stated the EDMCN should have informed ED management of the need and can not make the determination on their own to not have a patient on a cardiac monitor when there is a specific order from the physician.