This CONDITION is not met as evidenced by: Based on record review and interview, the hospital failed to integrate services with other departments of the hospital by 1) failing to provide needed treatment (control of BP and dialysis) and 2) facilitate transfer (from ED to ICU) when required for 1 (P #1) of 10 patient records reviewed (see tag A1103)

Based on record review and interview, the hospital failed to integrate services with other departments of the hospital resulting in the failure to provide needed treatment (control of BP and dialysis) and facilitate transfer (from ED to ICU) when required for 1 (P #1) of 10 patient records reviewed. This failed practice resulted in an adverse outcome for a critically ill patient who presented to the emergency department for care. The findings are: Control of BP A. Record review of P #1's "Emergency Medicine Note" dated 01/03/19 at 12:50 am revealed, "On evaluation the patient is significantly hypertensive (high blood pressure) with a blood pressure in the 220s over 130s" and "Per recommendation of renal, she will be admitted to inpatient for fistulogram, symptom control, blood pressure control, and hemodialysis." Recorded in the "Number of Diagnoses or Management options" section (exact time unknown) "Patient demonstrates a marked renal azotemia with a creatinine of 21.8 and a BUN of 117. As the patient has significant symptoms related to the renal azotemia including nausea, vomiting, headache and severely elevated blood pressure, she will need emergent dialysis." B. Record review of P #1's "Vital Signs" dated 01/03/19 revealed, P#1's BP recorded at time of arrival in the ED (12:49 am) was 226/114, at 2:17 am BP was 220/134, at 3:19 am BP was 217/119, at 5:30 am BP was 234/124, at 7:10 am BP was 226/114, and at 7:20 am BP was 208/115. C. Record review of "American Academy of Family Physicians" journal article dated 2019 reveals normal BP is 119/79 or lower for a person 22 years of age. D. Record review of facility "Completed Medications" revealed P#1 received Hydralazine 10 mg IV (medication used to control BP intravenously (via a tube inserted into vein) at 7:05 am on 01/03/19. The only other medication P#1 was given from time of arrival until 7:05 am on 01/3/19 was Tylenol 650 mg (medication used to treat pain and fever). Hydralazine 15 mg was again administered at 10:40 am on 01/03/19 when BP was 239/119 (10:28 am). At 11:08 am BP was 190/91. All of the BPs on 01/03/19 were recorded in red and as "(Abnormal) !". The final BP recorded in the ED prior to transfer to ICU (at 1:53 pm) was 195/105. E. Record review of "Completed Medication" revealed, P #1 received Tylenol 650 mg (milligrams) at 2:14 am on 01/03/19. F. Record review of "ED Quick Updates" (RN note) dated 01/03/19 at 3:20 am revealed, "pt continues to c/o (complain) of headache" documented as a 10 out of 10 for severity. Dialysis Treatment G. Record review of P #1's hospital record revealed patient arrived in the ED at 12:41 am on 01/3/19 via ambulance and was triaged by RN #9 at 12:51 am. RN #9 documented P #1 was experiencing "bloody emesis (vomiting blood), blackouts and abdominal pain". Also documented is, P #1 was a dialysis patient with end stage renal failure and an admission blood pressure of 195/105. Lab report dated 01/3/19 at 12:57 am revealed P #1's BUN was 117 mg/dL (hospital reference range 6-27 mg/dL) and Creatinine was 20.8 mg/dL (hospital reference range 0.55-1.02 mg/dL) . H. Record review of MD#1's "Emergency Medicine Note" dated 01/03/19 at 2:31 am revealed, "Spoke with [name of physician (Nephrologist,MD #6] who will dialyze pt. in next 2-3 hr. Recommended inpatient admission for symptom control and wants fistulogram by IR." I. Record review of MD #6's "Inpatient Services Dialysis Treatment Summary" dated 01/03/19 at 0700 (7:00 am) revealed MD ordered a 4 hour dialysis treatment. J. Record review of P #1's "Inpatient Services Dialysis Treatment Summary" dated 01/03/19 revealed, the dialysis treatment was started at 8:24 am on 01/03/19 and was discontinued after 18 minutes . Record indicates P #1's BP was 181/126 at 8:20 am in the dialysis multi-suite and patient initially consented to dialysis. In the "Post-Treatment" section of the record the dialysis technician/nurse (credentials unknown) stated P #1's treatment was discontinued early because "Patient Refusal-MD Notified". Also documented in the record is, "Pt. needs to be transferred to ICU to complete ordered dialysis, did not tolerate dialysis in multi-suite." K. On 03/19/19 at 4:34 pm, during interview, the Director of Operations for the contract dialysis company was asked about the rationale for discontinuation of dialysis treatment after 18 minutes ("did not tolerate dialysis in multi-suite") and stated, "It is not very descriptive, I would expect to see something more descriptive." Transfer to ICU L. Record review of MD #1's "Emergency Medicine Note" dated 01/03/19 at 7:20 am revealed, "[name of physician, MD #6 Nephrologist] was down to eval (evaluate) patient. Recommended inpatient admission for symptom control and wants fistulogram by IR". M. On 03/21/19 at 9:16 am, during interview, ED MD #7 was asked if he received a call from dialysis personnel to report P #1 was too agitated to continue dialysis and stated: "do not think they called me, but they called the ED to let us know she was agitated and coming back. I ordered a CT of the head at that point due to a decreased mental status. If someone had called I would have considered Haldol (medication used to treat agitation and anxiety)." When asked why the patient was not transferred to ICU at 8:30 am, MD #7 stated, "I wanted to get her dialyzed first and then she would be appropriate for the floor." MD#7 confirmed that he wanted to send the patient to a hospital area that did not require intensive care. MD #7 also confirmed that he called the ICU Intensivist (MD #4) and was instructed that MD #4 wanted to get the patient dialyzed 1st (prior to hospital admission). N. On 03/19/19 at 3:10 pm, during interview, RN #10 stated the reason given to her for discontinuation of the dialysis treatment after 18 minutes was, the patient was "too agitated, almost infiltrated her fistula". RN #10 also stated P #1 was "calm and cooperative" in the room (ED). RN #19 stated, "Dialysis wanted a sedation nurse because she (P #1) was too agitated." RN #10 confirmed that a transfer to anywhere other than ICU would probably not be justified since it would be very difficult to pull an RN from a step down unit (4th floor) to provide sedation in the dialysis unit (1st floor). O. Record review of MD #7 "Emergency Medicine Note" dated 01/03/19 at 7:36 am, revealed, "Spoke with [name of physician (MD #2 Hospitalist)]. He will not accept patient at this time, but will accept to step down once systolic BP (amount of pressure that blood exerts on vessels while the heart is beating. In a blood pressure reading (such as 120/80), it is the number on the top) below 200, but preferably below 180. The patient has just received hydralazine and is now going to dialysis." (at 7:10 am P #1's BP was documented as 226/114). P. Record review of Head CT (ordered by MD #7) dated 01/03/19 at 10:48 am, revealed, "No acute intracranial (space between the skull and the brain) abnormality. No hemorrhage (bleeding), infarction (clotting of the blood), or abnormal fluid collection." Q. Record review of MD #1's "ED Provider Note" (written by) dated 01/03/19 (exact time unknown) revealed, "Neurological: She is alert and oriented to person, place and time. No cranial nerve deficit." R. Record review of MD #6's "Renal Medicine Associates Progress Note" dated 01/03/19 at 7:38 am, revealed, "She is alert and oriented to person, place and time. She has normal range of motion." S. Record review of "Nursing Note" (ICU) dated 01/03/19 at 7:15 pm, revealed, "Patient had a sudden drop in O2 sat (level of oxygen in the blood). Providers notified. Pt bagged (given oxygen). Intubated (breathing tube placed) by React RN, (RN#11) Documentation revealed the reason for intubation was "impending respiratory failure." T. Record review of "Completed Medications" revealed that on 01/3/19 patient was given multiple medications to control BP after transfer to ICU (at 3:48 pm) including "Labetalol 10 mg (medication used to control BP) at 4:20 pm, Fentanyl 25 mcg (pain medication) at 4:36 pm, Labetalol 20 mg. at 6:07 pm, Ativan 1 mg (medication to control anxiety) at 6:23 pm, Morphine 1 mg (medication for BP and pain control) at 6:23 pm, and Ativan 4 mg. at 6:55 pm. In addition a NiCARdipine (BP control) infusion was started (time unknown) and stopped at 7:05 pm. U. Record review of NP #2's "Significant Event" note dated 01/03/19 at 7:26 pm revealed, "Patient was receiving dialysis-she was not having any fluid removed (dialysis initiated 16 hr 45 min after patient arrival in ED). Her blood pressure remained with systolic > 200 despite efforts to decrease blood pressure with labetolol and hydralazine. She was also given Ativan as she was becoming diaphoretic (sweating) and restless. She was started on a nicardipine gtt (drip infusion, intravenous medication used to control BP). The RN asked for a provider and stated the patient was agonal breathing (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing). Upon arrival in the room, sats were dropping, staff started to bag patient and her sats improved. She was unresponsive and unable to maintain airway (unable to breathe on her own). V. Record review of NP #2 note "24 hour subjective" dated 01/04/19 at 9:17 am, revealed, "Her blood pressure came down under 140 systolic after intubation. It is unclear whether she became responsive at all last night. RN reported she was only on propofol (used to induce or maintain anesthesia during certain surgeries, tests, or procedures) for 10 minutes. The day RN was told she was unresponsive throughout the night. Her blood pressure remained stable throughout the night. Upon assessment this morning her pupils were 6 non reactive-(dilated and not reactive to light) will order STAT (urgent) head CT and MRI", and neurologically "she is unresponsive." W. Record review of MRI of the brain done 01/04/19 at 10:48 am, revealed, "brain edema (swelling with fluid collection) with tonsillar herniation (abnormal fluid collection pushing the brain out into areas of the skull)." X. Record review of NP #2's note "24 hour subjective" dated 01/5/19 at 12:30 pm, revealed, "neurologic testing to determine that there is no neurological response and informed the family the patient was not likely to recover." Y. Record review of "Discharge Summary" dated 01/06/19 revealed, "Family made decision to withdraw support (breathing tube). Patient did not initiate any breaths. She was pronounced at 9:24 pm (time of death)." Z. On 3/19/19 at 9:35 am, during interview, ED Director confirmed that review of P#1's record was just being done and a report was made that there was an issue with this patient. ED director confirmed that built into the electronic record are BP parameters. P#1's BP should have come up as red, and alerted staff to the fact that P#1's BP was out of range. In addition, ED Director confirmed staff needed to look at care in ED and how timely it was. P#1's length of time in ED was more than 200 minutes and ED Director confirmed P#1's length of stay in the ED was a problem. AA. On 03/19/19 at 3:22 pm during interview, Intensivist (MD#4) confirmed receiving a call from ED at 7:00 am on 03/19/19 about needing a bed for a patient who needed dialysis, but the patient got agitated during the dialysis treatment, "so [name of ED MD] wanted to admit her to the ICU so she could get dialysis", but we were short on beds and [name of ED MD] also did not think agitation was an appropriate reason for ICU admission. BB. On 03/20/19 at 7:50 am during interview, MD#6, Nephrologist, confirmed that when he spoke with the ED MD at 9:00 am on 03/19/19 he said the "floor is never an appropriate place to dialyze a patient who may have dialysis disequilibrium syndrome." (occurrence of neurologic signs and symptoms, attributed to cerebral edema [swelling of the brain], during or following shortly after intermittent hemodialysis) and the patient needed to go to the ICU. An Immediate Jeopardy was identified and presented to hospital administration on 03/21/19 at 9:50 am. Hospital staff presented a Plan of Removal on 03/21/19 at 1:20 pm. Below is the plan of removal accepted on 03/21/19 at 1:20 pm. Plan of Removal COMMUNICATION Medical Doctor -Initiated 3/21/2019 - Chief Medical Officer - Evaluate current policy for provider to provider communication when a change in care or patient condition occurs, including documentation of reasoning. Evaluate current practice against policy and take appropriate action such as notifying the responsible person, notifying supervisors or submitting the event to peer review by May 20, 2019. -Initiated 3/21/2019 - Chief Medical Officer - Clearly define which provider is responsible for the patient from the time the admit order is written until patient is transferred to next level of care by May 20, 2019. Registered Nurse -Initiated 3/21/2019 - Chief Nursing Officer - Develop Situation Background Assessment Recommendation (SBAR) process between dialysis registered nurse and Registered Nurse (Emergency Department). The name of the responsible Medical Doctor will be included by May 20, 2019. -Initiated 3/21/2019 - Chief Nursing Officer - Fresenius -educate, implement, and evaluate existing Lovelace Medical Center Verbal Order Policy with Fresenius staff by May 20, 2019. -Initiated 3/21/2019 - Chief Nursing Officer - Develop, approve, implement and evaluate policy on the rationale of early termination of dialysis by May 20, 2019. DOCUMENTATION -Initiated 3/21/2019 - Corporate Chief Information Officer - Investigate EPIC interface with Fresenius system-long term solution by May 20, 2019. -Initiated 3/21/2019 - Clinical Operations Director - Develop Standard Work process for documentation in both electronic systems-standard document process-immediate action by May 20, 2019. CONTRACT MANAGEMENT -Initiated 3/21/2019 - Clinical Operations Director - Weekly meetings with Fresenius and Lovelace Medical Center Joint Operating Committee with metrics reported by May 20, 2019. -Initiated 3/21/2019 - Clinical Operations Director/Quality Director - Define metrics and report weekly service level agreement measures such as response time from dialysis order to dialysis treatment, staffing as required in contract, and other metrics (To Be Determined) associated with this contract by May 20, 2019. -Initiated 3/21/2019 - Clinical Operations Director - Review and evaluate Fresenius Policies for termination of dialysis by May 20, 2019. -Initiated 3/21/2019 - Clinical Operations Director - Evaluate current Fresenius onboarding process and revise as needed (including event reporting) by May 20, 2019. -Initiated 3/21/2019 - Chief Operating Officer - Validate/revise Fresenius contractual obligations to include timeliness of treatment, complete documentation in the electronic medical record provided to Lovelace Medical Center. [Name of Contractor] to provide remediation plan for any deficiencies related to this by May 20, 2019. -Initiated 3/21/2019 - Chief Nursing Officer - Evaluate the appropriateness of the number of contracted nurses for the volume of dialysis patients in relationship to current Fresenius staff by May 20, 2019. TIMELINESS OF CARE -Initiated 3/21/2019 - Chief Nursing Officer/Quality Director - Develop real-time monitoring process and standard work flow for managing timeliness of emergent dialysis treatments. Metrics, including but not limited to timeliness of initiation of renal consult by emergency department provider, renal provider, response time, timeliness of dialysis order, and initiation of dialysis treatment will be developed and reported as described below by May 20, 2019. QUALITY MANAGEMENT OVERSIGHT -Initiated 3/21/2019 - Chief Executive Officer/Quality Director - The Quality Department will be responsible for oversight of all metrics. A data collection plan will be developed which includes, the measure definition, the owner, the frequency and trigger events. Data will be analyzed and presented/discussed at the Joint Operating Committee by May 20, 2019. -Initiated 3/21/2019 - Chief Executive Officer/Quality Director - All metrics and reports will be discussed with senior leadership weekly for at least six weeks, then monthly or as needed thereafter. Metrics and reports may be altered after five months until standardized audit of all dialysis patients from Emergency Department to Fresenius service level times by May 20, 2019. -Initiated 3/21/2019 - Quality Director - All metrics will be discussed with Lovelace Medical Center's Performance Excellence council, and Medical Executive Committee for at least six months by May 20, 2019. HYPERTENSION -Initiated 3/21/2019 - Chief Medical Officer - The Chief Medical Officer will coordinate with Renal and Emergency department to develop and deliver education for early detection and treatment for hypertensive emergency and indications of acute dialysis Emergency Department at section meeting by 3/28/2019. -Initiated 3/21/2019 - Chief Medical Officer - The Chief Medical Officer in coordination with the quality department develop and perform audit of all patients with a diagnosis of hypertensive emergency for appropriate treatment for the next 60 days. Deficiencies will be handled through peer review and/or other mean necessary by May 20, 2019. Reports will be sent and reviewed by the Medical Executive Committee. TIMELINESS OF CARE -Initiated 3/21/2019 - Quality Director or designee will audit Emergency Department decision to admit to Intensive Care Unit arrival time for last 30 days to determine baseline and identify opportunities for improvement and determine the need to continue audits. Ownership of these improvements will be overseen by the Chief Nursing Officer by May 20, 2019. -Initiated 3/21/2019 - Chief Nursing Officer - Continue the Patient-Care Aligned Throughput Huddle (PATH) project, already underway to improve patient flow supporting the admission of emergency room patients by May 20, 2019. -Initiated 3/21/2019 - Chief Medical Officer - Initiate an audit of 10 patient emergency department charts to look at provider timeliness and clinical decision making. This will be reviewed by the Emergency Department directors and the Chief Medical Officer. Deficiencies will go to the general peer review with results provided back to the correct providers over the next 60 days and continued as needed by May 20, 2019.