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Based on interview and record review, the hospital failed to ensure nursing care was provided for one of one critically ill sampled patient (Patient 1) when:

1. A nursing physical assessment was not completed by the assigned nurse.
2. Warming measures were not implemented.

These failures resulted in the worsening of Patient 1's condition and had the potential to contribute to Patient 1's death.

Findings:

1. During a review of Patient 1's "Triage Assessment (TA)," dated 9/18/23 at 11:27 p.m., the "TA" indicated, Patient 1 was a 28 day old infant who was brought to the hospital's Emergency Department (ED) by his mother (FM 1). FM 1 told the triage registered nurse (RN 1) Patient 1 was born with a heart defect and his doctor told her to bring him to the ED if his lips look blue. The "Triage Assessment" indicated "Symptoms Upon Arrival to Unit - Bluish Lips or Face." The "Emergency Room Note" dated 9/19/23 at 12:40 a.m. indicated, "Patient is a 28 day old male presenting to the ED with mother for reported cyanotic [bluish color due to decreased amount of oxygen in the blood] lips and decreased PO [oral] intake [feeding]. Patient [sic] mother notes the patient being 'extra sleepy', somewhat difficult to arouse with increased stool output."

During a concurrent interview and record review on 10/9/23 at 1:41 p.m. with Emergency Services Nurse Manager (ESNM), Patient 1's medical record was reviewed. ESNM stated a nursing assessment was not completed by the assigned nurse.

During an interview on 10/9/23 at 2:07 p.m. with ESNM, ESNM stated her expectation was for nurses to complete the assessment for any care or interventions provided to patients.

2. During a concurrent interview and record review on 10/9/23 at 1:41 p.m. with ESNM, Patient 1's "Vital Signs (VS)," documentation dated 9/18/23 to 9/19/23 were reviewed. The "Vital Signs" indicated Patient 1 had a rectal temperature of 96.3°F (unit of measurement), a heart rate of 148 beat per minute, and a respiratory rate of 40 breaths per minute. ESNM stated no other vital signs were documented. ESNM stated no documentation of Patient 1 being placed in an infant warmer (device used to lay infant on a flat surface with the ability to apply a probe to the infant's skin which keeps the temperature at a clinically optimal temperature), and no documentation of a blood sugar being taken prior to Patient 1 suffering cardiac arrest.

During an interview on 10/11/23 at 10:45 a.m. with RN 4, RN 4 stated ED staff called and asked for a Neonatal Intensive Care Unit (NICU) nurse to go to the ED to start an IV because ED staff had failed multiple attempts to start an IV on an infant, the ED staff also asked for an infant warmer to be brought to the ED for the same patient. RN 4 stated she and a NICU nurse took the warmer to ED room 1 and when they arrived the ED staff had already started an IV. RN 4 stated about 3-4 minutes after she and the NICU nurse arrived to ED room 1, Patient 1 experienced cardiac arrest and a Code White was called.

According to the National Institutes for Health (NIH), hypothermia (a significant drop in body temperature) can lead to hypoglycemia (low blood sugar). When an infant gets cold, he uses up more glycogen (stored form of glucose) to keep warm. Then infant must use his glucose stores to keep warm, then the blood sugar drops, and the infant becomes hypothermic along with hypoglycemic. Abramowski A, Ward R, Hamdan AH. Neonatal Hypoglycemia. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537105/

Based on interview and record review, the hospital failed to ensure one of 30 sampled patients (Patient 1) medical record was complete and accurate. This failure resulted in lack of complete and accurate information in providing the appropriate care and treatment for Patient 1.

Findings:

During an interview on 10/9/23 at 10:17 a.m. with RN 1, RN 1 stated when an infant arrives in the ED with cyanosis and a known cardiac defect, the infant will be seen immediately.

During an interview on 10/9/23 at 10:29 a.m. with ESNM, ESNM stated for infants who present to the ED with symptoms of cardiac issues, the infant should be bedded and seen immediately.

During a concurrent interview and record review on 10/9/23 at 1:41 p.m. with ESNM, Patient 1's medical record dated 9/18/23 to 9/19/23 were reviewed. The following were noted:

9/18/23 at 11:24 p.m. Patient 1 arrived at hospital ED

9/18/23 at 11:27 p.m. "Triage Assessment" ..."Pt [patient] BIB [brought in by] mother who states pt lips appear to look 'bulish' [sic] [bluish.] Per mom pt has hx [history] congenital [born with] heart defect. . . and was advised by PCP [primary care provider] if pt's lips look 'blue' bring pt to ED... Symptoms upon arrival to unit: Bluish lips or face." Patient 1 was given a Emergency Severity Index (ESI-triage assessment score to determine priority of delivery of care) score of 2 indicating his condition was "Emergent" and his condition placed him in a high risk situation.

9/18/23 at 11:39 p.m. Patient 1 was taken from the triage desk to Rapid Medical Exam (RME) room 2 where his weight and vital signs were taken by an Emergency Technician (type of nursing attendant). Patient 1's rectal temperature was recorded as 96.3 L [low- hypothermic]degrees Fahrenheit (°F - unit of measure. Normal rectal temperature is 97.9°F to 100.4°F). ESNM stated there are no monitoring capabilities in RME 2 and the non-licensed care giver who weighed and took vital signs used a portable vital sign machine.

9/18/23 at 11:53 p.m. Patient 1 was assigned to RN 3.

9/19/23 at 12:35 a.m. Patient 1's ESI score was changed to 1 indicating his condition had become critical.

9/19/23 at 12:36 a.m. Orders placed for continuous cardiac (heart), pulse oximetry (measures amount of oxygen in blood) monitoring, and for intravenous (IV) access to be established.

9/19/23 at 12:40 a.m. First notes entered by physician (MD).

9/19/23 at 12:41 a.m. Swabs done for COVID-19 (highly contagious virus), Respiratory Syncytial Virus (RSV- contagious respiratory virus which can be dangerous in infants), and influenza (flu) virus.

9/19/23 at 12:44 a.m. Patient 1 moved to ED room 1 for space consideration.

9/19/23 at 12:55 a.m. IV started.

9/19/23 at 1:00 a.m. Patient 1 experienced cardiac arrest (heart stops beating) and a Code White (baby or child is experiencing a life-threatening medical emergency requiring resuscitation) was called.

9/19/23 at 1:03 a.m. Patient 1 was intubated (tube place into trachea to assist in providing artificial or mechanical respirations) by MD.

9/19/23 at 1:37 a.m. Patient 1 was pronounced dead.

During an interview on 10/9/23 at 2:07 p.m. with ESNM, ESNM stated no other nursing documentation was found in the chart. ESNM stated no documentation of Patient 1's condition or his condition being reported to the physician, no documentation of neonatal intensive care nurses being called to assist with Patient 1, and no blood sugar was done on Patient 1 until the Code White was in progress. ESNM stated her expectation was for the nurses to document any care or interventions provided to patients.

During an interview on 10/10/23 at 10:40 a.m. with Emergency Department Technician (EDT), EDT stated, she took Patient 1's vital signs, and Patient 1 seemed colder than he should be. . . and his skin color didn't look healthy. EDT stated she alerted the provider but does not remember the provider's name. EDT stated she told Patient 1's mother to cover him up but did not do any other interventions to warm Patient 1. EDT stated she did not document the vital signs or the name of the provider she notified.

During an interview on 10/10/23 at 2:46 p.m. with Medical Doctor (MD), MD stated, he was pulled into room 8 by a charge nurse to see Patient 1. MD stated he examined Patient 1 but did not document the assessment. . .

During a concurrent interview and record review on 10/11/23 at 9:40 a.m. with Director of Quality (DOQ), Patient 1's MR, dated 9/18/23 to 9/19/23 were reviewed. The MR indicated, there was no documentation that a provider saw Patient 1 prior to MD seeing patient on 9/19/23 at 12:40 a.m. DOQ confirmed there is no documentation that Patient 1 was seen prior to that time.

During a concurrent interview and record review on 10/11/23 at 1:54 p.m. with Senior Data Analyst (SDA), Patient 1's medical record (MR) dated 9/18/23 to 9/19/23 were reviewed. SDA stated there was no documented MSE in the MR.

During a review of the hospital's policy and procedure (P&P) titled, "Legal Medical Record Standards" undated, the P&P indicated, "All Medical Record entries should be made as soon as possible after the care is provided, or an event or observation is made. An entry should never be made in the Medical Record in advance of the service provided to the patient. Pre-dating or backdating is prohibited.

Based on interview and record review, the hospital failed to ensure one of 30 sampled patients (Patient 1) was provided with emergency services according to hospital policy. This failure had the potential for Patient 1's health status to decline.

Findings:

During a review of Patient 1's "Emergency Department Tracking Sheet (EDTS)," dated 9/18/23 to 9/19/23, the "EDTS" indicated, Patient 1 arrived at the Emergency Department (ED) on 9/18/23 at 11:24 p.m. and was assigned a priority level of "URGENT." The EDTS indicated Patient 1 was triaged (assessment to determine the urgency of the need for treatment) on 9/18/23 at 11:31 p.m. and was assigned a priority level of "EMERGENT [a life-threatening situation wherein the patient could suffer significant harm without rapid or immediate intervention]."

During a review of Patient 1's "Care Assessments (CA)," dated 9/18/23 at 11:27 p.m., the "CA" indicated, Skin Color Pallor [unhealthy pale appearance] Bluish Lips or Face. At 11:39 p.m., Temperature 96.3°F (L- low [normal temperature should be 97.6°F - 99.6°F]). Pulse Rate 148 H (high [normal pulse rate should be 116-140 beats/min [beats per minute]. Pulse Oximetry [blood oxygen level] of 93 L [Liter - a measure of oxygen] Room Air. (Pulse oximetry level should be "95 - 100 %). The CA dated 9/19/23 at 12:12 a.m. indicated, "General Pediatric Behavior - Lethargic [low energy, fatigue] Skin Color - Pallor, Skin Temperature - cool, Work of Breathing - increased."

During a review of Patient 1's "Emergency Room Note (ERN)," dated 9/19/23, the "ERN" indicated, ". . . Stated complaint: CYANOSIS (bluish discoloration) TO LIPS, NOT EATING WELL. Time seen by Provider: 09/19/23 00:40 (12:40 a.m.). Arrival date /time: 09/18/23 23:24"

During an interview on 10/9/23 at 10:17 a.m. with Registered Nurse (RN) 1, RN 1 stated she would place a patient with blue lips on a continuous monitor, and then notify the charge nurse, respiratory therapist, and the provider to see the patient as soon as possible. RN 1 stated she did not know why it would take a provider an hour to see a patient presenting in Patient 1's condition.

During an interview on 10/9/23 at 10:28 a.m. with Emergency Services Nurse Manager (ESNM), ESNM stated, her expectation of care with an emergent patient was for the provider to see the patient immediately.

During an interview on 10/9/23 at 10:46 a.m. with Emergency Department Charge Nurse (EDCN), EDCN stated, the triage nurse will call her for an emergent patient, and her expectation was for the provider to see the patient right away. The patient would be placed on continuous monitoring, and Respiratory Therapy (RT) would be called for a patient with respiratory symptoms.

During a concurrent interview and record review on 10/9/23 at 1:40 p.m. with ESNM, Patient 1's MR dated 9/18/23 to 9/19/23 were reviewed. ESNM confirmed the MR indicated, Patient 1 was triaged as an emergent patient at 11:31 p.m. on 9/18/23. ESNM confirmed Patient 1 was transferred into ED room 8 at 11:46 p.m. and assigned to RN 3. ESNM confirmed Patient 1 was triaged as critical (vital signs unstable) at 12:35 a.m. on 9/19/23. ESNM confirmed that the provider saw Patient 1 at 12:40 a.m. ESNM confirmed a "Code White [pediatric medical emergency] was called at 1:00 a.m.

During an interview on 10/10/23 at 10:10 a.m. with RN 2, RN 2 stated, she was the RN that triaged Patient 1. RN 2 stated she quickly took Patient 1 back to the triage room, and Patient 1's pulse oximetry was fluctuating between 88-93 %. RN 2 stated she notified the charge nurse that Patient 1 needed to be moved into a room as soon as possible.

During an interview on 10/10/23 at 10:40 a.m. with Emergency Department Technician (EDT), EDT stated, she took Patient 1's vital signs, and Patient 1 seemed colder than he should be. . . and his skin color didn't look healthy. EDT stated she alerted the provider but does not remember the provider's name. EDT stated she told Patient 1's mother to cover him up but did not do any other interventions to warm Patient 1. EDT stated she did not document the vital signs or the name of the provider she notified.

During an interview on 10/10/23 at 2:46 p.m. with Medical Doctor (MD), MD stated, he was pulled into room 8 by a charge nurse to see Patient 1. MD stated he examined Patient 1 but did not document the assessment. MD stated that was the first time he saw Patient 1, and ordered RT to come to the ED, and for Patient 1 to be moved into ED room 1. MD stated he "assumed" Patient 1 had been seen by a provider earlier.

During an interview on 10/10/23 at 4:28 p.m. with RN 3, RN 3 stated, she started caring for Patient 1 when he came to room 8. RN 3 stated Patient 1 looked pale, and his extremities were cold. RN 3 stated she got a blanket from the blanket warmer to cover Patient 1's feet. RN 3 stated she believes Patient 1 was not seen by a provider before MD saw him. RN 3 stated an emergent patient should be seen by a provider "quickly."

During a concurrent interview and record review on 10/11/23 at 9:40 a.m. with Director of Quality (DOQ), Patient 1's MR, dated 9/18/23 to 9/19/23 were reviewed. The MR indicated, there was no documentation that a provider saw Patient 1 prior to MD seeing patient on 9/19/23 at 12:40 a.m. DOQ confirmed there is no documentation that Patient 1 was seen prior to that time.

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Services Policy & Procedure Manual - Leadership," (undated), the P&P indicated, "The Emergency Department provides assessment, evaluation, stabilization, and management of all life-threatening, emergent, urgent, and non-urgent conditions to all ages. Patients are triaged by a registered nurse competent in emergency nursing using the Evaluation Severity Index or ESI 5 Level Triage System. . . ESI Level II (Emergent) patients are placed in a bed within 10-15 minutes of arrival. . . A physician or mid-level provider (PA) [Physician's Assistant] will evaluate patients within 30-45 minutes of placement in a patient room based on the severity of their complaints and or the assigned ESI triage level."

During a review of the facility's P&P titled, "Patient Care Services Policy & Procedure Manual - Patient Rights and Organizational Ethics," (undated), the P&P indicated, "ESI-II High risk situation, confused, lethargic, disoriented, severe pain, distress. . . Inform Emergency Department Treatment Nurse or Physician of all ESI I or II patients taken to the treatment area. Remain with the patient until relieved."

Based on interview and record review, the hospital failed to ensure one of 30 sampled patients (Patient 1) Medical Screening Exam (MSE- mandatory screening completed by qualified medical personnel to determine if an Emergency Medical Condition exists) was completed. This failure had the potential for a delay in providing needed care.

Findings:

During a review of Patient 1's "Triage Assessment (TA)," dated 9/18/23 at 11:27 p.m., the "TA" indicated, Patient 1 was a 28 day old infant who was brought to the hospital's Emergency Department (ED) by his mother (FM 1). FM 1 told the triage registered nurse (RN 1) Patient 1 was born with a heart defect and his doctor told her to bring him to the ED if his lips look blue. The "TA" indicated, "Symptoms Upon Arrival to Unit - Bluish Lips or Face."

During a review of the "Emergency Room Note (ERN)," dated 9/19/23 at 12:40 a.m., the "ERN" indicated, "Patient is a 28 day old male presenting to the ED with mother for reported cyanotic [bluish color due to decreased amount of oxygen in the blood] lips and decreased PO [oral] intake [feeding]. Patient [sic] mother notes the patient being 'extra sleepy', somewhat difficult to arouse with increased stool output."

During an interview on 10/9/23 at 10:17 a.m. with RN 1, RN 1 stated when an infant arrives in the ED with cyanosis and a known cardiac defect, the infant will be seen immediately.

During an interview on 10/9/23 at 10:29 a.m. with ESNM, ESNM stated for infants who present to the ED with symptoms of cardiac issues, the infant should be bedded and seen immediately.

During a concurrent interview and record review on 10/11/23 at 1:54 p.m. with Senior Data Analyst (SDA), Patient 1's medical record (MR) dated 9/18/23 to 9/19/23 were reviewed. SDA stated there was no documented MSE in the MR.

During a review of the hospital's "Medical Staff Rules and Regulations" (MSRR) dated 5/28/19, the MSRR indicated, "The 'initial medical screening examination' must be performed in hospital departments operated under the hospital's MediCare provider number and located in buildings contiguous to the inpatient facility (Emergency Department, Women's and Infant's Department). . . The 'medical screening examination' must be performed by a physician. Other qualified medical personnel may [include a] Family Nurse Practitioner in the Emergency Room [or a] Physician's Assistant in the Emergency Room."