HospitalInspections.org

Based on policy review, document review, record review, and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 7 of 20 emergency department (ED) patients reviewed when the nursing staff failed to: 1. Complete Electrocardiograms (EKG) per procedure for Patients 3, 4, 5 and 14; 2. Complete vital signs as required per policy for Patients 8 and 10; and, 3. Notify the provider of abnormal vital signs per procedure for Patient 1. This deficient practice has the potential to place patients at risk for harm and adverse outcomes.

Findings Include:

1. Failed to complete an Electrocardiogram (EKG) as per hospital procedure. (Patients 3, 4, 5 and 14)

Review of hospital document titled, "Assessment of the Acute Coronary Syndrome (ACS) Patient in ED..." last reviewed on 03/31/25, showed, " ...Assessment is an ongoing process, documented in the medical record at intervals as described in this procedure. These assessment and documentation time frames represent the minimum requirements. ...Chest pain or severe epigastric pain (discomfort in the upper region of the abdomen), nontraumatic in origin, with components of myocardial ischemia (the heart muscle having insufficient blood flow leading to reduced supply of oxygen) or myocardial infarction (type of heart attack, blockage of blood flow to a heart muscle) (MI): 1. Central/substernal crushing chest pain, pressure, tightness, heaviness, cramping, burning or aching sensation. Patients may also describe as "chest discomfort ...Obtain (or delegate to an ED technician) a 12-lead ECG within 5 minutes of arrival ..."

Patient 3

Review of Patient 3's medical record showed a 14-year-old presented to the Emergency Department on 04/16/25 at 10:00 PM, with a chief complaint of chest pain. Patient 3 had a diagnosis of atypical chest pain (chest pain that doesn't meet the criteria for typical or classic chest pain) and discharged home on 04/17/25 at 1:07 AM.

Review of Patient 3's medical record showed the first EKG was done at 10:55 PM, 54 minutes after arrival.

During an interview on 04/29/25 at 3:05 PM, Staff Q, Advance Practice Registered Nurse (APRN), stated that patients with chief complaint of chest pain, the goal is to complete an EKG within 10 minutes of their arrival. At our facility, respiratory therapists (RTs) are responsible for performing EKGs. However, delays can occur, especially if the RT is already attending to another critical patient or performing another EKG.

During an interview on 04/30/25 at 8:52 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that the hospital does not have an internal chest pain policy. Instead, we customize and follow [a publisher of professional health information company's] as procedure and standing orders.

The medical record failed to show documented evidence that Patient 3's EKG was completed within 5 minutes of arrival as required by hospital procedure.

Patient 4

Review of Patient 4's medical record showed a 77-year-old the patient who presented to emergency department (ED) on 04/21/25 at 10:28 AM by private vehicle. Patient 4 was triage at 10:41 AM. Her chief complaint was chest pain.

Review of Patient 4's medical record showed the first EKG was done at 11:16 AM, 48 minutes after arrival.

Review of Patient 4's medical record dated 04/21/25 at 3:10 PM showed Patient 4 was transferred by Advanced Life Support (ALS) air ambulance for diagnosis of non-ST elevation MI [Myocardial Infarction] (NSTEMI) (a type of heart attack).

During an interview on 04/29/25 at 4:11, PM, Staff K, Advance Practice Registered Nurse (APRN), stated that patients who have chest complaints, an EKG should be performed within 15 minutes of arrival. There should never be a situation where an EKG is delayed, then stated "48 minutes it is unacceptable."

The medical record failed to show documented evidence that Patient 4's EKG was completed within 5 minutes of arrival as required by hospital procedure.

Patient 5

Review of Patient 5's medical record showed a 47-year-old the patient who presented to ED on 01/16/25 at 11:34 AM by private vehicle. Patient 5 was triage at 11:40 AM. Her chief complaint was rapid heart rate.

Review of Patient 5's medical record showed the first EKG was done at 11:42 AM, 8 minutes after arrival.

Review of Patient 5's medical record dated 01/16/25 at 6:30 PM showed Patient 5 was transferred by ALS ground ambulance for diagnosis of Atrial fibrillation with RVR (heart rhythm disorder where the upper heart chambers for the atria beat irregularly and the lower heart chambers for ventricles beat too fast), Hyperthyroidism (overproduction of hormone by the gland in of the neck (thyroid), Hypomagnesemia (low magnesium levels in the blood).

During an interview on 04/29/25 at 2:28 PM, Staff M, Advance Practice Registered Nurse (APRN), stated that the EKG timing starts from the moment of the patient's first contact with a healthcare provider, not necessarily when they arrive in the ER. Not every patient presenting with chest pain is brought directly back, but the goal is always to perform the EKG as quickly as possible.

During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that any patient presenting with a primary complaint of chest pain, an EKG should be performed within the first 15 minutes.

The medical record failed to show documented evidence that Patient 5's EKG was completed within 5 minutes of arrival as required by hospital procedure.

Patient 14

Review of Patient 14's medical record showed a 67-year- old male who presented to the ED on 02/25/25 at 2:25 PM by private vehicle. Patient 14's chief complaint of chest pain resulted in diagnosis of Myocardial Infarction, (a heart attack, in which blood cannot reach the organ of the heart properly, usually due to blood clots) STEMI [ST-Elevation Myocardial Infarction] (a type of heart attack).

Review of Patient 14's medical record showed the first EKG was done at 2:36 PM, 11 minutes after arrival.

Review of Patient 14's medical record dated 02/25/25 at 2:56 AM showed Patient 14 was transferred to an acute care hospital via air ambulance.

During an interview on 04/29/25 at 4:33 PM, Staff L, RN, stated that an EKG should be performed immediately to rule out a STEMI, especially when the patient presents with chest pain. Typically, we aim to complete the EKG within the first 5 minutes of the patient's arrival to the ER room. Patients who report chest pain are brought directly to a room.

The medical record failed to show documented evidence that Patient 14's EKG was completed within 5 minutes of arrival as required by hospital procedure.

2. Failed to complete vital signs as required by policy. (Patients 8 and 10)

Review of hospital policy titled "Initial Patient Assessment," dated 02/2024, showed, " ...Emergency Department/OB Triage; Time Frame for Completion; Within 30 minutes of arrival ...Vital Signs ..."

Patient 8

Review of Patient 8's medical record showed Patient 8 presented to the Emergency Department on 02/27/25 at 7:05 PM, with a chief complaint of laceration of right thumb without foreign body without damage to nail, and pain of right clavicle (collarbone).

The medical record failed to show documented evidence that Patient 8's vital signs were done within 30 minutes upon arrival as required by policy.

Patient 8's medical record failed to show evidence vital signs were obtained. Patient 8 was discharged on 02/27/25 at 8:10 PM, 61 minutes after arrival.

During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that every patient should have a full set of vital signs.

During an interview on 04/30/25 at 10:00 AM, Staff A, Emergency Department Manager, stated that that there are no vital signs documented in Patient's 8 medical record.


Patient 10

Review of Patient 10's medical record showed Patient 10 presented to the Emergency Department on 03/26/25 at 7:39 PM, with a chief complaint of a suture removal .

The medical record failed to show documented evidence that Patient 10's vital signs were done within 30 minutes upon arrival as required by policy.

Patient 10's medical record failed to show evidence vital signs were obtained. Patient 10 was discharged on 03/26/25 at 8:05 PM, 6 minutes after arrival.

During an interview on 04/29/25 at 3:47 PM, Staff N, RN stated that every patient who presents to the emergency department regardless of their chief complaint should have a full set of vital signs.

During an interview on 04/30/25 at 10:00 AM, Staff A, Emergency Department Manager, stated that that there are no vital signs documented in Patient's 10 medical record.


3. Failed to notify the provider of abnormal vital signs (Patient 1).

Review of hospital document titled, "Obstetric triage of patients," dated 02/23/25, showed, " ...Clinical Alert: If the patient's systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks' gestation ..."
Review of hospital document titled, "Hypertension in pregnancy patient care," dated, 11/17/24 showed, " ... Hypertension [high blood pressure] in pregnancy is defined as systolic blood pressure greater than or equal to 140 mm Hg, diastolic blood pressure greater than or equal to 90 mm Hg .... Notify the practitioner of a systolic reading of 140 mm Hg or greater, a diastolic reading of 90 mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner's order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient's blood pressure at an interval determined by the practitioner's order and the patient's condition ..."

Patient 1

Review of Patient 1's medical record showed 23-year-old female, was seen in the Obstetric Unit (OB) on 04/21/25 at 12:45 AM with complaint of " ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ..."

Review of "Vital Signs" dated 04/21/25 at 1:01 AM, showed, " ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter: ...SBP (Systolic Blood Pressure is pressure exerted when blood in ejected into arteries)<80 or >140, DBP (Diastolic Blood Pressure is pressure blood exerts within the arteries between heartbeats)<50 or >90 ... (recheck hourly) ..."

Review of "Vitals," dated 04/21/25 showed Patient 1's blood pressure (BP)was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM.

Patient 1's medical record showed, " ...Discharge Date and Time: 4/21/2025 2:45 AM ..."

Patient 1's medical record failed to show evidence the nurse notified the provider of an elevated blood pressure in obstetrical triage.

Review of Patient 1's [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, " ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp [blood pressure] on arrival 168/88 ...takes 100 mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...to increase labetalol to TID [three times a day] ..."


During an interview on 04/29/25 at 10:30 AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from this hospital she sought care at another hospital where she received medications and labs for her blood pressure.

During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the Patient 1's blood pressure of 159/99 and that the patient was reporting symptoms of headache. Staff G stated that given these findings, the patient should have been admitted for additional care.