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Based on observation, document review and interview, it was determined the Hospital failed to ensure patients were appropriately supervised/monitored in the Emergency Department while awaiting a computed tomography (CT). Therefore, the Condition of Participation, 42 CFR 482.23 Nursing Services was not met. This has the potential to affect all patients receiving a CT in the ED, (approximately 1,200 cases a month).

Findings include:

1. The Hospital failed to ensure a patient was appropriately supervised/monitored based on the patient's condition, while waiting in the hallway for a computed tomography (CT) exam in the Emergency Department (ED), (A-395).

2. The Hospital failed to ensure vital signs were repeated as necessary based on patient's condition, (B-395).

A. Based on observation, document review and interview, it was determined that for 1 of 1(Pt #1) record reviewed of a patient death, the Hospital failed to ensure a patient was appropriately supervised/monitored based on the patient's condition, while waiting in the hallway for a computed tomography (CT) exam in the Emergency Department (ED). This has the potential to affect all patients receiving a CT exam in the ED (approximately 1,200 a month)

Findings include:

1. On 07/22/19 at 10:00 AM, the medical record of Pt #1 was reviewed with the Hospital Clinical Coordinator (E #20). Pt #1 presented to the ED on 05/05/19 at 3:40 PM with a chief complaint of abdominal pain and distension for 2 days with nausea/vomiting. Pt #1 had a history of a stab wound to the abdomen 40 years ago, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and a hiatal hernia repair in 2017. The patient was taken to the operating room for further evaluation and had an exploratory laparotomy performed (a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity). Pt #1 was admitted to the Medical Surgical Floor on unit 2 Center and developed an ileus (inability of the bowel to contract normally and move waste out of the body).

On the morning of 05/10/19 the patient developed shortness of breath. Pt #1's VTE (venous thromboembolism) risk was documented as "High, Risk Level: 4". General Surgeon (E #2) evaluated the patient and started the patient on supplemental oxygen. A STAT (immediate) computed tomography (CT) was ordered to rule out a pulmonary embolism (A serious condition in which one or more arteries in the lungs become blocked by a blood clot, which can be fatal if not treated promptly). At approximately 7:11 AM, Pt #1 was transported via wheel chair with 2 liters of oxygen/minute per nasal cannula to the ED for the STAT CT. Pt #1 was stationed and left unattended in the hallway outside the CT control room waiting for the CT scan to be conducted.

At 7:50 AM, Registered Nurse (E #16) charted "CT called 2 Center Nurses station to report that IV was not up high enough on arm and that (Radiology Technician E #23) needed a forearm IV. RN asked CT tech if someone from ED could come stick (Pt #1). Call placed to ED. Spoke with secretary, no one available at this time." At 7:51, E #16 charted "This RN left 2 Center to go place an IV for STAT CT."

At approximately 7:55 AM E #16 found Pt #1 unresponsive in Pt #1's wheel chair. Pt #1 was taken to an ED room and a CODE BLUE was called. Cardiopulmonary resuscitation (CPR) was initiated at 7:57 AM and continued until the patient was pronounced dead by ED Physician (E #4) at 8:12 AM. The preliminary cause of death was "cardiorespiratory arrest PE (pulmonary embolism) not excluded". The Hospitalist (E #5) "Death Summary" signed on 05/10/19 at 5:58 PM indicated the cause of death to be "cardiopulmonary arrest (cause unknown)".

2. On 07/24/19 at 8:35 AM an interview with the Risk Manager (E #22) was conducted and revealed the following: E #22 was made aware of Pt #1's incident on 05/10/19 and immediately conducted an investigation. E #22 determined there were areas within the Hospital that needed to be improved but would not go into detail because it was information that was placed in the Patient Safety Organization (PSO). E #22 confirmed that Pt #1 was left alone in the hallway by the CT room in the ED and that there was no means for the patient to contact nursing staff in an emergency. E #22 also indicated there had been no changes implemented to prevent a similar incident happening to another patient, as of 2:00 PM on 07/24/19.

3. On 07/24/19 at 9:15 am an interview with E #23 was conducted. E #23 was working in the CT room in the ED on 05/10/19 and was to conduct the CT exam on Pt #1. E #23 stated that she brought the patient from the hallway into the CT room to begin the procedure but did not proceed because the patient had the wrong intravenous (IV) catheter size and location for the type of CT ordered. E #1 contacted the nursing unit where the patient was admitted and requested a nurse come to the CT department and start another IV. The patient was taken back into the hallway and was left unattended awaiting the new IV.

At 7:55 AM, Registered Nurse (E #16) came to the ED to start the new IV and found the patient outside of the CT room unresponsive. A CODE BLUE was called and the patient was transported to an ED room. The patient expired at 8:12 AM. E #23 confirmed that patients are placed in the hallway by the CT room without being monitored. "We routinely place patients out in the hallway while they're waiting for a CT. I can't monitor them because I'm in the control room, running the CT machine." E #23 also confirmed she continues to place wheel chair bound patients who are waiting for a CT exam in the hallway outside the CT control room unmonitored.

4. An observational tour of the ED and CT Departments with the Risk Manager (E #22) was conducted on 07/24/19 at 09:49 AM. E #22 demonstrated where Pt #1 was sitting when the above incident occurred. Pt #1 was siting at the intersection of the two hallways, which connected the ED and CT Departments. Pt #1 was sitting in-between the CT Control Room and X-ray Room #10 doors, facing the ED hallway. The area where Pt #1 was sitting could not be visualized from the ED Nursing Desk, CT Control Room, or X-ray Room #10. The area where Pt #1 was sitting lacked any type of a emergency call system or video monitoring.


B. Based on document review, and interview, it was determined that for 1 of 10 patients (Pt #1) who presented to the Emergency Department (ED), the Hospital failed to ensure vital signs were repeated as necessary based on patient's condition. This could potentially affect all patients receiving care in the ED, (average daily census of 140 patients).

Findings include:

1. On 07/22/19 at 10:00 AM the medical record of Pt #1 was reviewed with the Hospital Clinical Coordinator (E #20). Pt #1 presented to the ED on 05/05/19 at 3:40 PM with a chief complaint of abdominal pain and distension for 2 days with nausea/vomiting. Triage vital signs were taken at 3:48 PM including: blood pressure 146/85, pulse 98, respirations 20, temperature 98.2 Fahrenheit, and pulse oximetry 97% on room air. At 8:13 PM Pt #1 left the ED and was taken to the operating room for an emergency exploratory laparotomy (a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity). The only vital signs that were taken while the patient was in the ED were the initial vitals signs taken at 3:40 PM.

2. On 07/24/19 at 4:21 PM, the Hospital policy "General Care of Emergency Patients" revised by the Hospital on March 2019 was reviewed. Under "Procedure" it reads "a. Vital signs will be repeated as necessary by patient's condition."

3. On 07/23/19 at approximately 3:00 PM, the Clinical Coordinator (E #20) confirmed the above times for the vital signs and indicated more frequent vitals should have been taken based on the patient's condition.