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Based on review of medical records, policy review, and staff interviews it was determined the facility failed to ensure that each individual which presented to the Dedicated Emergency Department (DED) and requested services was provided a medical screening examination and timely reassessment for one of 20 sampled patients, (Patient #1).

Findings included:

Refer to A2406.

Based on review of medical records, policy review, and staff interviews it was determined the facility failed to ensure that each individual which presented to the Dedicated Emergency Department (DED) and requested services was provided a medical screening examination and timely reassessment for one of 20 sampled patients, (Patient #1).

Findings included:

Review of the medical record for patient #1 revealed the patient presented to the facility ED on 1/26/2020 at 8:47 PM. The patient's complaint was abdominal pain, shortness of breath, nausea, and vomiting. Review of the record revealed the patient was triaged by an RN (Registered Nurse) at 9:26 PM. The patient's vital signs were blood pressure 103/71, temperature 98.0, pulse 110 bpm (beats per minute) (adult reference range 60-100), respiratory rate 22 (adult reference range 14-20), oxygen saturation 98% on room air, and pain level not documented. The patient was noted to have a history of breast cancer and had received chemotherapy on Monday, January 25th. She was advised to go to the emergency department (ED) by her physician.

Review of the triage assessment revealed the RN assigned the patient an acuity level of 2 - Emergent. The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. Review of the record revealed at 9:29 PM an EKG (Electrocardiogram) was completed which reflected sinus tachycardia (ST) at 113 bpm. Review of the record revealed the patient was sent back to the lobby to wait.

Review of the record revealed no further assessment of the patient until 1/27/2021 at 2:36 AM, more than five hours after the patient was triaged. Review of the facility policy, "Assessment/Reassessment of Adult Patients," #BC-NCL0132, on page 6 of 9, stated ED patient's time frame until initial assessment is upon arrival; and the time frame for reassessment is every 2 hours and as needed for intervention and treatment intervention. Review of the record revealed the patient was not reassessed for more than five hours after the initial triage assessment.

Review of the record revealed a Code Blue Flow Sheet, dated 1/27/2021 at 2:36 AM, which revealed the patient was found unresponsive, pulseless, with no cardiac activity in the ED lobby.

Interview was conducted with the Risk Manager on 2/15/2021 at 11:35 AM during the record review. She stated a family member of the patient had been outside and communicating with the patient who was sitting inside the ED lobby. She stated the family member became concerned when the patient stopped communicating. The family member came to the ED door and asked the security guard to check on the patient. The security guard approached the patient with no response. The security guard then alerted the Patient Care Technician (PCT) to check the patient. The PCT checked the patient who was unresponsive and the PCT called for assistance. The assistant nurse manager and then several other staff arrived and assisted with the patient. Review of the Code Blue Flow Sheet revealed at 2:36 AM resuscitation measures were initiated. Documentation revealed efforts continued, medications were administered, and intubation (insertion of a tube into the trachea for ventilation) was conducted by the physician at 2:41 AM. Resuscitation measures ended at 2:49 AM when the patient had return of circulation (ROC).

Review of physician documentation revealed the patient was first seen at 2:37 AM. The physician documented the patient presented with unknown medical history with complaint of shortness of breath. He documented the patient's downtime was unknown. The patient was approached by the PCT and found the patient unresponsive with no pulse. The patient was immediately taken to the ED bed where she received high quality CPR. Physician documentation revealed at 4:51 AM he talked to the patient's daughter and updated her on the patient's critical status. At 5:18 AM the physician reassessed the patient and noted the patient's blood pressure continued to deteriorate and additional vasopressive medication was ordered.

Review of the record revealed the patient continued to deteriorate and at 8:16 AM the patient became pulseless and resuscitative measures initiated. Physician documentation noted the patient's family was at bedside and requested resuscitative measures be discontinued. The patient expired with the time of death noted as 8:24 AM.
Interview was conducted with the Risk Manager on 2/15/2021 at 11:35 AM at which time she confirmed the above findings.