HospitalInspections.org

Based on observation of Emergency Department (ED) video footage, staff interview, review of the medical record (MR) of Patient #1 (P1), and review of facility documents, it was determined the facility failed to ensure the safety of a patient presenting to the ED with severe abdominal pain and back pain, as evidenced by: failing to perform a pain assessment on a patient presenting to the ED with abdominal pain and back pain, and failing to reassess a patient in the ED waiting area who was observed lying on the floor in the fetal position for nine minutes (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

The IJ was identified on 5/17/24 at 10:00 AM. The IJ template was provided to the facility on 5/17/24 at 12:00 PM and an acceptable IJ removal plan was received at 2:30 PM. On 5/20/24, verification of the IJ removal plan was conducted during an on-site visit and included the following: a tour of the ED, review of staff re-education sign-in sheets, and staff interviews regarding the facility's process for performing pain assessments and re-assessment of patients in the ED waiting area. The IJ was lifted on 5/20/24 at 2:15 PM, however, Condition level non compliance remains.

Cross Reference:
482.13(c)(2) - Patient Rights: Care in a Safe Setting

Based on review of 2 medical records (Patient (P) 1 and P20), observation of video footage of the Emergency Department (ED) waiting area, staff interview, and review of facility policies and procedures, it was determined that the facility failed to ensure that: 1) patients in the ED waiting area are kept safe by reassessing their clinical status after a change in their condition; and 2) patients presenting with pain have their pain assessed and managed.

Findings include:

1) Reference #1: Facility policy titled, "Assessment/Reassessment" (last reviewed 6/2021) states, " ... Procedure: ... Key Points ... Patient assessment and reassessment (including frequency of vital signs) should be based upon factors including, but not limited to, patient acuity, complaint, presentation, changes in condition."

Reference #2: Facility policy titled, "Emergency Department Triage Process" (last reviewed 5/2024) states, " ... Policy: ... 4. Reassessment of the patient in the ED lobby is dependent upon the patient acuity level, and or change in patient condition. ... Procedure: ... If a patient or visitor waiting in the ED lobby notifies the registration and/or security staff of ... uncontrolled pain ... or a reported significant concern about another patient's condition, the registrar and/or security staff will inform the triage nurse."

On 5/15/24 at 1:35 PM, review of video footage from the ED waiting room on 4/29/24 was conducted in the presence of Staff (S)1 (Regulatory Coordinator), S2 (Associate Chief Nurse), S3 (VP of Operations), S4 (AVP Quality, Safety, and Accreditation), S5 (ED Nurse Manager), and S28 (Assistant Chief Medical Officer). The video footage revealed the following:

At 1:09 PM, P1 entered the ED with a family member and walked up to the ED registration counter. While the family member spoke to S31 (Registrar), P1 leaned over the registration desk and placed his/her head on his/her arm. P1 was grimacing as if uncomfortable.

At 1:11 PM, a staff member brought P1 a wheelchair and blanket.

At 1:13 PM, P1's family member wheeled P1 away from the registration desk and into the ED waiting area.

At 1:15 PM, P1 was observed "heaving" into a blue bag as if he/she was going to vomit.

At 1:18 PM, P1 leaned forward in the wheelchair and held his/her head in his/her hands.

At 1:19 PM, P1 leaned back in the wheelchair and began grimacing, as if he/she was uncomfortable.

At 1:21 PM, P1 began "heaving" into the blue bag. The family member then begins wheeling P1 into Triage Room 1.

At 1:27 PM, P1 exits Triage Room 1 with his/her family member, S29 (Triage Nurse) and S30 (Medical Resident), then enters Triage Room 2.

At 1:32 PM, P1 exits Triage Room 2 and is wheeled back into the ED waiting area. P1's family member is with him/her.

At 1:36 PM, P1 begins "heaving" into blue bag.

At 1:38 PM, P1 begins looking around and grimacing as if uncomfortable.

At 1:40 PM, P1 is sitting in the wheelchair with his/her head in his/her hands. P1's family member goes over to the registration desk and begins speaking with S31. S31 then goes into Triage Room 1. S31 exits Triage Room 1, speaks to the family member, then walks behind the registration desk. The family member returns to the ED waiting area.

At 1:45 PM, the family member again walks toward the registration desk and is speaking to S31. S31 remains behind the registration desk.

At 1:46 PM, P1 stands up from the wheelchair, walks toward the registration desk while "hunched over," then lays on the floor in a corner between the side of the registration desk and Triage Room 1. P1 is laying in a fetal position.

At 1:47 PM, P1's family member is speaking with S31 and S31 is looking in the direction of where P1 is lying on the floor.

At 1:48 PM, P1's family member knocks on the door of Triage Room 1. The door opens and S33 (Patient Care Technician) is partially present in the doorway conversing with P1's family member. S33 does not come out of Triage Room 1 nor engage with the patient, who continues to lie on the floor in a fetal position.

At 1:49 PM, P1's family member crouches down to speak with P1 while talking on a cell phone.

At 1:52 PM, S32 (Physician's Assistant) exits Triage Room 2, enters the ED waiting area (and is briefly out of the camera's view), then returns to Triage Room 2. S32 does not have any interaction with the patient, who continues to lie on the floor in a fetal position.

At 1:53 PM, P1's family member exits the ED while talking on his/her cell phone.

At 1:55 PM, P1's family member returns to the ED, then walks over to P1 and assists him/her to his/her feet. Both P1 and the family member walk out of the ED.

At 2:20 PM, S1, S2, S3, S4, S5, and S28 confirmed that P1 laid on the floor of the ED in a fetal position for nine minutes without having a clinical staff member re-assess his/her condition.

Upon interview at 2:31 PM, S5 was asked what the expectation was, of the registrar, when a patient has a change in their condition while waiting in the ED waiting area. S5 stated, "The expectation is that the registrar notifies a clinical person, like the triage nurse." S5 was then asked what the expectation was, of the clinical person, when they are informed of a patient's change in condition. S5 stated, "The expectation is that they respond."

An interview was conducted with S31 at 3:06 PM, in the presence of S1. S31 stated that he/she remembered when P1 arrived to the ED on 4/29/24. S31 stated, "The patient came in with abdominal pain and back pain. I remember [P1's family member] was upset that [P1] was not being seen as soon as possible. [He/she] was being rude and said [P1] was here a long time and needs to be seen. [He/she] was going to go somewhere else and called an ambulance. [He/she] was not having it." S31 was asked if he/she notified anyone about P1. S31 stated, "I told the triage nurse." When asked the name of the triage nurse he/she notified about P1, S31 stated, "I don't remember who I spoke with." S31 was asked what he/she told the triage nurse. S31 stated, "I told [him/her] that [P1] was in a lot of pain and the [family member] was upset. I told the triage nurse that [P1] was laying on the floor. They said the patient was triaged already and that the patient would have to wait for a bed." S31 then stated, "I told my supervisor also, that the patient was laying on the floor. My supervisor asked me if I told triage and I said yes." When asked, S31 denied receiving training on what to do for patient emergencies when a patient is in the ED waiting area. Upon review of S31's education file it was determined that S31 received training on how to notify licensed personnel [nurses, doctors, technicians] if a medical emergency takes places, but because S31 is not licensed personnel he/she does not receive hands on training in responding to medical emergencies.

On 5/16/24 at 11:14 AM, an interview was conducted with S32 (Physician's Assistant) in the presence of S4. S32 confirmed that when he/she was returning to Triage Room 2, he/she saw P1 lying on the floor in the fetal position. S32 stated, "I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed." S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, "I remember telling either [S30] or the attending that the patient was laying on the floor. They said the plan was to get the patient back shortly." S32 was asked why he/she didn't assess P1 to make sure he/she was okay. S32 stated, "I saw the patient but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room." When asked when he/she was told this information about the patient, S32 indicated that he/she remembers being told the patient was angry but could not recall when he/she was told that information.

At 11:27 AM, S32 stated that when a patient sitting in the ED waiting area has a change in their condition, he/she was trained to "let the charge nurse and attending (physician) know." S32 confirmed he/she did not notify the charge nurse that P1 was lying on the floor in the fetal position. When asked, S32 stated he/she "did not recall" if he/she notified the medical resident or the attending physician that P1 was lying on the floor.

A telephone interview with S30 was conducted at 12:06 PM, in the presence of S28. S30 was asked if he/she was made aware that P1 was lying on the floor of the ED waiting area in a fetal position. S30 stated, "No. I don't recall that. It doesn't sound familiar."

Upon interview at 12:29 PM, S18 (ED Attending Physician) stated that if a patient in the ED waiting room has a change in their clinical status, the charge nurse and the attending "should be notified." S18 stated the patient would then be "immediately brought back into the ED." S18 was asked if he/she was made aware that on 4/29/24, P1 was lying on the floor in the ED waiting area in a fetal position. S18 stated, "I was not aware that [P1] was lying on the floor."

A telephone interview was conducted with S29 (Triage Nurse) at 2:04 PM, in the presence of S1. S29 stated he/she remembered P1 coming to the ED on 4/29/24. S29 stated P1 came into the ED with "10 out of 10 abdominal pain" and "looked super uncomfortable." S29 stated, "We didn't have any beds that day. We were jamb packed in the back. I say the same thing to all my patients that I have to put back in the waiting room - if anything changes let me know." S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, "I don't remember if anyone told me [P1] was still in pain." S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, "I don't remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient." S29 was asked what he/she is required to do if there is a change in the patient's condition while they are in the ED waiting area. S29 stated, "We are required to assess the patient. I would pull the patient back into triage or I would have to bring them in the back."

2) Reference #1: Facility policy titled, "Patient Rights and Responsibilities" (last reviewed June 2021) states, " ... As a patient at [name of facility], you have the following rights: ... The right to receive pain relief. The right to an appropriate assessment and management of your pain. You have a right to be educated about pain, pain relief measures, and to be included in setting goals for relieving identified pain."

Reference #2: Facility policy titled, "Emergency Department Triage Process" (last reviewed May 2024) states, " ... 3. Vital Signs: Vital signs shall include blood pressure, heart rate, temperature, pulse oximetry, respiratory rate, and pain. ... Procedure: ... 2. Upon arrival, the triage nurse will conduct a quick triage assessment consisting of a full set of vital signs and evaluation of the patient's chief complaint and focused physical assessment. ... ."

Reference #3: Facility policy titled, "Pain Management," (last reviewed December 2022) states, " ... Procedure: ... 4. If the patient complains of pain, the RN will document in the electronic medical record the assigned pain score AND conduct a detailed comprehensive pain assessment (CPA) which includes all of the following characteristics: a. Comfort/acceptable pain level[,] b. Body location[,] c. Pain rating[,] d. Frequency[,] e. Quality[,] f. Pain onset/duration[,] g. Pain management intervention[.] 5. The RN will complete a CPA with any new identified site of pain. ... "

Review of P1's medical record on 5/15/24 indicated P1 arrived to the ED on 4/29/24 with a chief complaint of abdominal pain and back pain. The triage note entered by Staff (S) 29 (Triage Nurse) at 1:17 PM states " HPI [History of Present Illness] Stated Reason for Visit: pt [patient] states right sided abd [abdominal] pain radiating to right lower/ mid back since this morning, pt reports n/v [nausea/vomiting], vomiting in the lobby, pt reports having a meal with butter yesterday, pt reports allergic to dairy, pt presents agitated and restless in triage. ..." There was no evidence of a pain assessment documented in P1's medical record.

S29 was asked why he/she did not document a pain assessment in P1's medical record. S29 stated, "We're required to document in the pain assessment portion of the chart. I'm confused why it's not there. I know that [he/she] had 10 out of 10 pain. I would have had no other reason to make [him/her] a level 2." S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, "I don't remember if anyone told me [P1] was still in pain." S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, "I don't remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient."

During a telephone interview on 5/16/24 at 12:06 PM, S30 stated, "I recall seeing the patient that day. I thought [he/she] had mild to moderate pain, but nothing emergent." S30 was asked why he/she did not document his/her assessment of P1, specifically P1's pain assessment, in the medical record. S30 stated, "I am a resident. Technically, residents don't do medical screening exams (MSEs). We do a brief history and a brief physical - just an overview. I opened the template, but I wasn't able to complete it because the patient left, so I just deleted it." There was no evidence in the medical record S30 performed a pain assessment for P1.

On 5/16/24 at 11:14 AM, an interview was conducted with S32 in the presence of S4. S32 confirmed that on 4/29/24, he/she was returning to Triage Room 2 and saw P1 lying on the floor in a fetal position. S32 stated, "I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed." S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, "I remember telling either [S30] or the attending that the patient was laying on the floor. They said the plan was to get the patient back shortly." S32 was asked why he/she didn't assess P1 to make sure he/she was okay. S32 stated, "I saw the patient, but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room."

Review of Patient (P)20's medical record on 5/15/2024 revealed that on 2/3/2024 at 1:32 PM, P20 arrived at the Emergency Department (ED) via EMS (Emergency Medical Services) with a chief complaint of "Abdominal Pain." The patient was triaged at 1:33 PM. Vital signs were obtained which included temperature, heart rate, respiratory rate, blood pressure, pulse oximetry, and height and weight. At 1:58 PM, an RN documented, "No available beds in ED, VSS [Vital Signs Stable], pt [patient] sent to WR [Waiting Room] in WC [wheelchair]." At 3:30 PM, documentation states, "Triage call 3x [three times]." ED disposition set to Left Without Treatment After RN Triage at 3:31 PM. There was no evidence of a pain assessment documented in P20's medical record.

These findings were reviewed with and confirmed by S1 (Regulatory Coordinator) on 5/16/2024 at 11:17 AM.

Based on observation of Emergency Department video footage, staff interviews, review of the medical record of P1, and review of facility documents, it was determined the facility failed to ensure patients in the ED waiting area are reassessed after a change in their condition, as indicated in the facility's ED policy (A1104).

Cross Reference:

482.55(a): Emergency Services - Policies and Procedures

Based on observation of video footage of the ED waiting area, staff interview, review of the medical record of P1, and review of ED policy and procedure, it was determined the facility failed to ensure patients in the ED waiting area are kept safe, by reassessing their clinical status after a change in their condition.

Findings include:

Reference: Facility policy titled, "Emergency Department Triage Process" (last reviewed 5/2024) states, " ... Policy: ... 4. Reassessment of the patient in the ED lobby is dependent upon the patient acuity level, and or change in patient condition. ... Procedure: ... If a patient or visitor waiting in the ED lobby notifies the registration and/or security staff of ... uncontrolled pain ... or a reported significant concern about another patient's condition, the registrar and/or security staff will inform the triage nurse."

On 5/15/24 at 1:35 PM, review of video footage from the ED waiting room on 4/29/24 was conducted in the presence of Staff (S)1 (Regulatory Coordinator), S2 (Associate Chief Nurse), S3 (VP of Operations), S4 (AVP Quality, Safety, and Accreditation), S5 (ED Nurse Manager), and S28 (Assistant Chief Medical Officer). The video footage revealed the following:

At 1:09 PM, P1 entered the ED with a family member and walked up to the ED registration counter. While the family member spoke to S31 (Registrar), P1 leaned over the registration desk and placed his/her head on his/her arm. P1 was grimacing as if uncomfortable.

At 1:11 PM, a staff member brought P1 a wheelchair and blanket.

At 1:13 PM, P1's family member wheeled P1 away from the registration desk and into the ED waiting area.

At 1:15 PM, P1 was observed "heaving" into a blue bag as if he/she was going to vomit.

At 1:18 PM, P1 leaned forward in the wheelchair and held his/her head in his/her hands.

At 1:19 PM, P1 leaned back in the wheelchair and began grimacing, as if he/she was uncomfortable.

At 1:21 PM, P1 began "heaving" into the blue bag. The family member then begins wheeling P1 into Triage Room 1.

At 1:27 PM, P1 exits Triage Room 1 with his/her family member, S29 (Triage Nurse) and S30 (Medical Resident), then enters Triage Room 2.

At 1:32 PM, P1 exits Triage Room 2 and is wheeled back into the ED waiting area. P1's family member is with him/her.

At 1:36 PM, P1 begins "heaving" into the blue bag.

At 1:38 PM, P1 begins looking around and grimacing as if uncomfortable.

At 1:40 PM, P1 is sitting in the wheelchair with his/her head in his/her hands. P1's family member goes over to the registration desk and begins speaking with S31. S31 then goes into Triage Room 1. S31 exits Triage Room 1, speaks to the family member, then walks behind the registration desk. The family member returns to the ED waiting area.

At 1:45 PM, the family member again walks toward the registration desk and is speaking to S31. S31 remains behind the registration desk.

At 1:46 PM, P1 stands up from the wheelchair, walks toward the registration desk while "hunched over," then lays on the floor in a corner between the side of the registration desk and Triage Room 1. P1 is lying in a fetal position.

At 1:47 PM, P1's family member is speaking with S31 and S31 is looking in the direction of where P1 is lying on the floor.

At 1:48 PM, P1's family member knocks on the door of Triage Room 1. The door opens and S33 (Patient Care Technician) is partially present in the doorway conversing with P1's family member. S33 does not come out of Triage Room 1 nor engage with the patient, who continues to lie on the floor in a fetal position.

At 1:49 PM, P1's family member crouches down to speak with P1 while talking on a cellphone.

At 1:52 PM, S32 (Physician's Assistant) exits Triage Room 2, enters the ED waiting area (and is briefly out of the camera's view), then returns to Triage Room 2. S32 does not have any interaction with the patient, who continues to lie on the floor in a fetal position.

At 1:53 PM, P1's family member exits the ED while talking on his/her cellphone.

At 1:55 PM, P1's family member returns to the ED, then walks over to P1 and assists him/her to his/her feet. Both P1 and the family member walk out of the ED.

At 2:20 PM, S1, S2, S3, S4, S5, and S28 confirmed that P1 laid on the floor of the ED in a fetal position for nine minutes without having a clinical staff member re-assess his/her condition.

Upon interview at 2:31 PM, S5 was asked what the expectation was, of the registrar, when a patient has a change in their condition while waiting in the ED waiting area. S5 stated, "The expectation is that the registrar notifies a clinical person, like the triage nurse." S5 was then asked what the expectation was, of the clinical person, when they are informed of a patient's change in condition. S5 stated, "The expectation is that they respond."

An interview was conducted with S31 at 3:06 PM, in the presence of S1. S31 stated he/she remembered when P1 arrived to the ED on 4/29/24. S31 stated, "The patient came in with abdominal pain and back pain. I remember [P1's family member] was upset that [P1] was not being seen as soon as possible. [He/she] was being rude and said [P1] was here a long time and needs to be seen. [He/she] was going to go somewhere else and called an ambulance. [He/she] was not having it." S31 was asked if he/she notified anyone about P1. S31 stated, "I told the triage nurse." When asked the name of the triage nurse he/she notified about P1, S31 stated, "I don't remember who I spoke with." S31 was asked what he/she told the triage nurse. S31 stated, "I told [him/her] that [P1] was in a lot of pain and the [family member] was upset. I told the triage nurse that [P1] was laying on the floor. They said the patient was triaged already and that the patient would have to wait for a bed." S31 then stated, "I told my supervisor also that the patient was laying on the floor. My supervisor asked me if I told triage and I said yes." When asked, S31 denied receiving training on what to do for patient emergencies when a patient is in the ED waiting area. Upon review of S31's education file it was determined that S31 received training on how to notify licensed personnel [nurses, doctors, technicians] if a medical emergency takes places, but because S31 is not licensed personnel he/she does not receive hands on training in responding to medical emergencies.

On 5/16/24 at 11:14 AM, an interview was conducted with S32 (Physician's Assistant) in the presence of S4. S32 confirmed that when he/she was returning to Triage Room 2, he/she saw P1 lying on the floor in the fetal position. S32 stated, "I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed." S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, "I remember telling either [S30] or the attending, that the patient was laying on the floor. They said the plan was to get the patient back shortly." S32 was asked why he/she didn't assess P1 to make sure he/she was okay. S32 stated, "I saw the patient, but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room." When asked when he/she was told this information about the patient, S32 indicated that he/she remembers being told the patient was angry but could not recall when he/she was told that information.

At 11:27 AM, S32 stated that when a patient sitting in the ED waiting area has a change in their condition, he/she was trained to "let the charge nurse and attending (physician) know." S32 confirmed he/she did not notify the charge nurse that P1 was lying on the floor in the fetal position. When asked, S32 stated he/she "did not recall" if he/she notified the medical resident or the attending physician that P1 was lying on the floor.

A telephone interview with S30 was conducted at 12:06 PM, in the presence of S28. S30 was asked if he/she was made aware that P1 was lying on the floor of the ED waiting area in a fetal position. S30 stated, "No. I don't recall that. It doesn't sound familiar."

Upon interview at 12:29 PM, S18 (ED Attending Physician) stated that if a patient in the ED waiting room has a change in their clinical status, the charge nurse and the attending "should be notified." S18 stated the patient would then be "immediately brought back into the ED." S18 was asked if he/she was made aware that on 4/29/24, P1 was lying on the floor in the ED waiting area in a fetal position. S18 stated, "I was not aware that [P1] was lying on the floor."

A telephone interview was conducted with S29 (Triage Nurse) at 2:04 PM, in the presence of S1. S29 stated he/she remembered P1 coming to the ED on 4/29/24. S29 stated P1 came into the ED with "10 out of 10 abdominal pain" and "looked super uncomfortable." S29 stated, "We didn't have any beds that day. We were jamb packed in the back. I say the same thing to all my patients that I have to put back in the waiting room - if anything changes let me know." S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, "I don't remember if anyone told me [P1] was still in pain." S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, "I don't remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient." S29 was asked what he/she is required to do if there is a change in the patient's condition while they are in the ED waiting area. S29 stated, "We are required to assess the patient. I would pull the patient back into triage or I would have to bring them in the back."