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TMC- BONHAM HOSPITAL
No Description Available
Tag No.: C0270
Based on observation, interview and record review the facility failed to:
A. ensure a patient in need of emergency medical care received a thorough assessment and timely interventions.
The facility failed to ensure medical care was provided timely after a patient had a change in condition which subsequently resulted in patient death in 1 (Patient #6) of 5 patients reviewed.
The facility failed to ensure 4 of 5 patients reviewed, received thorough assessments, timely interventions and medical care while in need of emergency services (Patient #s 23, 24, 46 and 48).
Refer to tag C0284 for additional information.
B. ensure nursing provided emergency services, thorough and on-going assessments, discharge assessments/instructions and timely interventions in 3 of 3 patients (Patient #6, 23 and 48).
Refer to tag C0295 for additional information.
It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and the likelihood of serious harm, injury, impairment, or death
to all patients receiving care at this hospital.
32143
No Description Available
Tag No.: C0284
Based on interview and record review the facility failed to ensure a patient in need of emergency medical care received a thorough assessments and timely interventions.
The facility failed to ensure medical care was provided timely after a patient had a change in condition resulting in patient death in 1(Patient #6) of 5 patients reviewed.
The facility failed to ensure 4 of 5 patients reviewed, received thorough assessments, timely interventions and medical care while in need of emergency services (Patient #s 23, 24, 46 and 48).
It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and had the likelihood to cause serious harm, injury, impairment, or death for all patients presenting to the ED of this hospital.
Findings include:
Review of an ED visit record dated 08/20/2014 revealed that Patient #6 was a 64 year old female who presented to the ED at 12:29 p.m.
At 12:37 p.m., Staff nurse #8 documented Patient #6 had a chief complaint of respiratory problem and the triage level was classified as urgent (meaning she should be placed in to an appropriate ED treatment room so that emergency measures can be initiated immediately). The following vital signs were documented: 103 (heart rate), 117/93 (blood pressure), 97.5 (temperature), 22 (respirations), and oxygen saturation was 92 percent on oxygen at 2 liters per nasal cannula. There was no documentation of an assessment of what the oxygen saturation was prior to oxygen administration. According to the ED record, the provider (physician) arrival time was 12:37 p.m.
Review of a "ED Respiratory" assessment completed by Staff nurse #8 at 12:42 p.m. revealed that Patient #6 breathing was labored, tachnypenic (more than 20 per minute), dyspneic (difficulty breathing) with activity, had clear lung sounds that were diminished in the upper and lower lobes, and with a non-productive cough.
Review of the emergency notes revealed that at 1:01 p.m., Physician #13 documented Patient #6 had an emergency medical condition. The patient's condition was such that the patient had a medical condition requiring further emergency medical evaluation, treatment, and/or stabilization.
Review of an "ED DOC Respiratory" assessment completed by Physician #13 at 1:01 p.m. revealed that he had reviewed the nursing assessment and agreed. His respiratory assessment revealed breath sounds were normal. Physician #13 documented that Patient #6 was in respiratory distress, splinting and using accessory muscle. Underneath the progress notes section, Physician #13 documented no wheezing heard, duoneb given and feels better, though breath sounds are unchanged, pulse oximetry in low 90/s with or w/o (without) oxygen or duoneb. The clinical impression was COPD (chronic obstructive pulmonary disease) and anxiety. The plan was to discharge patient home with prescriptions of Z-pak (antibiotic), Ativan (anti- anxiety agent) and Albuterol (bronchial dilator).
Review of vital signs dated 08/20/2014 at 1:26 p.m., revealed Patient #6 had an elevated heart rate of 108, blood pressure 112/83, temperature 97.9, respiration rate 20, and oxygen saturation of 96 percent on oxygen 2 liters per nasal cannula.
Review of a hospital note revealed Patient #6 was discharged home at 2:00 p.m.
There was no documentation of an assessment of the patient's respiratory status at the time of discharge. There was no documentation of staff obtaining lab on Patient #6 during the ED visit. There was no documentation of the patient's oxygen saturation being stable on room air prior to discharge. Discharge records revealed no documentation of the Patient #6 being discharged on oxygen or if the patient understood discharge instructions.
During an interview on 09/08/2014 at 1:26 p.m., Staff #2 confirmed the missing assessments and there being no documentation of the patient being sent home on oxygen.
During an interview on 09/08/2014 at 8:23 p.m., Physician #13 reported on admit of a patient, with respiratory problems/distress who did not have a pulse oximetry of 100 percent on room air would receive a triage first. Then a chest x-ray and possibly laboratory tests done. Patients being discharge without oxygen would be expected to have an oxygen saturation of 90-92 percent, preferably 95 percent on room air.
Review of an ED record dated 08/23/2014 (3 days later) revealed that Patient #6 returned to the hospital at 11:17 a.m., At 11:19 a.m., Patient #6 was documented as having respiratory problems and was assessed during nursing triage to be at a level of non-urgent (meaning no resources required or lowest priority to be seen). Patient #6 had a heart rate of 89, blood pressure of 86/69, temperature of 97.5, respirations of 26, and an oxygen saturation of 92 percent on 3 liters of oxygen.
Review of a physician assessment dated 08/23/2014 at 11:21 a.m., Physician #14 deemed the patient to have an Emergency medical condition. At 11:22 a.m., Physician #14 documented that Patient #6 was seen here 2 days ago, given Z-pak (antibiotic) and Ativan(anti-anxiety), presents today by ambulance, tachypenic at 30, sats 98 % RA. No respiratory distress, regular rate and rhythm, and breath sounds normal.
Review of an ED nursing note dated 08/23/2014 at 11:50 a.m., revealed Patient #6 presented to the ED via EMS with SOB and hypoxemia (low blood oxygen). Patients oxygen saturation was 84 (percent) on room air upon admittance to ED. Patient was placed on a non-rebreather mask at 15 Liters and maintained oxygen saturation at 99 percent. Patient was seen in this ED on Wednesday and given a Z-pak. Patient stated that she "believes the Z-pak is causing her breathing issues and anxiety." EMS stated they had attempted IV access 3 times prior to arrival without success. Patient placed in bed #2.
Review of nurses notes revealed on 08/23/2014 at 12:13 p.m., Patient #6 had intravenous fluids infusing at 75 cc per hour.
Review of laboratory results completed on 08/23/2014 at 12:10 pm. revealed the following:
White blood count elevated at 25.0 with reference ranges being 4.4-11.0;
Red blood count elevated at 6.36 with reference ranges being 4.20-5.40;
Platelet count elevated at 799 with reference ranges being 150-400.
According to
At 12:26 p.m.
Glucose was elevated at 177 with reference ranges being 74-106;
Blood urea nitrogen was elevated at 39 with reference ranges being 7-18;
Creatinine elevated at 1.3 with reference ranges being 0.6-1.3;
At 1:37 p.m.
Chest x-ray showed cardiac silhouette is mildly enlarged, stable from prior study. No gross consolidation or effusion. No pneumothorax. No grossly acute findings.
At 4:08 p.m.,
The Computed tomography scan of the abdomen and pelvis revealed small to moderate amount of ascites in the abdomen or pelvis. There is cholethiasis with wall thickening of the gallbladder appeared this may be reactive secondary to ascites. Primary inflammation of the gallbladder cannot be excluded. Prior splenectomy. Large and small bowel loops are normal in caliber. Normal appendix.
Review of nurses notes dated 08/23/2014 revealed at 3:12 p.m., Patient #6's IV infiltrated. The IV was not restarted until 2 hours later at 5:04 p.m.
Review of nurse's notes at 6:37 p.m., revealed Physician #15 was paged at this time for possible admission and he did not return the call until 8:10 p.m. (over 1.5 hours later). Patient #6 was to be admitted to observation/telemetry.
Review of ED vital sign sheet revealed the last documented set of vital signs taken were at 8:53 p.m before leaving the ED. Patient #6 had a 110 heart rate, 97/69 blood pressure, 98.6 temperature, 30 respiratory rate, and oxygen saturation of 92 percent on 2 liters of oxygen.
Review of a nursing assessment (at admission on the Medical-surgical unit) at 9:25 p.m., revealed the primary diagnosis was tachypnea and the secondary diagnosis was dehydration. Patient #6 vital signs were 98.0 temperature, 99 heart rate, 30 respirations, 83/44 blood pressure and oxygen saturation of 91 percent on 3 liters of oxygen (a decline in status). The patient's skin was documented as being pale, cyanotic and cool. She was on a telemetry and had a regular rhythm. Patient #6 had pain underneath the right underarm and rib area at a pain level of 2 on a scale of 10.
Review of nurses notes timed 9:30 p.m., revealed the following documentation: "informed doctor that patient, upon transfer upstairs to her room 200, was weighed and was assisted into bed on room air, patient appeared to be struggling to breath, reapplied oxygen and patient oxygen saturation was at 91%. Stated patient appeared to be cyanotic until we reapplied oxygen. Physician #14 (ED doctor) in turn ordered a d-dimer, pt/inr and a ptt."
Review of lab results dated 08/23/2014 revealed Patient #6 had a final elevated D-Dimer result at 10:30 p.m. of 1880 with reference range being 0-500. The PTT was 35.3 (Reference range 20.6-38.6), PT 14.4 (Reference range 8.0-14.0) and INR 1.4 (Reference range 0.8-1.4).
The D-dimer blood test is a very useful laboratory test that helps doctors rule out pulmonary embolism or deep vein thrombosis (DVT) in a patient. This is not a routine blood test and is performed only during emergencies or in cases where the patient is in pain.
Review of a medication administration record revealed Patient #6 was started on Normal saline 0.9 percent intravenous fluids at 40 cc per hour at 11:27 p.m. and was given 2 Tylenol with Codeine at 11:33 p.m. (2 hours after first complaining of pain).
Review of a vital sign sheet and medication flow sheets revealed Patient #6 had the following:
At 11:41 p.m., the vital signs were 99.5 temperature, 105 heart rate, 30 respiratory rate, 89/67 blood pressure and pain level of 5 and oxygen saturation of 90 percent on 3 liters of oxygen. There was no documentation of what was done about the dropping oxygen saturation.
Review of an anticoagulant flow sheet dated 08/24/2014 at 12:40 a.m., revealed Patient #6 was given a 4000 unit bolus of the anti-coagulant Heparin and started on a Heparin drip at 9 milliliters per hour for a PTT result of 35.3. This intervention was provided 3 hours after the documented change in condition and 2 hours after receipt of the lab results.
At 3:58 a.m., the monitor tech documented Patient #6 was in "sinus rhythm with decreased ST at 100"
At 4:23 a.m. (over 4 hours later after the change in condition) there was nursing documentation of a 96.0 temperature, 108 heart rate, 30 respiratory rate, 90/64 blood pressure and the oxygen saturation had dropped to 80 percent on 3 liters of oxygen. There was no documentation of what intervention was taken after this further decline in the patient's status.
Over an hour later the following was documented:
At 5:29 a.m., the monitor tech documented Patient #6 had a rhythm change: sinus rhythm with BBB (bundle branch block), primary atrioventricular block (nurse was notified).
At 5:31 a.m., the monitor tech documented Patient #6 was in BBB to V-tach (ventricular tachycardia). The tech made another entry that the nurse was called and informed patient was in V-tach and dying.
At 5:31 a.m., Physician #15 was called by the nurse and informed patient vital signs were "95.8, 108, 40, 11/49, 83 to 85 percent on 3L/m via n/c. Patient is mouth breathing, encouraged to breath through her nose and slow her resp. Dr. (Physician #15) said he would be here shortly."
At 5:33 a.m., the monitor tech documented calling an ER nurse to tell him the patient was dying.
Review of a "Code Blue Record" at 5:40 a.m. revealed Physician #14 (ER) doctor initiated the code and was in charge. Review of attached notes revealed Physician #14 documented at 6:00 a.m. he was called to see patient in acute cardiopulmonary arrest, by report, sudden onset. Upon arrival patient was not responsive, no pulse, no spontaneous responsive effort. CPR was initiated immediately. Patient was intubated and oxygenation/chest compressions and CPR meds were administered per CPR protocol. After 35 minutes, with no response, CPR was stopped, no pulse, no spontaneous respiratory effort.. Documentation on the "Code Blue Record" revealed Patient #6's time of death was 6:07a.m.
During an interview on 09/08/2014 after 12:55 p.m., Staff #2 revealed Patient #6's chart was under extra security because of issues with the family. Staff #2 confirmed Physician #15's delay in return call to nursing staff and nursing staff delay in treatment after Patient #6 had a change in condition at 4:23 a.m.. Staff #2 confirmed she could not find documentation of the nurse's response in the record.
During an interview on 09/08/2014 after 1:10 p.m., Staff #1 and #2 was asked questions about Patient #6's care and what happened on the floor. Staff #1 and #2 reported the chart was going through internal and external review. They had not completed their investigation yet. Because of the clinical nature they could not comment. No specific information could be shared with the surveyor.
During an interview on 09/11/2014 at 11:50 a.m., Physician #14 reported Patient #6 was kept in the ED a long time because it took a while to get the computed tomography results. Physician #14 reported he went to the floor to check the patient because Physician #15 called him. Physician #15 told him the nurse from the floor (medical surgical unit) had called him and said Patient #6 was hypoxic and tachycardic. Physician #14 confirmed when he got to the floor Patient #6 had already passed and he assisted with the code. Physician #14 reported a lot of the documentation he made on Patient #6 during her stay in the electronic record was missing. Physician #14 reported the information he was provided by the medical director was that Patient #6 died as a result of a pulmonary embolism.
Review of an ED visit record revealed Patient #48 was an 82 year old female, who presented to the ED on 09/02/2014 at 3:14 p.m. with a diagnosis of lower extremity pain. According to the notes the patient was triaged by nursing at 3:15 p.m. and was classified as being Non-Urgent (meaning no resources required or lowest priority to be seen) and possibly having a DVT. There was documentation that Patient #48 had a history of hypertension, heart failure and recent left shoulder surgery. Patient #48 was placed on oxygen 2 liters per nasal cannula and her oxygen saturation was 99 percent and the patient's heart rate was 68 and blood pressure was 119/74. There was no documentation of what the oxygen saturation was on room air prior to administration of oxygen. The physician was at the bedside with the nurse when peripheral pulses were assessed according to nursing documentation at 4:08 p.m...
Review of physician notes revealed documentation at 4:32 p.m. that Patient #48 had an Emergency Medical Condition and his assessment was timed at 4:35 pm, over an hour after Patient #48 presented to the ED. The physician documented Patient #48 had PVD bilaterally, homans negative bilaterally (test used to check for blood clots in the legs). Need to rule out UTI and other pathology, awaiting lab etc., CBC abnormal, leukocytosis, and d-dimer increase. Need IV a/b (antibiotic) and admit for observation.
Review of nurses notes revealed an IV was inserted at 5:38 p.m., over two hours after presenting to the ED.
Review of some of the lab results timed 5:47 p.m. revealed the following:
D-Dimer result >5000 with reference ranges being 0-500;
Potassium of 5.4 with reference ranges being 3.5-5.1;
Carbon dioxide of 33.3 with reference ranges being 21.0-32.0;
Blood urea nitrogen of 38 with reference ranges being 7-18;
White blood count of 18.1 with reference ranges being 4.4-11.0;
Red blood count of 3.16 with reference ranges being 4.20-5.40;
Hemoglobin of 9.6 with reference ranges being 12.0-16.0;
Hematocrit of 29.1 with reference ranges being 36-48.0
According to ED notes at 6:15 p.m., Patient #48 was discharged from the ED to observation/medical surgical.
At 6:18 p.m. a dose of the anticoagulant Lovenox was administered after 3 hours of presenting to the ED. There was no documentation of any antibiotics being started while in the ED.
At 7:15 p.m... Patient #48 had a decrease in vital signs of a heart rate of 60, blood pressure of 99/31, and oxygen saturation of 91 percent on 3 liters of oxygen. There was no documentation of what interventions that were taken.
Review of nursing notes at 7:30 p.m. revealed Patient #48's was transported to the 2nd floor (Med-Surgical floor).
Review of vital reports revealed Patient #48 was on oxygen from 09/02-04/2014 and the flow rate ranged from 2 -3.5 liters per nasal cannula. On 09/04/2014 at 3:00 p.m. Patient #48 was on oxygen 3 liters per nasal cannula and had an oxygen saturation of 98 percent.
Review of the chart revealed an order to be discharged on 09/04/2014 at 4:28 p.m. The discharge instructions were to discharge to a nursing home and listed medications. There was no documentation from nursing notes or discharge instructions to determine if Patient #48 was discharged on oxygen and what her oxygen saturation was on room air during her hospital stay.
During an interview on 09/09/2014 after 1:00 p.m., Staff #2 confirmed the time on the physician assessment and the lack of assessment.
Review of an ED visit record revealed Patient #24 was a 34 year old male who presented to the ED on 09/03/2014 at 10:06 p.m. with extremity pain/trauma. A triage assessment was performed at 10:21 p.m. and Patient #24 was classified as being semi-urgent (meaning the patient should be placed into an appropriate ED treatment room so that emergency measures could be initiated immediately). At 10:35 p.m. the physician arrived to the bedside according to nursing documentation. At 10:36 p.m. nursing documented Patient #24 had a large hematoma to the left leg, the temperature of the limb was warm and there was a pain level of 8. At 10:47 p.m. nursing documented after discussing plan of care, patient stated he didn't want x-ray or pain medication, patient states he will check out AMA.
There was no documentation on the record the physician provided a medical screening on Patient #24 when he arrived at 10:35 p.m.
Review of an ED record revealed Patient #23 was an 88 year old female who presented to the ED on 09/04/2014 at 10:26 a.m., with medical problems undefined. A triage assessment was performed at 10:47 a.m. and nursing classified the patient as being Urgent (meaning the patient should be placed intointo an appropriate ED treatment room so that emergency measures could be initiated immediately). According to the ED record the physician arrived at the bedside at 10:47 a.m. The physician documented at 12:17 p.m. (over an hour later) a medical screening was performed and Patient #23 was considered to have an emergency medical condition. The physician assessment was documented at 12:19 p.m. According to a clinical impression on the physician assessment Patient #23 had a dorsal/limb pain/muscle strain, early pneumonia. There was documentation underneath the plan which read follow-up condition improved, no physician consult, and discharge home. Prescription was Valium 5 milligrams, ½ to 1 tab po (by mouth) every HS (night) #8, Z pak. This documentation was on the same assessment timed for 12:19 p.m. There was no indication as to what time the physician wrote the plan.
The last documented set of vital signs from nursing was at 4:40 p.m.
Review of the ED disposition revealed Patient #23 was discharged home or self-care (routine discharge) at 5:00 p.m. There was no nursing assessment prior to discharge, nor an explanation of medications to be taken at home. There was no documentation of discharge instructions explained and patient acknowledgement of understanding the instructions.
Review of an ED visit record revealed Patient #46 was a 69 year old male who presented to the ED on 09/07/2014 at 4:24 p.m. with a chief complaint of cardiovascular problem. The nursing triage assessment was performed at 4:30 p.m. and Patient #46 was classified as being Urgent (meaning the patient should be placed into an appropriate ED treatment room so that emergency measures could be initiated immediately).
There was documentation the physician (provider) arrived at 4:30 p.m. At 5:49 p.m. over an hour after presenting to the ED there was documentation of a physician assessment. There was no documentation of the existence of an emergency medical condition nor when the medical screening was done by the physician.
Review of the record revealed Patient #46 was admitted to the floor at 7:30 p.m.
During an observation on 09/09/2014 at 10:25 a.m., Patient #46 was observed as an inpatient in ICU and receiving blood.
During an interview on 09/09/2014 after 1:00 p.m., Staff #2 confirmed the physician failed to document Patient #46 had an emergency medical condition.
Review of an undated "Emergency Department Protocol" revealed the following were to be used when the ED Doctor was expected to take more than 20 minutes to get the patient.
SOB
Asthma/Wheezing & Pulse Ox>93 %
Oxygen NC @ 2-4 LPM
Pulse Oximetry & Monitor
Pedi or Adult RT Protocol, or
Albuterol UD with Atrovent 500 mcg Neb.
With Pulse Ox <94 or distress,
CBC, CMP, BNP
P. (portable) CXR, EKG, Saline lock
D-Dimer if Well's criteria>2.5 points
With Fever & Cough, Possible Pneumonia add:
Blood Culture X 2, Sputum C & S
Review of policy named "EMTALA Medical Screening Exam and Stabilizing Treatment" dated 08/2014 revealed the following:
An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred.
Review of an emergency department policy named "Discharge Assessment/Teaching dated 11/2007 revealed the following:
3.1 Each patient will be assessed by the physician provider for readiness to discharge.
3.4 Discharged patients will receive written discharge instructions, in a form the individual can understand, which will include at least the following:
3.4.1 Assessment of learning needs concerning discharge medications.
3.4.4 Specific treatment procedures
3.5 Nursing staff will complete a brief discharge assessment including a note on patient status and discharge vital signs.
3.6 The nurse will record the patient's understanding of instructions on the ER record.
No Description Available
Tag No.: C0295
Based on observation, interview and record review, the facility failed to ensure nursing staff provided thorough and ongoing assessments, discharge assessments/instructions and timely interventions in 3 of 3 patients (Patient #6, 23 and 48).
It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and had the likelihood of serious harm, injury, impairment, or death for all patients presenting to the ED of this hospital.
Findings include:
Review of an ED visit record dated 08/20/2014 revealed Patient #6 was a 64 year old female who presented to the ED at 12:29 p.m.
At 12:37 p.m., Staff nurse #8 documented Patient #6 had a chief complaint of respiratory problem and the triage level was classified as urgent (meaning she should be placed in to an appropriate ED treatment room so that emergency measures can be initiated immediately). The following vital signs were documented: 103 (heart rate), 117/93 (blood pressure), 97.5 (temperature), 22 (respirations), and oxygen saturation was 92 percent on oxygen at 2 liters per nasal cannula. There was no documentation of an assessment of what the oxygen saturation was prior to oxygen administration. According to the ED record, the provider (physician) arrival time was 12:37 p.m.
Review of a "ED Respiratory" assessment completed by Staff nurse #8 at 12:42 p.m. revealed Patient #6 breathing was labored, tachnypenic (more than 20 per minute), dyspneic (difficulty breathing) with activity, had clear lung sounds that were diminished in the upper and lower lobes, and with a non-productive cough.
Review of the emergency notes revealed at 1:01 p.m., Physician #13 documented Patient #6 had an emergency medical condition. The patient's condition was such that the patient had an emergency medical condition requiring further emergency medical evaluation, treatment, and/or stabilization.
Review of an "ED DOC Respiratory" assessment completed by Physician #13 at 1:01 p.m. revealed he had reviewed the nursing assessment and agreed. His respiratory assessment revealed breath sounds were normal. Physician #13 documented that Patient #6 was in respiratory distress, splinting and using accessory muscle. Underneath the progress notes section Physician #13 documented no wheezing heard, duoneb given and feels better, though breath sounds are unchanged, pulse ox in low 90/s with or w/o (without) oxygen or duoneb. The clinical impression was COPD (chronic obstructive pulmonary disease) and anxiety. The plan was to discharge patient home with prescriptions of Z-pak (antibiotic), Ativan (anti- anxiety agent) and Albuterol (bronchial dilator).
Review of vital signs dated 08/20/2014 at 1:26 p.m., revealed Patient #6 had an elevated heart rate of 108, blood pressure 112/83, temperature 97.9, respiration rate 20, and oxygen saturation of 96 percent on oxygen 2 liters per nasal cannula.
Review of a hospital note revealed Patient #6 was discharged home at 2:00 p.m.
There was no documentation of an assessment of the patient's respiratory status at the time of discharge. There was no documentation of staff obtaining lab on Patient #6 during the ED visit. There was no documentation of the patient's oxygen saturation being stable on room air prior to discharge. Discharge records revealed no documentation of the Patient #6 being discharged on oxygen or if the patient understood discharge instructions.
During an interview on 09/08/2014 at 1:26 p.m., Staff #2 confirmed the missing assessments and there being no documentation of the patient being sent home on oxygen.
During an interview on 09/08/2014 at 8:23 p.m., Physician #13 reported on admit of a patient, with respiratory problems/distress who did not have a pulse oximetry of 100 percent on room air would receive a triage first. Then a chest x-ray and possibly lab done. Patients being discharge without oxygen would be expected to have an oxygen saturation of 90-92 percent, preferably 95 percent on room air.
Review of an ED vital record dated 08/23/2014 (3 days later) revealed Patient #6 returned to the hospital at 11:17 a.m., At 11:19 a.m. , Patient #6 was documented as having respiratory problems and was assessed during nursing triage to be at a level of non-urgent ( meaning no resources required or lowest priority to be seen). Patient #6 had a heart rate of 89, blood pressure of 86/69, temperature of 97.5, respirations of 26, and an oxygen saturation of 92 percent on 3 liters of oxygen.
Review of a physician assessment dated 08/23/2014 at 11:21 a.m. Physician #14 deemed the patient to have an Emergency medical condition. At 11:22 a.m., Physician #14 documented that Patient #6 was seen here 2 days ago, given Z-pak (antibiotic) and Ativan(anti-anxiety), presents today by ambulance, tachypenic at 30, sats 98 % RA. No respiratory distress, regular rate and rhythm, and breath sounds normal.
Review of an ED nursing note dated 08/23/2014 at 11:50 a.m., revealed that Patient #6 presented to the ED via EMS with SOB and hypoxemia (low blood oxygen). Patient's oxygen saturation was 84 (percent) on room air upon admittance to ED. Patient was placed on a non-rebreather mask at 15 Liters and maintained oxygen saturation at 99 percent. Patient was seen in this ED on Wednesday and given a Z-pak. Patient stated that she "believes the Z-pak is causing her breathing issues and anxiety." EMS stated they had attempted IV access 3 times prior to arrival without success. Patient placed in bed #2.
Review of nurses notes revealed on 08/23/2014 at 12:13 p.m., Patient #6 had intravenous fluids infusing at 75 cc per hour.
Review of lab results completed on 08/23/2014 at 12:10 pm. revealed the following:
White blood count elevated at 25.0 with reference ranges being 4.4-11.0;
Red blood count elevated at 6.36 with reference ranges being 4.20-5.40;
Platelet count elevated at 799 with reference ranges being 150-400.
According to
At 12:26 p.m.
Glucose was elevated at 177 with reference ranges being 74-106;
Blood urea nitrogen was elevated at 39 with reference ranges being 7-18;
Creatinine elevated at 1.3 with reference ranges being 0.6-1.3;
At 1:37 p.m.
Chest x-ray showed cardiac silhouette is mildly enlarged, stable from prior study. No gross consolidation or effusion. No pneumothorax. No grossly acute findings.
At 4:08 p.m.,
The Computed tomography scan of the abdomen and pelvis revealed small to moderate amount of ascites in the abdomen or pelvis. There is cholethiasis with wall thickening of the gallbladder appeared this may be reactive secondary to ascites. Primary inflammation of the gallbladder cannot be excluded. Prior splenectomy. Large and small bowel loops are normal in caliber. Normal appendix.
Review of nurses notes dated 08/23/2014 revealed at 3:12 p.m., Patient #6's IV infiltrated. The IV was not restarted until 2 hours later at 5:04 p.m.
Review of nurse's notes at 6:37 p.m., revealed Physician #15 was paged at this time for possible admission and he did not return the call until 8:10 p.m. (over 1.5 hours later). Patient #6 was to be admitted to observation/telemetry.
Review of ED vital sign sheet revealed the last documented set of vital signs taken were at 8:53 p.m before leaving the ED. Patient #6 had a 110 heart rate, 97/69 blood pressure, 98.6 temperature, 30 respiratory rate, and oxygen saturation of 92 percent on 2 liters of oxygen.
Review of a nursing assessment (at admission on the Medical-surgical unit) at 9:25 p.m., revealed the primary diagnosis was tachypnea and the secondary diagnosis was dehydration. Patient #6 vital signs were 98.0 temperature, 99 heart rate, 30 respirations, 83/44 blood pressure and oxygen saturation of 91 percent on 3 liters of oxygen (a decline in status). The patient's skin was documented as being pale, cyanotic and cool. She was on a telemetry and had a regular rhythm. Patient #6 had pain underneath the right underarm and rib area at a pain level of 2 on a scale of 10.
Review of nurses notes timed 9:30 p.m., revealed the following documentation: "informed doctor that patient, upon transfer upstairs to her room 200, was weighed and was assisted into bed on room air, patient appeared to be struggling to breath, reapplied oxygen and patient oxygen saturation was at 91%. Stated patient appeared to be cyanotic until we reapplied oxygen. Physician #14 (ED doctor) in turn ordered a d-dimer, pt/inr and a ptt."
Review of lab results dated 08/23/2014 revealed Patient #6 had a final elevated D-Dimer result at 10:30 p.m. of 1880 with reference range being 0-500. The PTT was 35.3 (Reference range 20.6-38.6), PT 14.4 (Reference range 8.0-14.0) and INR 1.4 (Reference range 0.8-1.4).
The D-dimer blood test is a very useful laboratory test that helps doctors rule out pulmonary embolism or deep vein thrombosis (DVT) in a patient. This is not a routine blood test and is performed only during emergencies or in cases where the patient is in pain.
Review of a medication administration record revealed Patient #6 was started on Normal saline 0.9 percent intravenous fluids at 40 cc per hour at 11:27 p.m. and was given 2 Tylenol with Codeine at 11:33 p.m. (2 hours after first complaining of pain).
Review of a vital sign sheet and medication flow sheets revealed Patient #6 had the following:
At 11:41 p.m., the vital signs were 99.5 temperature, 105 heart rate, 30 respiratory rate, 89/67 blood pressure and pain level of 5 and oxygen saturation of 90 percent on 3 liters of oxygen. There was no documentation of what was done about the dropping oxygen saturation.
Review of an anticoagulant flow sheet dated 08/24/2014 at 12:40 a.m., revealed Patient #6 was given a 4000 unit bolus of the anti-coagulant Heparin and started on a Heparin drip at 9 milliliters per hour for a PTT result of 35.3. This intervention was provided 3 hours after the documented change in condition and 2 hours after receipt of the lab results.
At 3:58 a.m., the monitor tech documented Patient #6 was in "sinus rhythm with decreased ST at 100"
At 4:23 a.m. (over 4 hours later after the change in condition) there was nursing documentation of a 96.0 temperature, 108 heart rate, 30 respiratory rate, 90/64 blood pressure and the oxygen saturation had dropped to 80 percent on 3 liters of oxygen. There was no documentation of what intervention was taken after this further decline in the patient's status.
Over an hour later the following was documented:
At 5:29 a.m., the monitor tech documented Patient #6 had a rhythm change: sinus rhythm with BBB (bundle branch block), primary atrioventricular block (nurse was notified).
At 5:31 a.m., the monitor tech documented Patient #6 was in BBB to V-tach (ventricular tachycardia). The tech made another entry that the nurse was called and informed patient was in V-tach and dying.
At 5:31 a.m., Physician #15 was called by the nurse and informed patient vital signs were "95.8, 108, 40, 11/49, 83 to 85 percent on 3L/m via n/c. Patient is mouth breathing, encouraged to breath through her nose and slow her resp. Dr.(Physician #15) said he would be here shortly."
At 5:33 a.m., the monitor tech documented calling an ER nurse to tell him the patient was dying.
Review of a "Code Blue Record" at 5:40 a.m. revealed Physician #14 (ER) doctor initiated the code and was in charge. Review of attached notes revealed Physician #14 documented at 6:00 a.m. he was called to see patient in acute cardiopulmonary arrest, by report, sudden onset. Upon arrival patient was not responsive, no pulse, no spontaneous responsive effort. CPR was initiated immediately. Patient was intubated and oxygenation/chest compressions and CPR meds were administered per CPR protocol. After 35 minutes, with no response, CPR was stopped, no pulse, no spontaneous respiratory effort.. Documentation on the "Code Blue Record" revealed Patient #6's time of death was 6:07a.m.
During an interview on 09/08/2014 after 12:55 p.m., Staff #2 revealed Patient #6's chart was under extra security because of issues with the family. Staff #2 confirmed Physician #15's delay in return call to nursing staff and nursing staff delay in treatment after Patient #6 had a change in condition at 4:23 a.m.. Staff #2 confirmed she could not find documentation of the nurse's response in the record.
During an interview on 09/08/2014 after 1:10 p.m., Staff #1 and #2 was asked questions about Patient #6's care and what happened on the floor. Staff #1 and #2 reported the chart was going through internal and external review. They had not completed their investigation yet. Because of the clinical nature they could not comment. No specific information could be shared with the surveyor.
During an interview on 09/11/2014 at 11:50 a.m., Physician #14 reported Patient #6 was kept in the ED a long time because it took a while to get the computed tomography results. Physician #14 reported he went to the floor to check the patient because Physician #15 called him. Physician #15 told him the nurse from the floor (medical surgical unit) had called him and said Patient #6 was hypoxic and tachycardic. Physician #14 confirmed when he got to the floor Patient #6 had already passed and he assisted with the code. Physician #14 reported a lot of the documentation he made on Patient #6 during her stay in the electronic record was missing. Physician #14 reported the information he was provided by the medical director was that Patient #6 died as a result of a pulmonary embolism.
Review of an ED visit record revealed Patient #48 was an 82 year old female who presented to the ED on 09/02/2014 at 3:14 p.m. with a diagnosis of lower extremity pain. According to the notes the patient was triaged by nursing at 3:15 p.m. and was classified as being Non-Urgent (meaning no resources required or lowest priority to be seen) and possibly having a DVT. There was documentation that Patient #48 had a history of hypertension, heart failure and recent left shoulder surgery. Patient #48 was placed on oxygen 2 liters per nasal cannula and her oxygen saturation was 99 percent and the patient's heart rate was 68 and blood pressure was 119/74. There was no documentation of what the oxygen saturation was on room air prior to administration of oxygen. The physician was at the bedside with the nurse when peripheral pulses were assessed according to nursing documentation at 4:08 p.m...
Review of physician notes revealed documentation at 4:32 p.m. that Patient #48 had an Emergency Medical Condition and his assessment was timed at 4:35 pm, over an hour after Patient #48 presented to the ED. The physician documented Patient #48 had PVD bilaterally, homans negative bilaterally (test used to check for blood clots in the legs). Need to rule out UTI and other pathology, awaiting lab etc., CBC abnormal, leukocytosis, and d-dimer increase. Need IV a/b (antibiotic) and admit for observation.
Review of nurses notes revealed an IV was inserted at 5:38 p.m., over two hours after presenting to the ED.
Review of some of the lab results timed 5:47 p.m. revealed the following:
D-Dimer result >5000 with reference ranges being 0-500;
Potassium of 5.4 with reference ranges being 3.5-5.1;
Carbon dioxide of 33.3 with reference ranges being 21.0-32.0;
Blood urea nitrogen of 38 with reference ranges being 7-18;
White blood count of 18.1 with reference ranges being 4.4-11.0;
Red blood count of 3.16 with reference ranges being 4.20-5.40;
Hemoglobin of 9.6 with reference ranges being 12.0-16.0;
Hematocrit of 29.1 with reference ranges being 36-48.0
According to ED notes at 6:15 p.m., Patient #48 was discharged from the ED to observation/medical surgical.
At 6:18 p.m. a dose of the anticoagulant Lovenox was administered after 3 hours of presenting to the ED. There was no documentation of any antibiotics being started while in the ED.
At 7:15 p.m... Patient #48 had a decrease in vital signs of a heart rate of 60, blood pressure of 99/31, and oxygen saturation of 91 percent on 3 liters of oxygen. There was no documentation of what interventions that were taken.
Review of nursing notes at 7:30 p.m. revealed Patient #48's was transported to the 2nd floor (Med-Surgical floor).
Review of vital reports revealed Patient #48 was on oxygen from 09/02-04/2014 and the flow rate ranged from 2 -3.5 liters per nasal cannula. On 09/04/2014 at 3:00 p.m. Patient #48 was on oxygen 3 liters per nasal cannula and had an oxygen saturation of 98 percent.
Review of the chart revealed an order to be discharged on 09/04/2014 at 4:28 p.m. The discharge instructions were to discharge to a nursing home and listed medications. There was no documentation from nursing notes or discharge instructions to determine if Patient #48 was discharged on oxygen and what her oxygen saturation was on room air during her hospital stay.
During an interview on 09/09/2014 after 1:00 p.m., Staff #2 confirmed the time on the physician assessment and the lack of assessment.
Review of an ED record revealed Patient #23 was an 88 year old female who presented to the ED on 09/04/2014 at 10:26 a.m., with medical problems undefined. A triage assessment was performed at 10:47 a.m. and nursing classified the patient as being Urgent (meaning the patient should be placed intointo an appropriate ED treatment room so that emergency measures could be initiated immediately). According to the ED record the physician arrived at the bedside at 10:47 a.m. The physician documented at 12:17 p.m. (over an hour later) a medical screening was performed and Patient #23 was considered to have an emergency medical condition. The physician assessment was documented at 12:19 p.m. According to a clinical impression on the physician assessment Patient #23 had a dorsal/limb pain/muscle strain, early pneumonia. There was documentation underneath the plan which read follow-up condition improved, no physician consult, and discharge home. Prescription was Valium 5 milligrams, ½ to 1 tab po (by mouth) every HS (night) #8, Z pak. This documentation was on the same assessment timed for 12:19 p.m. There was no indication as to what time the physician wrote the plan.
The last documented set of vital signs from nursing was at 4:40 p.m.
Review of the ED disposition revealed Patient #23 was discharged home or self-care (routine discharge) at 5:00 p.m. There was no nursing assessment prior to discharge, nor an explanation of medications to be taken at home. There was no documentation of discharge instructions explained and patient acknowledgement of understanding the instructions.
Review of an undated "Emergency Department Protocol" revealed the following were to be used when the ED Doctor was expected to take more than 20 minutes to get the patient.
SOB
Asthma/Wheezing & Pulse Ox>93 %
Oxygen NC @ 2-4 LPM
Pulse Oximetry & Monitor
Pedi or Adult RT Protocol, or
Albuterol UD with Atrovent 500 mcg Neb.
With Pulse Ox <94 or distress,
CBC, CMP, BNP
P. (portable) CXR, EKG, Saline lock
D-Dimer if Well's criteria>2.5 points
With Fever & Cough, Possible Pneumonia add:
Blood Culture X 2, Sputum C & S
Review of policy named "EMTALA Medical Screening Exam and Stabilizing Treatment" dated 08/2014 revealed the following:
An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred.
Review of an emergency department policy named "Discharge Assessment/Teaching dated 11/2007 revealed the following:
3.1 Each patient will be assessed by the physician provider for readiness to discharge.
3.4 Discharged patients will receive written discharge instructions, in a form the individual can understand, which will include at least the following:
3.4.1 Assessment of learning needs concerning discharge medications.
3.4.4 Specific treatment procedures
3.5 Nursing staff will complete a brief discharge assessment including a note on patient status and discharge vital signs.
3.6 The nurse will record the patient's understanding of instructions on the ER record.
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