HospitalInspections.org

Based on observation, interview, medical record review, Medical Staff Bylaws review, and Autopsy Review the hospital failed to ensure that when an individual comes to the emergency department, they receive STAT laboratory blood work. and in a setting with consistent observation by staff for changes in condition, both of which are required to help ensure the ultimate provision of an appropriate medical screening examination for 1 of 20 sampled patients (#1). The hospital's failure to obtain the ordered STAT blood work resulted in the patient being placed back in the Emergency Department (ED) lobby instead of being placed in a bed in the ED proper for observation, and monitoring for constant chest pain. The patient fell to the floor in the lobby and required cardiopulmonary resuscitation.

Refer to findings in Tag A-2406.

Based on observation, interviews, medical record review, Autopsy review, Facility Chest Pain Protocol review, Hospital policies and procedures review and Facility Bylaws review, it was determined the facility failed to ensure when an individual comes to the emergency department the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department including ancillary services (STAT Laboratory blood work) routinely available to the emergency department (ED) to determine whether or not an emergency medical condition exists for 1 of 20 sampled patients (#1).

Findings:


MEDICAL RECORD REVIEW

Patient #1's medical record revealed demographic information that the patient arrived in the Emergency Department (ED) at 10:55 AM on 6/07/22. An electrocardiogram (ECG) was performed at 11:02 AM. The patient was triaged on 6/07/22 at 11:22 AM (charted at 11:45 AM) by RN K. The triage nurse's note at this time, 11:45 AM, read, "Pt (patient) states that he is having chest pain, headache, bilateral arm pain and back pain . . . woke up like this this morning. Pain level: 10 (severe)." The triage nurse's note by RN K indicated that the following vital signs were obtained on 6/07/22 at 11:42 AM: "Temperature temporal: 98.2DegF (degrees Fahrenheit); Heart Rate: 68 BPM (beats per minute); Respiratory Rate Spontaneous: 28 br (breaths)/min (HI); Systolic Blood Pressure NBP (normal blood pressure): 152 mmHg (Milliliters mercury) (HI); Diastolic Blood pressure NBP (normal blood pressure): 88 mmHg; O2 (oxygen) saturation: 97%." The patient's problem list indicated the following: BPH (Benign Prostatic Hypertrophy) Type II Diabetes; HTN (hypertension); Hypercholesteremia (high cholesterol level).

On 6/07/22 at 2:14 PM, RN O wrote, "Pt notified triage nurse of continued symptoms of headache and CP (chest pain), vitals retaken, will prioritize to a bed."

6/07/22 at 2:30 PM, RN O wrote, "Triage RN heard a thud, another pt in the WR (waiting room) called for help, RN found pt face down on floor with snoring respirations, called for assistance, log rolled, no palpable pulse, compressions started and assisted with BVM (bag, mask, ventilation), ROSC (return of spontaneous circulation) achieved . . . pt applied to backboard and taken to room 1 via stretcher."

The patient's medical record revealed that cardiopulmonary resuscitation (CPR) was initiated on 6/27/22 at 2:37 PM, after the patient collapsed to the floor.

Laboratory blood results of 6/07/22 at 2:49 PM, drawn during CPR, indicated critical levels for the following: Potassium (1.5 mmol/l) (normal is 3.6 - 5.2); CO2 level (9 mmol/L) (normal 23 - 29); and Calcium (2.4 mg/dl) (normal 8.5 - 10.5).

On 6/07/22 at 4:01 PM, physician L that he was with the patient at 1:30 PM. The note read: "Arrival mode: private vehicle . . . Chief complaint detail: chest pain . . . The patient presents in Chest pain . . . y/o (year old) presents in Chest pain . . . y/o Mw (male with) /PMHX (past medical history) of HTN (hypertension), HLD (hyperlipidemia), DM (diabetes mellitus), and BPH (benign prostatic hypertrophy) who presents to the ED with complaints of Chest pain which radiated to his L (left) arm X 3 arm. Per triage RN (Registered Nurse), the pt presented to the ED with complaints of L sided chest pain with radiation to the L arm which started 3 hr prior to arriving to the ED. However, during his wait in the ED waiting room, the pt collapsed to the ground, was noted to be asystole, patient was immediately started on ACLS (Advanced Cardiac Life Support) protocol and brought back to trauma room . . . Physical Examination: Vital signs: Time: 06/07/2022 2:32 PM. General: Severe distress, unresponsive. Glasgow coma scale (tool used to assess level of consciousness): Total score; Total score: 3 (Glasgow Score of 3 is the lowest possible score and is associated with extreme mortality rate. jamanetwork.com) h. Neurological: Level of consciousness: unresponsive . . . Cardiovascular: Asystole, no palpable pulse." The entry also read, "Pt collapsed in the waiting room and triage RN found the pt to be pulseless. Chest compressions were initiated . . . Patient was waiting in the waiting room when he suddenly collapsed, bystanders called for help, staff immediately began CPR (cardiopulmonary resuscitation) and ACLS protocol. Patient was transported onto a backboard, placed on a stretcher, and transported over to the trauma bed in the emergency department. Patient underwent 45 minutes of ACLS protocol. Patient remained in cardiac standstill drained 45 minutes, no shockable rhythm present, patient remained in PEA (pulseless electrical activity) arrest . . . Time of death was called 45 minutes after initiation of CPR."

An autopsy report of 8/09/22 read, "Cause of Death: Cardiac tamponade due to Hemopericardium due to rupture of ascending aortic arteriosclerotic aneurysm with Type A dissection."

There was no evidence in the patient's medical record of any unsuccessful attempts at obtaining laboratory blood work prior to the patient collapsing to the floor on 6/07/22 at 2:30 PM.


FACILITY MEDICAL STAFF BYLAWS

The facility's bylaws (No Date) were reviewed. Section 1.2 of the Bylaws DEFINITION SPECIFIC TO THE RULES AND REGULATIONS stated in part, "1.22 "Emergency Medical Condition" means a condition manifesting symptoms (including but not limited to severe pain, psychiatric disturbances and/or symptoms of substance abuse) which in the absence of immediate medical attention, is likely to result in serious dysfunction or impairment to any bodily organ or function or serious jeopardy to the health of the individual ... 1.26 "Medical Screening Examination means an examination in which can include all he necessary ancillary services of the hospital routinely available to the ED to determine if an individual is experiencing an emergency medical condition. Article 2. PATIENT MANAGEMENT IN THE ED (emergency department) ...2.3 Medical Screening Examination: Every Patient who comes to the ED ...requesting Examination or treatment must be provided with a medical screening examination."


FACILITY POLICY - PROTOCOL

A review of the document "ED Protocol Chest Pain" revealed that the following laboratory blood work was to be done as "STAT" (as quickly as possible) with chest pain presentations: Basic Metabolic Profile, Hepatic Function Panel, Troponin T Level High Sensitivity, Troponin ED

Review of hospital policy "Venous Access Devices Insertion - Adult" read, "PIV (Peripheral Intravenous) Insertion Attempts: 1) No more than two (2) attempts at insertion shall be made by any one nurse. The physician/allied health provider shall be contacted after a maximum of four (4) attempts." Failure to initiate STAT laboratory blood work and notifying the physician if unsuccessful, violated the requirements of the "ED Protocol Chest Pain as well as the policy "Venous Access Devices Insertion - Adult".


STAFF INTERVIEW - STAT LABORATORY BLOOD WORK

On 9/07/22 at 3:25 PM, RN K stated he triaged the patient. He stated that a laboratory blood work draw needed was conveyed to the Medic, who customarily performs them. He stated that he had not heard of any laboratory blood collection issues concerning patient #1 during the patient's stay. He stated that he saw a request for ultrasound to assist in the laboratory blood draw on the ED tracker board. The tracker board is a computer monitor display which shows pending treatment activities for ED staff to address.

On 9/07/22 at 2:15 PM, the ED Nurse Manager stated that the computer-based tracker board in use on 6/07/22 was tied in with their medical record system; it was electronic, and any staff member could place a patient need on it. He stated that the Assistant ED Nurse Manager or Charge Nurse regularly checks the board to see if patient needs are being addressed in a timely manner. He stated that all ED staff help meet the needs as stated on the tracker board. He stated that if something needed to be done STAT, the requesting staff member is expected to notify the Physician or Assistant Nurse Manager. He stated that special trained nurses can use ultrasound for intravenous (IV) insertion.

On 9/07/22 at approximately 1:28 PM, RN O stated that she saw a notation next to the patient's name which indicated that the patient needed an "ultrasound IV" on the ED tracker board. She stated that ultrasound IVs are commonly used if staff have a difficult time obtaining venous access. She did not see any "STAT" notation on the board during the time of patient #1's ED visit. She did not pursue anything regarding obtaining blood work.

On 9/07/22 at 2:30 PM, Medic P stated that he saw the order for blood work and that the patient had informed him that he was a "hard stick (a person with whom intravenous access could not be easily obtained)". He attempted access but was unsuccessful. He stated he looked for access with the assistance of trans-illumination (vein finder) without success. He stated that he determined a need for ultrasound assistance. He stated he indicated this need on the ED tracker board. He did not mention that access was required for STAT blood work. He stated that the expectation was that qualified staff would see it and provide assistance. He stated that he did not verbally inform anyone of the need for ultrasound assistance.

On 9/07/22 at 3:40 PM, the Assistant ED Nurse Manager stated that no one conveyed to her the need for STAT blood work. She stated that she would expect verbal notification if anything was deemed as STAT.

On 9/07/22 at approximately 1:28 PM, RN O stated that, as indicated in her medical record entry, the patient had come up to her complaining of continued symptoms. She stated that she took his vital signs and found that there was no significant change from the prior vital signs.

Although the Medic P stated that this need was indicated on the ED tracker board, there was no evidence that anyone was informed that this was for a required STAT lab draw.

Although blood work had been attempted (per interview), there was no evidence from interview or record review that any physician was notified of the unmet need for STAT blood work to be drawn, as stated in the facility's policy.


STAFF INTERVIEW - LOBBY OBSERVATION

On 9/07/22 at 3:25 PM, RN K stated that during patient #1's visit on 6/07/22, he was at the secondary triage desk and could not see patient #1, who he indicated was in an alcove of the lobby.

On 9/07/22 at approximately 1:28 PM, RN O stated that during the patient's visit on 6/07/22, she was at the triage desk which was to the right of the entrance corridor. She stated that the patient was seated in the alcove area which was off to the side of the ED lobby, and that she could not see the patient from where she was seated. She stated that she became aware of the fall when another patient came to her and reported it. She stated that the fall was in in the alcove area of the lobby.

On 9/07/22 at 2:30 PM, Medic P stated that during patient #1's visit on 6/07/22, a three-panel barrier screen was positioned at his desk. He indicated that this prevented him from seeing into the alcove area of the ED lobby unless he maneuvered himself to enable a view.

On 9/07/22 at 3:40 PM, the Assistant ED Nurse Manager stated patient #1 fell in the alcove area of the lobby.


OBSERVATION - LOBBY OBSERVATION

On 9/06/22 at approximately 1:50 PM, the ED lobby area was observed. The layout of the area, with respect to staff ability to observe patients, was as follows. A patient would walk into an entrance. A patient would encounter a Concierge desk and work area (for registration) on the left. On the right, the patient would encounter a triage nurse's desk and work area. Straight ahead, past these two respective areas, the patient would encounter the lobby seating area in a circular-shaped room. Upon entering the ED lobby, an alcove area with an additional fifteen (15) chairs was observed towards the left side of the lobby proper. A line of site observation from both of the above-mentioned staff work areas found that the view from the respective desks allowed only minimal observation of the ED lobby seating area and no view of the alcove. In the center of the ED lobby was an island-type structure which incorporated a central column approximately 10 feet tall which housed a video screen. When viewed head-on from the entrance corridor which passed the two above-mentioned staff work areas, it obscured the view of any patients who would be sitting on the opposite side of the structure. Upon moving rightward, after entering the lobby, was a Medic area with a desk. The expansive view of the ED lobby which was available from this location was obscured by a three-panel privacy screen of about six feet in height placed next to the desk. A partial view into the alcove was possible when discounting the privacy screen.

On 9/06/22 at approximately 1:56 PM, RN Q stated that the barrier had been placed a few months ago.

On 9/07/22 at 12:55 PM, the Risk Manager stated that during high volume times since the prior November (2021), the barrier screen had been used to provide greater privacy to patients who were at the Medic's desk. In the ED lobby area, close to the Medic's desk, was a desk and workspace for the Second Triage Nurse. It offered a considerable, though not complete, view of the ED lobby but did not have a view of the alcove. It also had a glass barrier or window which was semi-opaque. This lessened the clarity of any views toward the ED lobby.

While awaiting a bed in the ED proper, patient #1 was seated in a designated lobby or waiting room area which was not readily visible to ED staff. There was no guarantee that all patients who waited in the lobby on 6/07/22 or other days would be readily observed by clinical staff if there was a sudden change in condition which was visually discernable. This could be a risk to patient health. The patient's collapse was reported to staff by a fellow lobby patient or visitor.

The facility failed to ensure that on 6/7/2022, Patient #1 received an appropriate medical examination that was within the capability of the hospital's emergency department by failing to obtain the initial STAT blood work ordered, and not done until after 4 hours, which is a necessary ancillary service routinely available to determine whether or not an Emergency medical condition existed for Patient #1. Additionally, the patient had unstable VS patient was tachypneic, and had complained to the staff that he was feeling worse.