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Based on observation, interview, and record review, the facility failed to comply with CFR 489.24 by failing to ensure patients arriving to the Emergency Department by ambulance;

1. Were triaged appropriately (assigned a level of severity [ESI] consistent with their illness or injury) when the patients were assigned ESI levels of three instead of two (A2406); and,

2. Were received by the ED staff in a manner consistent with standards of practice for accepting report on ED patients, when the ED staff did not assume care of any patients arriving at the ED by ambulance until they were removed from the ambulance gurney and placed in an ED bed (A2406).

These failed practices resulted in a delay in providing a timely and appropriate MSE (medical screening examination) for the purposes of determining whether an emergency medical condition existed, and delay in treating patients with serious injury or illness.

Based on observation, interview, and record review, the facility failed to ensure two of five patients who arrived at the ED (Emergency Department) by ambulance (Patients 101 and 301):

1. Were triaged appropriately (assigned a level of severity [ESI] consistent with their illness or injury) when the patients were assigned ESI levels of three instead of two; and,

2. Were received by the ED staff in a manner consistent with standards of practice for accepting report on ED patients, when the ED staff did not assume care of any patients arriving at the ED by ambulance until they were removed from the ambulance gurney and placed in an ED bed.

These failed practices resulted in a delay in providing a timely and appropriate MSE (medical screening examination) for the purposes of determining whether an emergency medical condition existed, and delay in treating patients with serious injury or illness.

[The ESI (Emergency Severity Index) is a five level tool used by nurses to triage patients in the ED (Emergency Department). Patient acuity (severity of illness or injury) is rated from level one (most urgent and requiring immediate evaluation and treatment) to level five (least urgent and requiring the least amount of resources to evaluate and treat the patient).

A review of ESI guidelines for the facility indicated the ESI levels corresponded with patient acuity as follows:

ESI Level One (Resuscitation) - Patient requires immediate life saving intervention. When ESI Level One condition is identified, the triage process stops, the patient is taken directly to a room, and immediate physician intervention is requested;

ESI Level Two (Emergent) - The patient presents with a condition posing a potential threat to life, limb, or function and requires rapid medical intervention. These include high risk situations. Patients who might fall into level two are those with heart rate, respiratory rate or oxygen saturation rate in the danger zone. Danger zone vitals signs for an adult include a heart rate greater than 100, respiratory rate greater than 20 and an oxygen saturation rate less than 92 %. When ESI Level Two condition is identified, the triage process is discontinued, the patient is taken directly to a room, and an immediate physician intervention is requested;

ESI Level Three (Urgent) - The patient presents with a condition that could progress to a serious problem. The presenting condition is anticipated to require utilization of two or more resources (lab, radiology, EKG, respiratory, etc.); and,

ESI Level Four (Semi Urgent) - The patient presents with a condition that has a low potential for deterioration or complications. One resource is expected to treat this patient].

ESI Level Five (Least Urgent) - The patient presents with a condition that requires the least amount of resources to evaluate and treat.

Findings:

The facility had a 29 bed ED and provided basic emergency services. A review of the ED staffing plan indicated, to be adequately staffed, the 7 a.m. to 7 p.m. shift required 10 RNs (registered nurses). The 11 a.m. to 11 p.m. shift required an additional three RNs (a total of 13 RNs between the hours of 11 a.m. and 11 p.m.) and one LVN or technician. The 7 p.m. to 7 a.m. shift required 10 RNs. The plan indicated sufficient staffing was provided to have available staffing coverage for the RME (rapid medical exam) area, the ED beds, and provided coverage for a CN (charge nurse) and a triage nurse.

During a tour of the ED on January 23, 2014, at 1:05 p.m., accompanied by the ED director, the director stated patients who came by ambulance waited in the hallway by the ambulance entrance when no beds were available to put them in.

1. During an interview with the family member of Patient 101 on January 9, 2014, at 4:30 p.m., the family member stated the patient was taken to the facility by ambulance the night of November 28, 2013, with a complaint of severe head pain. The family member stated Patient 101 had a brain aneurysm in the past, and this felt just like the other aneurysm. The family member stated when she arrived at the facility, she entered the ED to visit Patient 101, and saw her in the hallway on an ambulance gurney, where she stayed for, "about one hour," before she was moved to an ED bed. The family member stated the ED staff did not seem to be in a hurry to assist Patient 10. She stated the staff did not respond until Patient 101 was placed in an ED bed and started breathing (agonal [gasping] type description) respirations.

The record for Patient 101 was reviewed. The record indicated Patient 101, a 79 year old female, presented to the ED via EMS (Emergency Medical Services [ambulance]) on November 28, 2013, with a chief complaint of sudden onset of a headache and a history of a brain aneurysm. According to the EMS record, upon their arrival to her home, the patient was holding her head in her hands, had sudden onset of a headache with pain 10/10 on a pain scale of 0-10 (10 being the worst pain), had nausea and vomiting, and had HTN (high blood pressure). The record indicated Patient 101's BP (blood pressure) was 204/100 (normal 120/80) upon EMS arrival to her house, they transported her to the hospital, and arrived there at 11:39 p.m.

The ED record indicated Patient 101 arrived at 11:45 p.m., and was triaged by LN (licensed nurse) 2 at six minutes after midnight (21 minutes after arrival to the ED). The record indicated Patient 101 had a history of a brain aneurysm, was complaining of a headache (10/10 on the pain scale), had a BP of 204/100 (the same BP obtained by the EMS personnel), and was restless. Patient 101 was assigned an ESI of three (urgent).

The ED record indicated Patient 101 was moved from the ambulance gurney in the hallway to an ED bed at 56 minutes after midnight (one hour and 11 minutes after arrival), and seen by the ED physician. Physician orders were entered at 56 minutes after midnight that included a CT (computerized tomography) of the brain.

According to the ED record, "approximately five minutes," after Patient 101 was examined by the ED physician, she became unresponsive and required intubation (a tube placed through her mouth and into her trachea to provide an airway) and placement on a ventilator (a machine to assist with breathing).

At 1:07 a.m., a CT of the brain was reordered using stroke protocol. The CT was performed at 1:30 a.m. (one hour and 45 minutes after arrival to the ED). The CT results were called back to the ED physician at 2:14 a.m. (44 minutes after the CT was done, and two hours and 29 minutes after Patient 101 arrived in the ED). The results indicated Patient 101 had a diffuse subarachnoid hemmorhage (bleeding in the brain from the aneurysm).

According to the ED record, Patient 101 had a BP of 190/68 at 1:30 a.m. (one hour and 24 minutes after arrival to the ED - the first BP taken by LN (Licensed Nurse) 2 after the patient was placed in an ED bed), Nipride (a medication given by continuous IV [intravenous] drip to lower the blood pressure) was started at 1:55 a.m. (40 minutes after intubating Patient 101, and two hours and 10 minutes after she arrived to the ED).

Patient 101 was transferred to another acute care facility for a higher level of care at 4:51 a.m., where she expired.

During an interview with the ED director on January 23, 2014, the director stated the condition Patient 101 presented to the ED with should have been assigned an ESI level two (with the physician being notified immediately), not a level three.

During an interview with the CNO (Chief Nursing Officer) on March 18, 2014, at 11:50 a.m., the CNO stated during the facility investigation into the care of Patient 101, LN 2 indicated she used the vital signs (including BP) taken by EMS prior to arrival at the ED for her triage vital signs. LN 2 indicated she did not retake the vital signs on arrival. LN 2 further indicated Patient 101 stayed on an ambulance gurney until she was moved to an ED bed (about one hour later), and she was not seen by a physician during that time.

Patient 101 was not triaged in compliance with the facility policy (should have been an ESI level two), and her MSE was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway.

2. During a tour of the ED on March 17, 2014, at 2:50 p.m., accompanied by the ED director, three ED beds were observed with no patients in them. The director stated the beds were empty but they could not put patients in them because the ED was, "short staffed," so four beds were, "closed." Two EMS (Emergency Medical Systems [ambulance]) gurneys were observed in the hallway near the ambulance entrance. A patient was on each gurney with an EMS personnel standing by.

During an interview with the EMS personnel, both stated they were told the ED was short a nurse, so there were four beds closed. According to the EMS personnel, one patient had been waiting for a bed assignment for 45 minutes, with no staff monitoring the patient and no exam or evaluation by a physician. They stated this occurred, "about half the time," when they brought patients into the ED.

During a tour of the ED on March 17, 2014, at 9:30 p.m., three patients (two on gurneys and one in a wheelchair), including Patients 301 and 302, were observed in the back hall by the ambulance entrance. Each patient had two EMS personnel standing nearby.

In a concurrent interview with EMS 1, she stated Patient 301 was brought to the ED for further evaluation of a possible stroke. She stated Patient 301 was having difficulty putting sentences together, and had slurred speech. EMS 1 stated they had been at the ED for a little over an hour. She stated LN 10 had been over to triage Patient 301 after they arrived in the ED. She stated the physician had not seen the patient yet. EMS 1 stated she was responsible for Patient 301 until the facility was able to place the patient into a room.

On March 17, 2014, at 10:15 p.m., LN 10 was interviewed. LN 10 stated he triaged Patient 301 when the patient arrived to the ED. He stated he took vital signs and did a quick history on the patient. LN 10 stated he assessed the patient with a ESI level 3. When asked if he was the Triage Nurse, he stated no, he just saw him there so he triaged him. LN 10 stated he was just a "floater" nurse. He stated that meant he was floating within the ED, and not assigned to any specific patients. He stated he was available to help the Charge Nurse or any other staff that needed help. He stated at 11 p.m., another nurse would be going home, and at that time he would start taking patient assignments. When asked why the patients from EMS providers were lined up in the hall, he stated there was no where to put them, but Patient 301 had just been assigned to a room, so he was in the process of moving him. LN 10 was not sure if there were any other empty beds at the time.

On March 18, 2014, the record for Patient 301 was reviewed. The EMS "Patient Care Report," indicated EMS was dispatched to Patient 301's home on March 17, 2014, at 7:30 p.m., for complaints of "Difficulty speaking." The report indicated the onset of symptoms was 45 minutes earlier. The medical record, "Triage Report," indicated Patient 301 arrived to the ED, via ambulance, on March 17, 2014 at 8:22 p.m., with complaints of slurred speech (one hour and 20 minutes after the onset of symptoms). The triage time was at 8:47 p.m., by LN 10. Patient 301 was assigned a ESI level 3.

The "Daily Focus Assessment Report," indicated at 10:30 p.m., (when Patient 301 was placed in an ED bed) the patient was awaiting physician evaluation. Patient 301 was first seen by the physician at 10:39 p.m., at which time, "CT brain w/o [with out] Contrast Stroke Procedure," was ordered (two hours and 17 minutes after the patient arrived to the ED and three hours and 54 minutes after the onset of symptoms).

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. LN 11 stated if a patient came to the ED via ambulance, then those patients were the responsibility of the EMS personnel, who was to "Keep one hand on the gurney at all times." She stated the patients would remain in the hall under the care and monitoring of EMS until such time the patient was placed in a room and a hand off report was given to the assigned nurse. LN 11 stated the patients were not fully triaged until they were in a patient room. However, she stated, if a patient presented to the ED with symptoms associated with a possible stroke, including slurred speech and difficulty speaking, then there was a stroke protocol that could be implemented immediately, even before the patient was seen by the physician. This would include getting the patient to radiology for a CT scan as quickly as possible, because early detection was important for course of treatment. LN 11 reviewed Patient 301's record and stated the standing orders should have been implemented for this patient when he first arrived to the ED and was triaged at 8:47 p.m. LN 11 verified that no diagnostic orders or monitoring were implemented until after the medical screening exam at 10:39 p.m. (one hour and 52 minutes after triage).

A blank "ED Triage Standing Orders," was reviewed. There was an order set for "Suspected CVA" (Cerebral Vascular Accident - Stroke). The order set included, but was not limited to, blood tests, EKG, STAT CT of brain, oxygen and cardiac monitoring.

Patient 301 was not triaged in compliance with the facility policy (should have been an ESI level two), and his MSE was delayed due to failure of ED staff to assume responsibility for his care while he remained in the EMS hallway.

A review of the ED staffing for March 17, 2014, indicated the 7 a.m. to 7 p.m. shift had 11 RNs, increasing to 14 RNs at 11 a.m. (one RN more than needed according to the staffing plan). The 7 p.m. to 7 a.m. shift had 14 RNs, decreasing to 11 RNs at 11 p.m. (one RN more than needed according to the staffing plan).

During an interview with the CNO (chief nursing officer) on March 17, 2014, at 10:05 p.m., the CNO stated when patients arrived to the ED by ambulance, they were the responsibility of the EMS personnel until the ED staff took them off of the EMS gurney and got report on the patient. She stated at that point, they became the facility's patients.

During an interview with the ED CN on March 17, 2014, at 11:10 p.m., the CN stated the ED staff did not monitor or take responsibility for patients who arrived by ambulance until they, "hit," the ED gurneys. He stated, "their gurney, their patient - my gurney, my patient."



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