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Based on record review and interview, the facility's direct care staff failed to provide necessary care and services to patients who entered the facility's emergency center requesting examination of a medical condition, i.e. patients were not monitored in a timely manner, complete medical screening were not conducted, critical laboratory results were not reviewed, reported, and acted upon by clinical staff. These failures resulted in a patient being discharged from the facility's emergency center records. The patent was found later unresponsive and pulseless in the facility's bathroom and ultimately expired.

The facility failed to timely reassess patients after presentation or notify patients timely regarding critical laboratory values;

The facility failed has no system in place to tract and report critical laboratory values;

The facility failed to provide staff in the emergency center retraining on timely monitoring of patients and reporting of critical laboratory values.

This findings puts all patients in the facility's emergency center, health and safety at risk.


Findings:

Patient #1

Review of Patient #1's clinical record ( triage record ) dated 04/11/2019 indicated, the patient was admitted to the facility's emergency center on 04/11/2019, at 12:46 P.M., with chief complaint of abdominal pain for 8 days, loss of appetite for 5 days, vomiting, and history of diabetes mellitus. The patient's vital signs were taken at 12:48 p.m. during the triage. The patient was triaged as a ESI level 2.

Review of a medical screen provider's notes dated 4/11/2019 revealed, a partially completed medical screen which was conducted at 1339, without review of critical laboratory values drawn on 04/11/2019 at 1305 and resulted at 1309 with the following values:

Glucose 508 mg/dl; (point of care) reference range 74-106 mg/dl.

CO2 17 mmol/L; (point of care) reference range 21-32 mmol/L

Sodium 124 mmol/L; (point of care) reference range 136- 145 mmol/L


The patient's clinical record revealed no further reassessment of the patient by facility's staff after the triage assessment comducted at 12:48 p.m. The record indicated calls/announcement were made by staff of the emergency center to locate the patient in the emergency center waiting area on 04/11/2019 at 1900, 04/11/2019 at 1930 and 04/11/2019 at 2102.

The record revealed there was no response from the patient to the announcements and no physical inspection of other areas within the emergency center to locate the patient. The patient was then discharged from the facility's emergency center records.

The record indicated the patient was called for service/revaluation at 1900 hours, over six hours after being triaged, although critical laboratory results were available on 04/11/2019 at 1309.

Review of the physician's progress notes, dated 04/13/2019 revealed, the patient was brought into shock room, pulseless with cardiac arrest. He was found in one of the emergency center's bathroom unconscious. At time cardiac arrest code was initiated, staff did not know how long the patient has been unconscious and unresponsive. Patient became asystole twice during the cardiac arrest code procedure. Time of Death was recorded as 1734. Note the progress notes was dated 4/13/2019 but the episode happened on 04/12/2019.

Interview on 06/05/2019, at 9:05 a.m., with Medical Screen Provider (Physician I) revealed, he does medical screen before results of laboratory values are made available. He said he was not notified regarding Patient #1's critical laboratory values.

Interview with Patient Care Technician (K) revealed, she saw Patient (#1) on 04/12/2019 at approximately 8:00 a.m. She said the patient approached her and she checked his armband and he was not one of the patients she had done vital signs on when she came on duty. She then directed him to the triage nurse.

Interview on 06/05/2019, at 1:50 p.m., with Registered Nurse (P) revealed, on 04/12/2019 at approximately 1:00 p.m. she was called to the rest room by a security officer who asked her to check on a patient who was in the rest room. She said, on entering the rest room, she knocked on the door and asked the patient if he was ok.The patient responded that he was fine.

She said towards the afternoon, at approximately 4-5 p.m., the security guard told her somebody had passed out in the bathroom. She called for help and when she went in the bathroom the patient was unresponsive. She placed the patient on the bathroom floor and started CPR. The patient was then taken to the shock room with CPR in progress. The patient became asystole twice and expired at 1734.

Based on the above findings it is determined that facility's action did puts the patient's health and safety in jeopardy.

Cross Reference A144

Based on observation, record review, and interview, the facility's direct care staff failed to provide necessary care and services to patients who come to the facility's emergency center requesting examination of a medical condition. Patients were not reassessed in a timely manner, complete medical screening were not conducted, critical laboratory results were not reviewed, reported, and acted upon by clinical staff. These failures resulted in a patient being discharged from the facility's emergency center records. The patient was found later in one of the emergency center's bathroom, unresponsive and pulseless and ultimately died.

The facility failed to coduct reassessment of patients timely or inform the patient timely regarding critical laboratory values;

The facility failed to have a system in place to tract and report critical laboratory values of patients;

The facility failed to provide staff in the emergency center retraining on timely monitoring of patients in the emergency center and reporting of critical laboratory values.

This finding puts all patients in the facility's emergency center, health and safety at risk.


Findings:

Observation

Observation on 06/04/2019 of the facility's emergency center revealed, on entering the emergency center there were two separate entries, one for patients arriving by ambulance and one for ambulatory patients. Ambulatory patients are first seen by a registered nurse identified as a (Sort Nurse). The nurse was observed interacting with patients, conducting vital signs, and obtaining information i.e. (presenting symptoms). After being seen by the Sort nurse, determination is made based on the patients' presenting symptoms how the patients were triaged.

Patients were observed in the waiting room of the emergency center, in pods, in three large holding areas, out of bed and in the hemodialysis unit.

The emergency center has accommodation for 63 patients, 35 of the beds are assigned for medical usage and the other beds assigned for patients with psychiatric symptoms and trauma emergencies.

Observation of the emergency center revealed a 63 bed holdings area fully occupied with patients who were triaged and examined by physicians or the mid- level provider. There were eleven patients in the medical holding area who were admitted to the facility but was awaiting the availability of a bed on the various units.


Patient #1

Review of Patient #1's clinical record (triage record) dated 04/11/2019 indicated, the patient was admitted to the facility's emergency center on 04/11/2019 at 12:46 P.M with chief complaint of abdominal pain for 8 days, loss of appetite for 5 days, vomiting, and history of diabetes mellitus. The patient's vital signs were taken at 12:48 p.m. during triage. The patient was triaged as a ESI level 2.

Review of a medical screen provider's notes dated 4/11/2019 revealed a partially completed medical screen which was conducted at 1339, without review of critical laboratory values drawn on 04/11/2019 at 1305. The laboratory test results wera reported at 1309 with the following values:

Glucose 508 mg/dl; (point of care) reference range 74-106 mg/dl.

CO2 17 mmol/L; (point of care) reference range 21-32 mmol/L

Sodium 124 mmol/L; (point of care) reference range 136- 145 mmol/L


Medical Screening Examination Provider's notes:

Review of a medical screen provider's notes conducted by emergency center physician I at 1339 revealed the following entry:

"I evaluated and initiated the medical screening examination of patient #I. Key symptoms and Findings:
Vitals: BP 118/85, Pulse 91, Respiration 20, Temperature 98.4 F (36.9 C), SpO2 100%, nausea, vomiting, diarrhea, abdominal pain for 8 days with poor PO. No other GI/GU SX. No distress.

Assessment:
Further evaluation will be necessary in order to determine if an emergency medical condition exists. The Patient will continue in process until such time they are deemed ready for disposition."

The patient's clinical record revealed no further reassessment of the patient by facility's staff after the triage assessment timed 12:48 p.m. The record indicated calls/announcement were made by staff of the emergency center to locate the patient in the emergency center waiting room on 04/11/2019 at 1900, 04/11/2019 at 1930 and 04/11/2019 at 2102. There were no physical inspections done on areas of the emergency center to locate the patient.

The record revealed there was no response from the patient to the calls/announcements and he was then discharged from the emergency center records.

The record indicated the patient was called for service/revaluation at 1900 hours, over six hours after being triaged, although critical laboratory results were available on 04/11/2019 at 1309.


Progress notes

Review of the patient's progress notes dated 04/12/2019 at 5:00 p.m. revealed the following documentation from physician S:

"Trauma Code activated for patient found down in bathroom pulseless. CPR initiated and continued prior to trauma activation. No overt signs of external trauma."

04/12/2019 at 5:00 p.m., nurse's progress notes documented "66 Y/O Hispanic male brought to SR4, in progress of ongoing CPR. Per triage RN, pt was found in the triage restroom on the ground unresponsive and pulseless, unwitnessed time of fall/ unresponsiveness. Ongoing CPR start at 1700. physician (T) in charge of code. Pt placed on CM, Vfib pulseless. No O2/bp readings. RT radiology, anesthesia, RNs at bedside assisting with code. Pt expelling copious amount of dark brown contents, suctioned oral cavity. LMA placed by MD U."

Review of physician (O's) progress notes dated 04/13/2019 revealed, the patient was brought into shock room, pulseless with cardiac arrest. He was found down in the bathroom. At time of code it was unknown how long the patient has been unconscious. Patient became asystole twice during the code. Time of Death was documented as 1734.


Review of Critical Care Progress Notes

Review of critical care progress notes of physician O, dated 04/13/2019 revealed the following documentation:

"66-year-old male who was brought into shock room pulseless with cardiac arrest. He was found down in the bathroom, at time of code for unknown amount of time. Upon arrival, ACLS followed. Initially had head LMA placed then he was intubated by EC resident with good end tidal and breath sounds bilaterally. He continued to have good end tidal and O2 waveform during code. He had an IO placed. Initially patient with PEA and asystole then developed A- fib refractory to multiple shocks as well as dual sequential defibrillation. He was given epi, amiodarone, lidocaine, bicarb insulin, calcium magnesium and stat block blood without regain pulses. POCUS u/s did not show cardiac tamponade. he had good lung sliding bilaterally RT bagging. POCUS did not show sign of RV strain or bowing of septum. Cardiology was also called for refractory v fib. All members of care team were asked of any additional thoughts after patient's rhythm changed from v-fib to asystole X 2. Cardiology in agreement. TOD at 1734. Patient had no family when speaking with SW. He had a friend who arrived and DR T spoke with friend, Chaplain services was also available."


Review of a Death Notice and Status Report Form

Review of the Patient's clinical record revealed a Death Notice and Status Report Form which was partially completely which indicated the probable cause of death as cardiac arrest. Autopsy was not applicable.


Interviews

Registered Nurse (F)

During an interview on 06/04/2019 at 10:44 a.m., with Registered Nurse (F) revealed, he works the 7 p.m. - 7:00 a.m. shift in the facility's emergency center. He said, he cannot recall "laying eyes on patient" (referring to Patient #1), but he knows, patient care technicians were assigned to monitor patients' vital signs. This process involves bringing patients in batches to a specific area to have their vital signs monitored. He stated, "We call them once, call them 30 minutes after and if they do not answer after the third call, then they are taken out of the system (referring to patients in the waiting room). He said the triage nurse makes the determination to take the patient out of the system.

He said prior to removing the patient from the system, radiology or CAT scan departments are contacted to see if the patient was sent for a procedure. If the response is no, then the patient is removed from the system.

Registered Nurse (F) said, his involvement with Patient #1, included going through the patient's chart to determine if there were critical laboratory results or orders that were lingering. He said he identified that the patient had a blood glucose level in excess of 500 and he told the Medical Screen Examiner Registered Nurse (R) of the result. He said he did not notify the physician of the critical laboratory result on the patient because once he becomes aware of critical laboratory results then he relays the information to the medical screen examiner registered nurse, who in turn will notify the physician or mid-level provider.

He said, he had no further contact with the patient's information. He said, patients who are triaged at a ESI level 2, vital signs were monitored every 4 hours, but recently in the last two to three weeks, monitoring is done every 2 hours for ESI level 2 patients. He said patients triaged as ESI level 3, 4 and 5 vital signs are still monitored every 4 hours.

He said, since the incident, discussions are held with staff in the emergency center during shift change, regarding increasing the frequency of ESI level 2 patients' vital signs monitoring, rounding in the lobby and being diligent about checking with radiology before taking someone out of the system.


Interviewed Registered Triage Nurse (G)

During an interview on 06/04/2019 at 11:00 a.m. with Registered Triage Nurse (G) revealed, she triaged Patient #1 from the triage desk at approximately 12:48 P.M. on 04/11/2019. She said, the patient presented with chief complaint of diffused abdominal pain, nausea, and vomiting. The patient was seen by her at the sort desk and triaged as a ESI level 2, based on the information provided to her of the patient having diffused abdominal pain for 8 days, not eating and having a diagnosis of Diabetes Mellitus. She said the Patient should have been placed in a pod for close monitoring but there was no bed available.

She said, she ordered an EKG, cardiac panel, CBC, and BNP on the patient and after doing expedited laboratory orders, she does not follow through with the results of the laboratory ordered. She said The MSE nurse is generally given the laboratory results, who in turn passes the results to the medical provider.
She said, vital signs on ESI level two patients were done every 4 hours but within the last two months it is done every 2 hours.

She said, since the new monitoring process was implemented, staff huddle at the beginning of the shift to be reminded of expectations but she was not provided with training on monitoring of patients.

She said, she can only recall her initial contact with the patient, where she started the laboratory work up, but she does not follow up on ambulatory triages. She said, her shift ended at 7:00 p.m. and she did not know what happened to the patient after her initial contact.


Interviewed Registered Nurse (E)

Subsequent interview on 06/04/2019 at 2:10 p.m. with Registered Nurse (E) revealed, the patient was found by a security guard in a bathroom stall with the door locked. The security guard then notified a nurse from the emergency center who responded and started CPR on the patient. He said, the door to the bathroom stall had to be kicked in, and the patient was found on the toilet with his wheelchair beside him.


Interviewed Registered Nurse (H)

During an interview on 06/04/2019 at 2:16 p.m. via the telephone with Registered Nurse (H) revealed, on the day of the incident on 04/12/2019, with Patient #1, she was sitting in the medical screening room when she noticed a physician hurriedly went across to the bathroom. He followed the doctor into the bathroom and the doctor with two patient care technicians were putting the patient on the floor, while the doctor was giving instruction to initiate CPR. She said, there were a lot of vomitus on the floor. She said, all staff in the bathroom picked up the patient and placed him on the stretcher while continuing to do CPR. The patient was taken to the critical care area where the care was turned over to the critical care team.

She said, the patient was not on her census but she knew the patient was a DNA from the evening before.
She said since the incident, patients triaged as ESI level 2, vital signs are done every two hours and the facility has initiated checking the physical census with the patient's arm band every 6 hours. She said, 4 hourly vital signs can be monitored from the tracking board in the EPIC system but two hourly tracking of vital signs cannot be done.


Interviewed physician (I) Emergency Services

Interview on 06/5/2019 at 9:05 a.m. with physician (I) revealed, he saw Patient #1 on 04/11/2019. He said, he was not made aware of the critical laboratory results on the patient. He said, generally he does the medical screen on patients long before labs are drawn on patients. He said, there is never any laboratory results available at the time of medical screening because it is not his responsibility to follow up on laboratory results. He said he is constantly conducting assessments on patients or responding to questions from patients and other staff, so he does not track the result of laboratory drawn on patients.

He said since the incident, he came up with his own system of allowing the EPIC computer system to pull in the laboratory results from the lab, however laboratory results done at point of care in the emergency center have to be relayed to him by other staff. He said there was no current system in place to track laboratory results.

Interviewed physician (J)

Interview on 06/05/2019 at 9:10 a.m. with physician (J) revealed, the Sort Nurse enters patients' laboratory orders in the system and the emergency room technician draws the patients' blood. He said there is no control point of entrance or exit in the emergency center, so patients utilize the ability to go and come as they please. He said, there is a disconnect when laboratory results are reported.

He said, the emergency center is currently working with the laboratory staff to determine what meets threshold for critical findings. He said, a new emphasis is being developed for better communication between the laboratory and point of care testing.

He said, the facility's emergency center has a significant boarding problem, in that the department has 63 emergency center beds. Of the total number of emergency center beds, there are currently 20 patients admitted to the facility who are boarding in the emergency center, 10 psychiatric patients in the holding area i.e. half of the emergency center beds are in lock down.

He said, regarding staff training systems implemented to address laboratory reporting and monitoring of patients in the emergency room, he said, this is deferred to nursing leadership.


Interviewed Registered Nurse (N)

Interview on 06/05/2019 at 11:30 a.m. with Registered Nurse (N) revealed, she had implemented a risk reduction strategy which she developed. The staff conduct huddle at the beginning of each shift but there was no formalized training provided to staff since the incident. She said, as part of the risk reduction strategy facility's staff is expected to round on patients in the waiting room every 6 hours and for ESI level 2 patients monitored every two hours.

When asked by the Surveyor what monitoring tool is utilized to ensure monitoring on patients are done by staff in the emergency center, she said, she did not have any documentation of training of staff for the risk reduction strategy or monitoring of patients.


Interviewed Compliance Officer (M)

During an interview on 06/05/2019 at 11:40 a.m., with Facility's Compliance Officer (M) revealed, since the incident a RCA was conducted on April 24th 2019, and a risk reduction strategy was developed. She said, the facility's Board was not made aware of the risk reduction strategy. It was discussed in the Patient Safety Collaborative Meetings which is held every two weeks, but it was not sent to the Patient Safety Committee, because the committee meets quarterly and the last meeting was held on April 9, 2019, prior to the incident.
She said, the incident was not reported to the State Survey Agency because the facility was trying to get through some of the investigation. She said the facility did not execute its plan well and escalate its strategy regarding addressing the incident.


Interviewed Patient Care Technician K

On 06/05/2019 at 1:15 p.m., an interview was conducted with Patient Care Technician (K) via the telephone. Interview with Patient Care Technician (K) revealed, she saw Patient #1 on 04/12/2019 at approximately 8:00 a.m. She said, the patient approached her and she checked his armband and he was not one of the patients she had done vital signs on when she came on duty. She told him, he was not in the system and she directed him to the triage nurse. The Patient then went into the direction of the nurse but she did not know what transpired next.

She said, during the course of the day she saw him "Just hanging around during the morning." She said, she observed him talking to Registered Nurse P. She was the nurse who found him in the bathroom down and called her over to help, at about 4:30 p.m.

She said, on entering the bathroom, the patient was lying on the floor and there was liquid vomitus on the floor. She started CPR on the patient and did two rounds of CPR on him with the other nurse, and then the patient was taken to the shock room.

She said, during shift change there is a huddle and at that time she is told to make more frequent rounds, make sure there are no patient hanging out. Vital signs are done every 4 hours with the exception of ESI 2 patients which is done every two hours.

She said, the tracker in EPIC system alerts her when the vital signs are to be done every 4 hours on patients, but for the 2-hour vital sign monitoring "We just have to keep our eyes out to ensure they are not hitting the two hours' mark."


Interviewed Registered Nurse (P)

Interview on 06/05/2019 at 1:50 p.m. with Registered Nurse (P) revealed, on 04/12/2019 at approximately 1:00 p.m., she was called to the restroom by a security officer who asked her to check on a patient who was in the restroom.

She said, on entering the restroom, she knocked on the door and asked the patient if he was ok. The patient said he was fine and so she then left the patient with the security guard and went back to the sort desk. She said. she knew he was a patient because he had been to the facility before.

She said, towards the afternoon, at approximately 4 - 5 p.m., the security guard told her somebody had passed out in the bathroom. She called for help and when she went in the bathroom, the patient was unresponsive. She placed the patient on the bathroom floor and started CPR. The Patient was then taken to the shock room.

She said, the nurse manager makes frequent rounds. EPIC triggers for 4-hour vital sign monitoring but not 2 hourly vital sign monitoring. She said "We have had no training regarding monitoring of patients and timely reporting of laboratory results."


Interviewed Deputy Security (L)

On 06/05/2019 at 2:40 p.m., an interview was conducted with Deputy Security Officer (L) via the telephone. Interview revealed, he generally starts his shift at 3:00 p.m. He said, at approximately 4:30 p.m. on 04/12/2019, a visitor approached him and told him a patient was in the bathroom for some hours.

He said, on entering the bathroom, the stall was locked and so he was able to look through a small crevice into the stall. He said Patient #1 was sitting on the toilet with his head slumped over resting against the wall. He called the patient's name and there was no response, and so he climbed up on the adjacent stall and looked over into the stall where the patient was located.

He said, the patient's skin was yellowish in color and he did not respond when his name was called. He kicked in the door, touched the patient on his shoulder but there was no response. He then went and told the nurse at the triage station that there was a patient in the bathroom who was not responding.

The nurse called the response team and they pumped his chest and a "whole lot of black stuff came out." He then went back to his post after they had placed the patient on the gurney and took him to the back.


Reviewed Emergency Center Staffing Roster

Review of the facility's staffing roster revealed, 156 staff currently were employed to the facility's emergency center. These staff included nurse clinicians, patient care technician, psychiatric technician, health unit coordinator, guest transportation representative, and supply /record clerk.

Review of the RCA revealed no evidence that staff were provided training on timely reporting of critical laboratory and monitoring of patients in the emergency center.


Review of Facility's Policy and Procedure

Review of the Facility's current Policy on EMTALA: Screening, stabilization and Transfer; Policy Number 3.56, effective 03/2013 directs staff as follows:

MSE:

" The MSE must be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination, such as a brief history and physical, to a complex examination that may include laboratory tests, Magnetic Resonance Imaging, (MRI) or diagnostic imaging, lumbar puncture, other diagnostic tests and procedures and if necessary, the use of on -call consultants."


"Reassessment of Patients Awaiting Treatments:

All patients who have been triaged and/ or received an MSE and are awaiting further treatment will be monitored and reassessed in a timely manner or urgently if it is observed that the patient may be deteriorating or the patient complains of increased pain or reports a more severe or additional complaint.

The PCT will collect the patient's current vital signs and statement of status and immediately report all remarkable changes to a RN or QMP.

If the PCT reports remarkable changes, the RN or QMP will reassess the patient. The RN may consult with QMP regarding the results of the reassessment.


Treatment, Discharge or transfer of stabilized patients:

"Once the MSE is completed and there is a determination that the Patient does not have an EMC or EMC has been stabilized, the Patient may be: treated (either in the DED, in observation or as an inpatient: Discharged; or transferred for continued care.

(B) Patients may be discharged from the DED if: The patient's EMC has been resolved and no further care for the immediate problem is needed; or the further care needed can be performed on an outpatient basis or on an in- patient basis at a later scheduled date.

Discharged patients are given a plan for appropriate follow up care and discharge instruction."


Reporting

Review of Facility's current Policy and Procedure on Self Reporting Requirements for Department of Aging and Disability Services and Department of State Health Services Agencies; Policy # 1.0 directs staff as follows: "Type of Reportable Incidents: Death: Upon receipt of significant incident or event, Accreditation department will report the incident to TDSHS Quality of Care Unit as specified below: Telephone notification made to TDSHS Quality of Care Unit Local office in Houston, TX at 713-767-3340.

A written investigation report will be submitted within seven working days from the day the oral report is made."


Reviewed Risk reduction strategy

Review of the facility's risk reduction strategy (DNA process) implemented April 26th 2019 revealed the following instruction:

Become familiar with the ESI levels, especially level 2, and to appropriately put the correct level for patients- triage techs- Please remember to complete Q2 hour vital signs on ESI Level 2 patients."

" Please exercise due diligence when dismissing patients that are not in the waiting room. but active in EPIC. Use overhead paging when calling patients to ensure that you are heard by everyone. Review charts and double check if they are somewhere else., i.e. x-ray, ultrasounds, etc. Document your attempts to locate the patient in epic."

The risk reduction strategy did not address what quality measures will be implemented to ensure compliance with the new monitoring process.

The risk reduction strategy provided did not address follow up action to be taken for patients with critical laboratory results while in the waiting room.

The risk reduction strategy did not address system developed and implemented to address timely reporting of point of care laboratory results.


Patient #2

Review of Patient #2's clinical record with the Registered Nurse Director of the Emergency Center, revealed the patient presented to the emergency center on 06/03/2019 at 1838 with history of chest pain, sinus pain, and diabetes mellitus.

The record indicated a partial medical screen was conducted on the patient at 2103. The record indicated the patient was removed from the system and discharged from the facility at 2153. The patient was triaged as a ESI level 2.

The record indicated the patient was not monitored every two hours as indicated in the emergency center risk reduction strategy.

Review of the patient's clinical record revealed no follow up call or discharge instructions documented in the patient's record. The patient was listed as leaving without been discharged.

Based on record review and interview, the facility's direct care staff failed to provide necessary care and services to patients who come to the facility's emergency center requesting examination of a medical condition. Patients were not reassessed in a timely manner, complete medical screening were not conducted, critical laboratory results were not reviewed, reported, and acted upon by clinical staff. These failures resulted in a patient being discharged from the facility's emergency center records and later found unresponsive and pulseless in one of the emergency center's bathrooms and ultimately died
.
The facility failed to reassess patients timely or follow up contact with the patient in order to notify him of the critical laboratory values;

The facility failed to have a system in place to tract and report critical laboratory values;

The facility failed to provide staff in the emergency center retraining on timely monitoring of patients in the emergency center and reporting of critical laboratory values.

This findings puts all patients in the facility's emergency center, health and safety at risk.


Findings:

Patient #1

Review of Patient #1's clinical record ( triage record ) dated 04/11/2019 indicated, patient was admitted to the facility's emergency center on 04/11/2019 at 12:46 P.M with chief complaint of abdominal pain for 8 days, loss of appetite for 5 days, vomiting, and history of diabetes mellitus. The patient's vital signs were taken at 12:48 p.m. during triage. The patient was triaged as a ESI level 2.

Review of a medical screen provider's notes dated 4/11/2019 revealed a partially completed medical screen which was conducted at 1339. The blood specimen was drawn on 04/11/2019 at 1305 but the physician failed to review and act upon the critical laboratory values reported at 1309 with the following values:

Glucose 508 mg/dl; (point of care) reference range 74-106 mg/dl.

CO2 17 mmol/L; (point of care) reference range 21-32 mmol/L

Sodium 124 mmol/L; (point of care) reference range 136- 145 mmol/L


The patient's clinical record revealed no further reassessment of the patient by facility's staff after the triage assessment timed 12:48 p.m. The record indicated calls/announcement were made by staff of the emergency center to locate the patient in the emergency center waiting area on 04/11/2019 at 1900, 04/11/2019 at 1930 and 04/11/2019 at 2102. There were no physical inspections of areas in the emergency center to locate the patient.

The record revealed there was no response from the patient to the verbal announcements and he was then discharged from the facility's emergency center records.

The record indicated, the patient was called for service/revaluation at 1900 hours, over six hours after being triaged, although critical laboratory results were available on 04/11/2019 at 1309.

Review of physician (O's) progress notes, dated 04/13/2019 revealed, the patient was brought into shock room, pulseless with cardiac arrest. He was found in the bathroom. At the time of the cardiac arrest code, it was not known how long the patient had been unconsious. Patient became asystole twice during the cardiac arrest code procedure. Time of Death was documented as 1734. The progress notes was dated 4/13/2019 but the episode happened on 04/12/2019.

Interview on 06/05/2019 at 9:05 a.m., with Medical Screen Provider (Physician I) revealed, he does medical screen before results of laboratory values are made available. He said, he was not notified regarding Patient #1's critical laboratory values.

Interview with Patient Care Technician (K) revealed, she saw Patient (#1) on 04/12/2019 at approximately 8:00 a.m. She said, the patient approached her and she checked his armband and he was not one of the patients she had done vital signs on when she came on duty. She then directed him to the triage nurse.

Interview on 06/05/2019 at 1:50 p.m. with Registered Nurse (P) revealed, on 04/12/2019 at approximately 1:00 p.m., she was called to the rest room by a security officer who asked her to check on a patient who was in the rest room. She said, on entering the rest room, she knocked on the door and asked the patient if he was ok.The patient responded that he was fine.

She said, towards the afternoon, at approximately 4-5 p.m., the security guard told her somebody had passed out in the bathroom. She called for help and when she went in the bathroom the patient was unresponsive. She placed the patient on the bathroom floor and started CPR. The patient was then taken to the shock room with CPR in progress. The patient became asystole twice and pronounced dead at 1734.

Based on the above findings it is determined that facility's action did puts the patient's health and safety in jeopardy.

Based on observation, record review, and interview, the facility's direct care staff failed to provide necessary care and services to patients who come to the facility's emergency center requesting examination of a medical condition. The patients were not monitored in a timely manner, complete medical screening were not conducted, critical laboratory results were not reviewed, reported, and acted upon by clinical staff. These failures resulted in a patient being discharged from the facility's emergency center records. The patient was found later unresponsive and pulseless in one of the facility's bathrooms and ultimately died.

The facility failed to reassess patients timely or follow up with the patient regarding critical laboratory values;

The facility failed has no system in place to tract and report critical laboratory values;

The facility failed to provide staff in the emergency center retraining on timely monitoring of patients in the emergency center and reporting of critical laboratory values.

This finding puts all patients in the facility's emergency center, health and safety at risk.

Findings:

Observation

Observation on 06/04/2019 of the facility's emergency center revealed, on entering the emergency center there were two separate entries, one for patients arriving by ambulance and one for ambulatory patients. Ambulatory patients are first seen by a registered nurse identified as a (Sort Nurse).

The nurse was observed interacting with patients, conducting vital signs and obtaining information, i.e. presenting symptoms. After being seen by the Sort nurse, determination is made based on the patients' presenting symptoms how the patients were triaged.

Patients were observed in the waiting room of the emergency center, in pods, in three large holding areas, out of bed, and in the hemodialysis unit.

The emergency center has accommodation for 63 patients, 35 of the beds are assigned for medical usage and the other beds assigned for patients with psychiatric symptoms and trauma emergencies.

Observation of the emergency center revealed a 63 bed holdings area fully occupied with patients who were triaged and examined by physicians or the mid- level provider. There were eleven patients in the medical holding area who were admitted to the facility but was awaiting the availability of inpatient beds on the various units.

Patient #1

Review of Patient #1's clinical record (triage record) dated 04/11/2019 indicated the patient was admitted to the facility's emergency center on 04/11/2019 at 12:46 P.M with chief complaint of abdominal pain for 8 days, loss of appetite for 5 days, vomiting, and history of diabetes mellitus. The patient's vital signs were taken at 12:48 p.m. during triage. The patient was triaged as a ESI level 2.

Review of a medical screen provider's notes dated 4/11/2019 revealed a partially completed medical screen which was conducted at 1339, without review of critical laboratory values. The blood specimen was drawn on 04/11/2019 at 1305 and the results were reported at 1309 with the following values:

Glucose 508 mg/dl; (point of care) reference range 74-106 mg/dl.

CO2 17 mmol/L; (point of care) reference range 21-32 mmol/L

Sodium 124 mmol/L; (point of care) reference range 136- 145 mmol/L


Medical Screening Examination Provider's notes:

Review of a medical screen provider's notes conducted by emergency center physician (I) at 1339 revealed the following entry:

"I evaluated and initiated the medical screening examination of patient #I. Key symptoms and Findings:

Vitals: BP: 118/85 Pulse 91, Respiration 20, Temperature 98.4 F (36.9 C), SpO2 100%, nausea, vomiting, diarrhea, abdominal pain for 8 days with poor PO. No other GI/GU SX. No distress.

Assessment:

Further evaluation will be necessary in order to determine if an emergency medical condition exists. The Patient will continue in process until such time they are deemed ready for disposition."

The patient's clinical record revealed no further monitoring of the patient by facility's staff after the triage assessment timed 12:48 p.m.. The record indicated calls/announcement were made by staff of the emergency center to locate the patient in the emergency center waiting room on 04/11/2019 at 1900, 04/11/2019 at 1930 and 04/11/2019 at 2102. There was no physical inspection done of areas in the emergency center to locate the patient. The record revealed there was no responseto the verbal calls/announcements from the patient and he was then discharged from the emergency center records.

The record indicated the patient was called for service/revaluation at 1900 hours, over six hours after being triaged, although critical laboratory results were available on 04/11/2019 at 1309.


Progress notes

Review of the patient's progress notes dated 04/12/2019 at 5:00 p.m. revealed the following documentation from physician S:

"Trauma Code activated for patient found down in bathroom pulseless. CPR initiated and continued prior to trauma activation. No overt signs of external trauma."

04/12/2019 at 5:00 p.m. nurse's progress notes documented, "66 Y/O Hispanic male brought to SR4, in progress of ongoing CPR. Per triage RN, pt was found in the triage restroom on the ground unresponsive and pulseless, unwitnessed time of fall/ unresponsiveness. Ongoing CPR start at 1700. MD (T) in charge of code. Pt placed on CM, Vfib pulseless. No O2/bp readings. RT radiology, anesthesia, RNs at bedside assisting with code. Pt expelling copious amount of dark brown contents, suctioned oral cavity. LMA placed by MD U."

Review of physician (O's) progress notes dated 04/13/2019 revealed, the patient was brought into shock room, pulseless with cardiac arrest. He was found down in the bathroom, and at the time of the code it was unknown amount of time the patient has been pulseless. Patient became asystole twice during the c=cardiac code procedure. Time of Death was documented as 1734.


Review of Critical Care Progress Notes of physician O

Review of critical care progress notes of physician O, dated 04/13/2019 revealed the following documentation:

"66-year-old male who was brought into shock room pulseless with cardiac arrest. He was found down in the bathroom, at time of code for unknown amount of time. Upon arrival, ACLS followed. Initially had head LMA placed then he was intubated by EC resident with good end tidal and breath sounds bilaterally. He continued to have good end tidal and O2 waveform during code. He had an IO placed. Initially patient with PEA and asystole then developed A- fib refractory to multiple shocks as well as dual sequential defibrillation. He was given epi, amiodarone, lidocaine, bicarb insulin, calcium magnesium and stat block blood without regain pulses. POCUS u/s did not show cardiac tamponade. he had good lung sliding bilaterally RT bagging. POCUS did not show sign of RV strain or bowing of septum. Cardiology was also called for refractory v fib. All members of care team were asked of any additional thoughts after patient's rhythm changed from v-fib to asystole X 2. Cardiology in agreement. TOD at 1734. Patient had no family when speaking with SW. He had a friend who arrived and DR T spoke with friend, Chaplain services was also available."


Review of a Death Notice and Status Report Form

Review of the Patient's clinical record revealed a Death Notice and Status Report Form which was partially completely which indicated the probable cause of death as cardiac arrest. Autopsy was not applicable.


Interviews

Registered Nurse (F)

During an interview on 06/04/2019 at 10:44 a.m. with Registered Nurse (F) revealed, he works the 7 p.m. - 7:00 a.m. shift in the facility's emergency center. He said he cannot recall "laying eyes on patient" (referring to Patient #1), but he knows, patient care technicians were assigned to monitor patients' vital signs. This process involves bringing patients in batches to a specific area to have their vital signs monitored. He stated, "We call them once, call them 30 minutes after and if they do not answer after the third call, then they are taken out of the system (referring to patients in the waiting room). He said the triage nurse makes the determination to take the patient out of the system.

He said prior to removing the patient from the system, radiology or CAT scan departments are contacted to see if the patient was sent for a procedure. If the response is no, then the patient is removed from the system.

Registered Nurse (F) said, his involvement with Patient #1, included going through the patient's chart to determine if there were critical laboratory results or orders that were lingering. He said, he identified that the patient had a blood glucose level in excess of 500 and he told the Medical Screen Examiner Registered Nurse (R) of the result. He said he did not notify the physician of the critical laboratory result on the patient because once he becomes aware of critical laboratory results then he relays the information to the medical screen examiner registered nurse, who in turn will notify the physician or mid-level provider.

He said, he had no further contact with the patient's information. He said patients who are triaged at a ESI level 2, vital signs were monitored every 4 hours, but recently in the last two to three weeks, monitoring is done every 2 hours for ESI level 2 patients. He said, patients triaged as ESI level 3, 4, and 5 vital signs are still monitored every 4 hours.

He said since the incident, discussions are held with staff in the emergency center during shift change, regarding increasing the frequency of ESI level 2 patients' vital signs monitoring, rounding in the lobby and being diligent about checking with radiology before taking someone out of the system.


Interviewed Registered Triage Nurse (G)

During an interview on 06/04/2019 at 11:00 a.m. with Registered Triage Nurse (G)revealed, she triaged Patient #1 from the triage desk at approximately 12:48 P.M on 04/11/2019. She said, the patient presented with chief complaint of diffused abdominal pain, nausea, and vomiting. The patient was seen by her at the sort desk and triaged as a ESI level 2, based on the information provided to her of the patient having diffused abdominal pain for 8 days, not eating, and having a diagnosis of Diabetes Mellitus. She said, the Patient should have been placed in a pod for close monitoring but there was no bed available.

She said, she ordered an EKG, cardiac panel, CBC, and BNP on the patient and after doing expedited laboratory orders, she does not follow through with the results of the laboratory ordered. She said The MSE nurse is generally given the laboratory results, who in turn passes the results to the medical provider. She said, vital signs on ESI level two patients were done every 4 hours but within the last two months it is done every 2 hours.

She said, since the new monitoring process was implemented, staff huddle at the beginning of the shift to be reminded of expectations but she was not provided with training on monitoring of patients.

She said, she can only recall her initial contact with the patient, where she started the laboratory work up, but she does not follow up on ambulatory triages. She said her shift ended at 7:00 p.m. and she did not know what happened to the patient after her initial contact.


Interviewed Registered Nurse (E)

Subsequent interview on 06/04/2019 at 2:10 p.m. with Registered Nurse (E) revealed, the patient was found by a security guard in a bathroom stall with the door locked. The security guard then notified a nurse from the emergency center who responded and started CPR on the patient. He said, the door to the bathroom stall had to be kicked in, and the patient was found on the toilet with his wheelchair beside him.


Interviewed Registered Nurse (H)

During an interview on 06/04/2019 at 2:16 p.m. via the telephone with Registered Nurse (H) revealed, on the day of the incident on 04/12/2019, with Patient #1, she was sitting in the medical screening room when she noticed a physician hurriedly went across to the bathroom. He followed the doctor into the bathroom and the doctor with two patient care technicians were putting the patient on the floor, while the doctor was giving instruction to initiate CPR. She said, there were a lot of vomitus on the floor. She said, all staff in the bathroom picked up the patient and placed him on the stretcher while continuing to do CPR. The patient was taken to the critical care area where the care was turned over to the critical care team.

She said, the patient was not on her census but she knew the patient was a DNA from the evening before. She said, since the incident patients triaged as ESI level 2, vital signs are done every two hours and the facility has initiated checking the physical census with the patient's arm band every 6 hours. She said 4 hourly vital signs can be monitored from the tracking board in the EPIC system but two hourly tracking of vital signs cannot be done.


Interviewed physician (I) MD Emergency Services

Interview on 06/5/2019 at 9:05 a.m. with physician (I) revealed, he saw Patient #1 on 04/11/2019. He said, he was not made aware of the critical laboratory results on the patient. He said, generally, he does the medical screen on patients long before labs are drawn on patients. He said there is never any laboratory results available at the time of medical screening, because it is not his responsibility to follow up on laboratory results. He said he is constantly conducting assessments on patients or responding to questions from patients and other staff, so he does not track the result of laboratory drawn on patients.

He said since the incident, he came up with his own system of allowing the EPIC computer system to pull in the laboratory results from the lab, however laboratory results done at point of care in the emergency center have to be relayed to him by other staff. He said there was no current system in place to track laboratory results.


Interviewed physician (J) Emergency Center Medical Director

Interview on 06/05/2019 at 9:10 a.m. with physician (J) Emergency Center Medical Director revealed, the Sort Nurse enters patients' laboratory orders in the system and the emergency room technician draws the patients' blood. He said, there is no control point of entrance or exit in the emergency center, so patients utilize the ability to go and come as they please. He said there is a disconnect when laboratory results are reported.

He said, the emergency center is currently working with the laboratory to determine what meets threshold for critical findings. He said a new emphasis is being developed for better communication between the laboratory and point of care testing.

He said, the facility's emergency center has a significant boarding problem, in that the department has 63 emergency center beds. Of the total number of emergency center beds, there are currently 20 patients admitted to the facility who are boarding in the emergency center, 10 psychiatric patients in the holding area i.e. half of the emergency center beds are in lock down.

He said, regarding staff training systems implemented to address laboratory reporting and monitoring of patients in the emergency room, he said this is deferred to nursing leadership.


Interviewed Registered Nurse (N) Director of Nursing Emergency Center

Interview on 06/05/2019 at 11:30 a.m. with the Director of Nursing Emergency Center revealed, she had implemented a risk reduction strategy which she developed. The staff conduct huddle at the beginning of each shift but there was no formalized training provided to staff since the incident. She said, as part of the risk reduction strategy facility's staff is expected to round on patients in the waiting room every 6 hours and for ESI level 2 patients monitored every two hours.

When asked by the Surveyor what monitoring tool is utilized to ensure monitoring on patients are done by staff in the emergency center, she said she did not have any documentation of training of staff for the risk reduction strategy or monitoring of patients.


Interviewed Compliance Officer (M)

During an interview on 06/05/2019 at 11:40 a.m. with Facility's Compliance Officer (M) revealed, since the incident a RCA was conducted on April 24, 2019, and a risk reduction strategy was developed. She said the facility's Board was not made aware of the risk reduction strategy. It was discussed in the Patient Safety Collaborative Meetings which is held every two weeks, but it was not sent to the Patient Safety Committee, because the committee meets quarterly and the last meeting was held on April 9, 2019, prior to the incident.
She said, the incident was not reported to the State Survey Agency because the facility was trying to get through some of the investigation. She said, the facility did not execute its plan well and escalate its strategy regarding addressing the incident.


Interviewed Patient Care Technician K

On 06/05/2019 at 1:15 p.m. an interview was conducted with Patient Care Technician (K) via the telephone. Interview with Patient Care Technician (K) revealed, she saw Patient #1 on 04/12/2019 at approximately 8:00 a.m. She said, the patient approached her and she checked his armband and he was not one of the patients she had done vital signs on when she came on duty. She told him he was not in the system and she directed him to the triage nurse. The Patient then went into the direction of the nurse but she did not know what transpired next.

She said, during the course of the day she saw him "Just hanging around during the morning." She said, she observed him talking to Registered Nurse P. She was the nurse who found him in the bathroom down and called her over to help, at about 4:30 p.m. She said, on entering the bathroom, the patient was lying on the floor and there was liquid vomitus on the floor. She started CPR on the patient and did two rounds of CPR on him with the other nurse, and then the patient was taken to the shock room.

She said, during shift change there is a huddle and at that time she is told to make more frequent rounds, make sure there are no patient hanging out. Vital signs are done every 4 hours with the exception of ESI 2 patients which is done every two hours.

She said, the tracker in EPIC system alerts her when the vital signs are to be done every 4 hours on patients, but for the 2-hour vital sign monitoring "We just have to keep our eyes out to ensure they are not hitting the two hours' mark."


Interviewed Registered Nurse (P)

Interview on 06/05/2019 at 1:50 p.m. with Registered Nurse (P) revealed, on 04/12/2019 at approximately 1:00 p.m., she was called to the restroom by a security officer who asked her to check on a patient who was in the restroom.

She said, on entering the restroom, she knocked on the door and asked the patient if he was ok. The patient said he was fine and so she then left the patient with the security guard and went back to the sort desk. She said she knew he was a patient because he had been to the facility before.

She said, towards the afternoon, at approximately 4 - 5 p.m. the security guard told her somebody had passed out in the bathroom. She called for help and when she went in the bathroom the patient was unresponsive. She placed the patient on the bathroom floor and started CPR. The Patient was then taken to the shock room.

She said, the nurse manager makes frequent rounds. EPIC triggers for 4-hour vital sign monitoring but not 2 hourly vital sign monitoring. She said "We have had no training regarding monitoring of patients and timely reporting of laboratory results."


Interviewed Deputy Security (L)

On 06/05/2019 at 2:40 p.m. an interview was conducted with Deputy Security Officer (L) via the telephone. Interview revealed he generally starts his shift at 3:00 p.m. He said, at approximately 4:30 p.m. on 04/12/2019, a visitor approached him and told him a patient was in the bathroom for some hours.

He said, on entering the bathroom, the stall was locked and so he was able to look through a small crevice into the stall. He said, Patient #1 was sitting on the toilet with his head slumped over resting against the wall. He called the patient's name and there was no response, and so he climbed up on the adjacent stall and looked over into the stall where the patient was located.

He said the patient's skin was yellowish in color and he did not respond when his name was called. He kicked in the door, touched the patient on his shoulder but there was no response. He then went and told the nurse at the triage station that there was a patient in the bathroom who was not responding.

The nurse called the response team and they pumped his chest and a "whole lot of black stuff came out." He then went back to his post after they had placed the patient on the gurney and took him to the back.


Reviewed Emergency Center Staffing Roster

Review of the facility's staffing roster revealed 156 staff currently were employed to the facility's emergency center. These staff included nurse clinicians, patient care technician, psychiatric technician, health unit coordinator, guest transportation representative, and supply/record clerk.

Review of the RCA revealed no evidence that staff were provided training on timely reporting of critical laboratory and monitoring of patients in the emergency center.


Review of Facility's Policy and Procedure

Review of the Facility's current Policy on EMTALA: Screening, stabilization and Transfer; Policy Number 3.56, effective 03/2013 directs staff as follows:

MSE:

" The MSE must be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination, such as a brief history and physical, to a complex examination that may include laboratory tests, Magnetic Resonance Imaging, (MRI) or diagnostic imaging, lumbar puncture, other diagnostic tests and procedures and if necessary, the use of on -call consultants."


"Reassessment of Patients Awaiting Treatments:

All patients who have been triaged and/ or received an MSE and are awaiting further treatment will be monitored and reassessed in a timely manner or urgently if it is observed that the patient may be deteriorating or the patient complains of increased pain or reports a more severe or additional complaint.

The PCT will collect the patient's current vital signs and statement of status and immediately report all remarkable changes to a RN or QMP.

If the PCT reports remarkable changes, the RN or QMP will reassess the patient. The RN may consult with QMP regarding the results of the reassessment.


Treatment, Discharge or transfer of stabilized patients:

"Once the MSE is completed and there is a determination that the Patient does not have an EMC or EMC has been stabilized, the Patient may be: treated (either in the DED, in observation or as an inpatient: Discharged; or transferred for continued care.
(B) Patients may be discharged from the DED if: The patient's EMC has been resolved and no further care for the immediate problem is needed; or the further care needed can be performed on an outpatient basis or on an in- patient basis at a later scheduled date.
Discharged patients are given a plan for appropriate follow up care and discharge instruction."


Reporting

Review of Facility's current Policy and Procedure on Self Reporting Requirements for Department of Aging and Disability Services and Department of State Health Services Agencies; Policy # 1.0 directs staff as follows: "Type of Reportable Incidents: Death: Upon receipt of significant incident or event, Accreditation department will report the incident to TDSHS Quality of Care Unit as specified below: Telephone notification made to TDSHS Quality of Care Unit Local office in Houston, TX at 713-767-3340.
A written investigation report will be submitted within seven working days from the day the oral report is made."


Reviewed Risk reduction strategy

Review of the facility's risk reduction strategy (DNA process) implemented April 26th 2019 revealed the following instruction:
Become familiar with the ESI levels, especially level 2, and to appropriately put the correct level for patients- triage techs- Please remember to complete Q2 hour vital signs on ESI Level 2 patients."

" Please exercise due diligence when dismissing patients that are not in the waiting room. but active in EPIC. Use overhead paging when calling patients to ensure that you are heard by everyone. Review charts and double check if they are somewhere else., i.e. x-ray, ultrasounds, etc. Document your attempts to locate the patient in epic."

The risk reduction strategy did not address what quality measures will be implemented to ensure compliance with the new monitoring process.

The risk reduction strategy provided did not address follow up action to be taken for patients with critical laboratory results while in the waiting room.

The risk reduction strategy did not address system developed and implemented to address timely reporting of point of care laboratory results.


Patient #2

Review of Patient #2's clinical record with the Registered Nurse Director of the Emergency Center, revealed the patient presented to the emergency center on 06/03/2019 at 1838 with history of chest pain, sinus pain, and diabetes mellitus.

The record indicated a partial medical screen was conducted on the patient at 2103. The record indicated the patient was removed from the system and discharged from the facility at 2153. The patient was triaged as a ESI level 2.

The record indicated the patient was not monitored every two hours as indicated in the emergency center risk reduction strategy.

Review of the patient's clinical record revealed no follow up call or discharge instructions documented in the patient's record. The patient was listed as leaving without been discharged.