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Based on interview, and record review, the facility failed to take actions aimed at performance improvement to measure success and track performance to ensure that improvements (timely intervention, escalation, qualified staff, and transfer process) were sustained for 1 (SP#1) out of 8 sample patients (SP).

Findings include:

Review of sample patient (SP) #1 Emergency Services Triage Encounter Form dated 09/30/2018 revealed that patient arrived by Fire Rescue with a Chief Complaint of Syncope.

Review of SP#1 Emergency Department Triage Assessment Form dated 09/30/2018 revealed recommended Emergency Severity Index (ESI) Acuity Level is 3. Peripheral Pulse Rate: 48 beats per minute (LOW). Pediatric Sepsis Screen: Heart Rate Normal for age.

According to the "General Vital Signs and Guidelines" provided by the hospital, for 4-6 years old, the normal heart rate is 70-120 beats/ minute.

Review of staff A Nursing Notes showed on 09/30/2018 at 08:50 am SP #1 heart rate reading low 39-48 but child is a/a (awake/alert) MD called to bedside. At 08:55 am MD at bedside made aware of hr. (heart rate) monitor with heart rate 98 (O2) sat 100%, hr (heart rate) keep fluctuating from low 30 to 73. At 11:13 am, child becoming agitated, taking off leads, and pulse oximeter, color pale, MD at bedside, child is not responding, will prepare for intubation, CPR started right away.

Review of SP#1 Emergency/Trauma Documentation dated 09/30/2018 revealed the patient presented to the Emergency Department by Emergency Medical Services (EMS) after what was reported as a possible syncopal episode at home. According to the patient's mother, patient was having nausea, vomiting and diarrhea for 3 days associated with fever. On Sunday, the child had an episode of vomiting and diarrhea an episode where the child was clenching fists and having a stare and was nonresponsive afterwards. During this episode, the patient's face hit the nightstand and developed an abrasion of the upper lip. Patient's mother attempted to do cardiopulmonary resuscitation and called EMS. On EMS arrival patient was alert and oriented. Intravenous access was established and patient was transported to hospital pediatric emergency department. The onset was just prior to arrival. Triage vitals showed heart rate initially of 48, within few minutes the heart rate was in the upper 70s to 80s. At 10:06AM, the heart rate went up to 199 beats per minute. The Emergency department physician was notified. Patient was alert and hemodynamically stable. Medication was given for the heart rate but was ineffective. An electrocardiogram was performed and showed sinus tachycardia in the 190s with short PR and right bundle branch block( irregular heart rate). Blood work was still pending and a Computed Tomography (CT) of the brain was ordered.

The hospital transfer line was called at 10:17AM, patient was accepted and report was given to receiving physician. Patient pending transfer. After the patient returned from the CT scan patient had an episode of seizure activity associated with stare and unresponsiveness. At 11:26AM patient became bradycardic (slow heart rate) and bradypneic (slow breathing) and was immediately resuscitated. During this extensive code, patient recovered pulses briefly for few minutes on several occasions. During the code, the hospital transfer center was called to provide a new report to the Pediatric Intensive Care Unit (PICU) attending physician for transfer when the patient is stable. After almost 2 hours of resuscitation that was unsuccessful and the patient being back in asystole, patient was pronounced dead.


On 12/04/2018 during interview with the Director of ED ( Emergency Department) at 12:45 PM revealed a delay in care was identified. Nurse informed MD (Medical Doctor); however, nurse felt that MD did not implement interventions in a timely manner and did not notify Charge Nurse of the concern because MD was at the bedside. Nurse was counseled about escalation policy and received remediation. Also, ED department is receiving on-going training.
There are no pediatrician's on-staff. Physicians scheduled for Pediatric ED are board certified and privileged to assess, evaluate and initially treat patients of all ages. Risk Management did a review of communication for the transportation via recordings. Transfer Center Leadership identified a process change to be implemented in order to expedite the pediatric transfer process. This is related to the change in criteria that required the assembling of specific staff for the transfer.

Interview on 01/02/2019 with Risk Management at 2:00 pm also revealed the [named children's hospital at the main campus] physicians are Board Certified Pediatricians, no added training for physicians at this campus were completed.


Review of the Pediatric ER Education/ Action Plan for the nurses received on 01/02/2019 at 01:33 PM showed there will be completion of observations, chart audits, and 1:1 supervision.
Facility only had audits of 3 nurses provided on 01/02/2019 to measure success and track performance of the training for Pediatric Emergency Department Nurses.

Interview with Chief Nursing Officer on 01/02/2019 at 1:07PM revealed there was a Pediatric Emergency Department Comprehensive Exam that all current Pediatric Emergency Department Registered Nurses passed the assessment with a score of 80% or greater which identified competence. There was one nurse that was not successful with the exam and the re-take; therefore, the nurse was removed from the Pediatric Emergency Department area.


Review of the ED Pediatric Re-take Exam Analysis previously taken by the ED nurse referenced above was not provided until 1/02/2019. The ED Pediatric Re-take Exam Analysis showed ED Registered Nurses staff A, B, E, G, H, and I did not pass with a score 80%. The ED Pediatric Re-take Exam was completed on 12/13/2018 showed that staff B did not pass the re-take exam.
Review of sample patient # 1 record showed that staff A was the Registered Nurse of SP #1.

The Risk Manager stated on 12/4/2018 that a review of communication for the transportation via recordings. Transfer Center Leadership identified a process change to be implemented in order to expedite the pediatric transfer process. This is related to the change in criteria that required the assembling of specific staff for the transfer.
Risk Management did a review of communication for the transportation via recordings. Transfer Center Leadership identified a process change to be implemented in order to expedite the pediatric transfer process. This is related to the change in criteria that required the assembling of specific staff for the transfer.

The Risk Manager also stated on 12/4/2018 that the transfer process from the facility to the Children's Hospital. A Meeting was held with the facility and the Transfer Center leadership on November 27, 2018 to discuss opportunities to improve the inter-hospital transfer process. The patient was initially accepted for transfer to a regular pediatric unit but the patient's condition deteriorated and needed to be admitted to the Pediatric Intensive Care Unit.
On 01/02/2019 a policy for Transfer labeled as "Draft" was provided but there was nothing to substantiate that a modification in policy was implemented. It was noted that the concern was presented at the meeting.

Interview with Director of Quality on 01/02/2019 at 3:46PM revealed that there were currently no quality assessment performance improvement projects/indicators related to SP#1.

Based on interview, record and policy review, the facility failed to provide medical and nursing personnel qualified in emergency care to meet the emergency needs of 1 (SP#1) out of 6 sample patients (SP) in accordance with acceptable standards of practice.

Findings include:

Review of sample patient (SP) #1 Emergency Services Triage Encounter Form dated 09/30/2018 revealed that patient arrived by Fire Rescue with a Chief Complaint of Syncope.

Review of SP#1 Emergency Department Triage Assessment Form dated 09/30/2018 revealed recommended Emergency Severity Index (ESI) Acuity Level is 3. Peripheral Pulse Rate: 48 beats per minute (LOW). Pediatric Sepsis Screen: Heart Rate Normal for age.

Review of staff A Nursing Notes showed on 09/30/2018 at 08:50 am SP #1 heart rate reading low 39-48 but child is a/a (awake/alert) MD called to bedside. At 08:55 am MD at bedside made aware of hr. (heart rate) monitor with heart rate 98 (O2) sat 100%, hr (heart rate) keep fluctuating from low 30 to 73. At 11:13 am, child becoming agitated, taking off leads, and pulse oximeter, color pale, MD at bedside, child is not responding, will prepare for intubation, CPR started right away.

Staff A assessment and documentation revealed that patient arrived at 08:59 to the Pediatric Emergency Department (PED) bradycardic with heart rate of 48. Initial triage note gave the patient an Emergency Severity Index (ESI) Level of 3 and stated patient has normal heart rate on Pediatric Sepsis Screen.

According to the "General Vital Signs and Guidelines" provided by the hospital, for 4-6 years old, the normal heart rate is 70-120 beats/ minute.

Review of SP#1 Emergency/Trauma Documentation dated 09/30/2018 revealed the patient presented to the Emergency Department by Emergency Medical Services (EMS) after what was reported as a possible syncopal episode at home. According to the patient's mother, patient was having nausea, vomiting and diarrhea for 3 days associated with fever. On Sunday, the child had an episode of vomiting and diarrhea an episode where the child was clenching fists and having a stare and was nonresponsive afterwards. During this episode, the patient's face hit the nightstand and developed an abrasion of the upper lip. Patient's mother attempted to do cardiopulmonary resuscitation and called EMS. On EMS arrival patient was alert and oriented. Intravenous access was established and patient was transported to hospital pediatric emergency department. The onset was just prior to arrival. Triage vitals showed heart rate initially of 48, within few minutes the heart rate was in the upper 70s to 80s. At 10:06 AM, the heart rate shot up to 199 beats per minute. Emergency department physician was notified. Patient was alert and hemodynamically stable. Medication was given for the heart rate but was ineffective. An electrocardiogram was performed and showed sinus tachycardia in the 190s with short PR and right bundle branch block (irregular heart rate). Blood work was still pending and a Computed Tomography (CT) of the brain was ordered.

The hospital transfer line was called at 10:17AM, patient was accepted and report was given to receiving physician. Patient pending transfer. After the patient returned from the CT scan patient had an episode of seizure activity associated with stare and unresponsiveness. At 11:26AM patient became bradycardic (slow heart rate) and bradypneic (slow breathing) and was immediately resuscitated. During this extensive code, patient recovered pulses briefly for few minutes on several occasions. During the code, the hospital transfer center was called to provide a new report to the Pediatric Intensive Care Unit (PICU) attending physician for transfer when the patient is stable. After almost 2 hours of resuscitation that was unsuccessful and the patient being back in asystole, patient was pronounced dead.

Review of SP#1 Transfer Log dated 09/30/201 at 10:17AM revealed Reason for Transfer: Service not provided at the facility. Diagnosis: Tachycardia. Service: Pediatric Intensive Care Unit (PICU). Outcome of call: Pending. Follow-up Call at 11:08AM. Outcome of Call: Accepted. Additional Comments: Expired.

Review of the Medication Administration record showed on 09/30/2018 Lorazepam 1 mg IV push was given. The order for Lorazepam 1 mg IV push was ordered on 09/30/2018 at 20:43 PM.

Interview with Emergency Department Medical Director on 12/03/2018 at 12:53 PM revealed that physicians are the only provider scheduled to work in the Pediatric Emergency Department (PED). Physicians are certified in emergency medicine by the American Board of Emergency Medicine. The PED (Pediatric Emergency Department) is functional 24 hours a day and 7 days a week. There is a physician available for 12 hour schedules of 8:00AM - 8:00PM and 8:00PM - 8:00AM.

On 12/04/2018 during interview with the Director of ED (Emergency Department)at 12:45 PM revealed a delay in care was identified. Nurse informed MD (Medical Doctor); however, nurse felt that MD did not implement interventions in a timely manner and did not notify Charge Nurse of the concern because MD was at the bedside. Nurse was counseled about escalation policy and received remediation. Also, ED department is receiving on-going training.
There are no pediatrician's on-staff. Physicians scheduled for Pediatric ED are board certified and privileged to assess, evaluate and initially treat patients of all ages. Risk Management did a review of communication for the transportation via recordings. Transfer Center Leadership identified a process change to be implemented in order to expedite the pediatric transfer process. This is related to the change in criteria that required the assembling of specific staff for the transfer.
Interview on 01/02/2019 with Risk Management at 2:00 pm also revealed the [named children's hospital at the main campus] physicians are Board Certified Pediatricians, no added training for physicians at this campus were completed.

Interview with Chief Nursing Officer on 01/02/2019 at Interview with Chief Nursing Officer on 1:07 PM revealed there was a Pediatric Emergency Department Comprehensive Exam that all current Pediatric Emergency Department Registered Nurses passed the assessment with a score of 80% or greater which identified competence. There was one nurse that was not successful with the exam and the re-take; therefore, the nurse was removed from the Pediatric Emergency Department area.


Interview with Director of Quality on 01/02/2019 at 3:46PM revealed that there were currently no quality assessment performance improvement projects/indicators related to SP#1.

Review of Policy Number 602 - Section: Clinical Management: Pediatrics - Subject: Pediatric Triage Criteria last revised 02/2011 revealed pediatric patients are defined as persons under the age of 18 years. Triage performed based on the presenting problem, illness or injury noted a guideline for establishing the acuity of a patient as life threatening, emergent, stable and non-urgent.

Review of Policy Number 306 - Section: Clinical Management: Triage - Subject: Triage Management Policy last revised (06/2013) revealed Emergency Severity Index (ESI) Acuity Levels:
Level 1 - The patient is unable to wait in triage; taken to designed treatment area immediately. Patient is dying and requires life-saving interventions.
Level 2 - The patient able to wait in triage for a chart before being taken to the assigned treatment area. Patient has a high-risk situation. Patient is acutely confused/ lethargic/ disoriented.
Level 3 describes the patient can wait in triage for the next available space in the assigned treatment area. Patient requires two or more resources.
A Registered Nurse will perform the patient assessment and determine the individual's acuity based on sound clinical judgement and the appropriate standard as described according to patient complaints and symptoms. It is noted that Triage Protocols are meant as a "blue print" or "guide" for practice to assist the clinician, and may not address all practice situations. No written guide can replace the clinician's good clinical judgement and experience. If in doubt, the clinician is advised to seek senior resources to guide judgement and appropriately assign acuity in an individual case.

Review of Policy Number 138 - Section: 100-200 Administration - Subject: Chain of Command Policy created (04/09/2018) revealed Nursing and Ancillary Chain of Command a: After the clinical staff evaluates the patient and the prescribed treatment regimen and makes the determination that there is a patient management issue, he/she shall contact the attending provider or the appropriate consultation of the orders or prescribed treatment. If a consultant is called, the attending provider should be notified and debriefed of the patient's condition. b: If, after discussion with the attending provider, the clinical staff remains concerned that the issue at hand may adversely affect the patient or does not comply with established policy and procedure of the hospital, or if the staff is unable to reach the attending provider, (s) he shall take the following steps: i. Document the calls to the attending provider. ii. Notify the Supervisor/Manager/Director or Administrator in Charge of the situation. Document such notification in the patient's medical record, including date, time and person notified and what was communicated or decided during the exchange. iii. Retain accountability for the patient; continue to monitor the patient's status and perform actions necessary to provide for the patient's well-being.