HospitalInspections.org

Based on interview and record review, the Governing Body (GB) did not provide adequate oversight to ensure safe and effective patient care. This occurred when:

1. Governing Body failed review the contract services policy and procedures for one of one contracted dialysis (a treatment for people whose kidneys are failing) service (Company A). (Refer to A - 0084).

2. The facility failed to ensure medical staff for one (1) of five (5) sampled patients (Patient 1) had written policies and procedures to provide continuous monitoring, reassess the effectiveness of medication administered for the chest pain with a diagnosis of Non-STEMI (Non-ST [a segment of the electrical signal from the heart to check for different heart conditions] Elevation Myocardial Infarction is a type of heart attack in which a minor artery of the heart is completely blocked or a major artery of the heart is partially blocked) and follow treatment of patient if admitted by a cardiologist. (Refer to A - 0093).

3. The facility failed to ensure medical staff for one (1) of five (5) sampled patients (Patient 1) follow facility's policy and procedure for chest pain management for patient presenting in the emergency room of the hospital by:

a. Not administering medication (Morphine [pain medication] and Nitroglycerin [medication used to for chest pain to help open the blood vessel]) according to facility's policy and procedure for chest pain.

b. Monitoring patient's cardiac rhythm (heart monitor) continuously and documented in the patient medical record.
(refer to A - 0093).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment and in accordance with 482.12 Condition of Participation for Governing Body.

Based on interview and record review, the facility's Governing Body failed to review and approve the contract services policy and procedures for one of one contracted dialysis (a treatment for people whose kidneys are failing) service (Company A).

The deficient practice had the potential for unsafe care for dialysis patient due to no oversight from the Governing Body.

Findings:

During an interview with the Chief Nursing Officer (CNO) and Dialysis Manager, on 6/28/2023 at 11:00 a.m. and concurrent record review of the facility's Dialysis Services policy and procedure. CNO stated Dialysis Contract Services Policies and Procedures were to be reviewed and approved by the Governing Body. Dialysis Manager stated facility's Dialysis Contract Services Policies and Procedures (Company A) were not reviewed by the Governing Body.

A review of the facility's Dialysis Contract Services Policies and Procedures (Company A) under the Service Agreement indicated, the service agreement was made on 12/1/2022 for with Company A. The description of duties and responsibilities of Company A included inpatient acute (patient requiring immediate dialysis) hemodialysis care (dialysis provided by filtering the blood). The Dialysis Contract Services Policies and Procedures did not have any Governing Body evaluation or approval date.

Based on interview and record review, the facility failed to enusre medical staff for one (1) of five (5) sampled patients (Patient 1):

1. Had written policies and procedures to provide continuous monitoring, reassess the effectiveness of medication administered for the chest pain with a diagnosis of Non-STEMI (Non-ST [a segment of the electrical signal from the heart to check for different heart conditions] Elevation Myocardial Infarction is a type of heart attack in which a minor artery of the heart is completely blocked or a major artery of the heart is partially blocked) and follow treatment of patient if admitted by a cardiologist (heart doctor).

2. Follow facility's policy and procedure for chest pain management for Patient 1 presenting in the emergency room of the hospital by:

a. Not administering medication (Morphine [pain medication] and Nitroglycerin [medication used for chest pain to help open the blood vessel]) according to facility's policy and procedure for chest pain.

b. Monitoring Patient 1's cardiac rhythm (heart monitor) continuously and documented in the patient medical record.

Patient 1 was admitted for chest pain in the emergency room (ED), 5/20/2023 at 2:27 p.m. Patient 1 was diagnosed as a Non-STEMI, was administered with Morphine and Nitroglycerin.

This deficient practice resulted to the delayed treatment for Patient 1's chest pain. Patient 1 did not have continued assessment and monitoring of the chest pain, and became unresponsive, pulseless, and had general convulsions (a sudden, violent, irregular movement of a limb or of the body). Patient 1 was pronounced dead at 5/20/2022 at 8:01 p.m. (5 hours and 34 minutes after admission).

On 6/29/2023 at 5:05 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Quality Manager, Chief Financial Officer (CFO), Chief Executive Officer (CEO), Assistant Chief Nursing Officer (ACNO), and Director of Quality.

On July 1, 2023, at 5 p.m., facility submitted an IJ removal plan (intervention to correct the deficient practices needing immediate attention from the facility). The surveyor onsite verified the implementation of the IJ removal plan. The IJ was removed in the presence of the interim CEO, CNO, ACNO and CFO.

The acceptable removal plan was as follows:

1. The hospital will create a Non-STEMI Chest Pain Policy and Procedure that will address how to assess, manage, and treat Non-STEMI patients with chest pain in the emergency department. This is to be completed by July 1, 2023.This policy will base on official clinical policies statement for managing Non-STEMI endorsed by American College of Emergency Physicians.

2. The current Chest Pain Policy will be revised to reflect current standards based on most current American Heart Association (AHA) Guidelines.

3. Both policies will be presented to the Department of Medicine and Critical Care Committee by the Medical Director of ED for review and approval.

4. The new policy for Non-STEMI Chest Pain will be presented to the Department of Medicine and Critical Care Committee by the Medical Director of ED for ad hoc review and approval.

5. Once approved, policy will be presented to Medical Executive Committee (MEC) for review and approval, then, the medical staff will be educated by the Medical Director of the ED.

6. Chart audits will focus on documentation of vital signs, cardiac rate and rhythm, pain assessment and re-assessment and will be monitored by the ED Nursing Director.

7. Thirty (30) Non-STEMI Chest Pain patient charts per month will be reviewed beginning 7/17/2023. This will be a part of the Emergency Department's Performance Improvement project until compliance is at 100% for three consecutive months. Random checks will be performed every quarter thereafter. This will be reported to the Quality Council, Critical Care Committee and Medical Executive Committee.

8. The primary nurse will monitor and document patient's vital signs and will include patient's cardiac rate and cardiac rhythm every hour and when a change in cardiac rhythm should occur. Every change in cardiac rhythm will be captured and cardiac strip will be printed and placed in the Electronic Health Record (EHR). This will be implemented effective immediately, 6/30/2023. The education of nursing staff will be conducted by the Emergency Department (ED) charge nurses at the beginning of their shift huddles until 100% have been educated of this process. ED Director will ensure completion of this training.

9. Pain assessment and reassessment, using the Wong-Baker Pain Scale/Numerical Rating Scale, will be completed and documented by the primary nurse prior to and after administering medications for chest pain effective immediately. A reassessment field will be added in the ED nursing documentation effective 6/30/2023.

Findings:

A review of Patient 1's Emergency Department Triage record, dated 5/22/2022 at 2:27 p.m., indicated Patient 1 had a complaint of "Sudden onset of mid-chest pain 5 hours ago." The record indicated Patient's chest pain was 9/10 (pain scale from 1 to 10; zero [0] indicating no pain and 10 for severe pain). Patient 1 was assigned an Emergency Severity Index (ESI, a five-level emergency triaging assessment, one [1] indicated urgent needs and five indicated least urgent) of 3. ESI 3 indicated urgent conditions that could potentially progress to a serious problem.

A review of Patient 1's electrocardiogram (ECG or EKG records the electrical signal from the heart to check for different heart conditions), dated 5/22/2023 time at 2:51 p.m.(24 minutes after admission) indicated Patient 1 was sinus rhythm (normal heart rhythm) with first degree AV (Anterior Ventricular) block (a condition of abnormally slow conduction through the AV node [generates an electrical signal to the lower heart chambers (ventricles) of the heart, causing them to contract or pump), possible left atrial enlargement (when one of your heart chambers gets bigger than normal), right bundle branch block (there's a delay or blockage along the pathway that electrical impulses travel to make the heart beat for the right side of the heart), and EKG was, "Abnormal." A review of Patient 1's entire record indicated the cardiac rhythm documentation in Patient 1's entire medical record was the EKG at 2:51 p.m. and was not placed on continuous cardiac monitoring.

A review of Patient 1's vital signs (V/S, measurements of the body's most basic functions) record, date 5/22/2022, indicated initial vital signs were at 2:42 p.m. (15 minutes after admission) with blood pressure (BP) 166/88 millimeters of mercury (mmHg, unit of measurement) (normal blood pressure level between 90 mmHg and 120 mmHg systolic [relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries] and 90 mmHg to 60 mmHg diastolic (relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood) mmHg, oxygen (O2) at saturation (the amount of oxygen is circulating in the blood) 93% (percentage) (normal level is between 95% and 100%) on room air, pulse 83 beats per minute (normal level 60 to 100 beats per minute), and temperature at 97.8 degrees Fahrenheit (F, normal level between 97 degrees F and 99 degrees F). The second V/S was at 4 p.m. (1 hour and 18 minutes after the first recorded V/S), with BP at 152/86 mmHg, pulse 82 beats per minute, and respiration 17 per minute (normal level 12 to 18 breaths per minute). The third V/S was at 6 p.m. (2 hours after the second V/S) with temperature at 98.2 degrees F, pulse 92 beats per minute, respiration 17 per minute, and O2 saturation was 96 % on 2 liters O2. The V/S record had no pain assessment documented. The V/S record did not indicate V/S prior and after administering the Nitroglycerin ointment topical (medication applied on the skin) 2% at 3:32 p.m.

A review of Patient 1's Emergency Department History and Physical, dated 5/22/2022 indicated, Emergency Physician (ED MD)'s time of evaluation was at 3 p.m. The record indicated Patient 1 was treated with Aspirin (blood thinner medication), Nitroglycerin, and Morphine for chest pain. The record indicated Patient 1 was stable and diagnoses included Non-STEMI. Patient 1's disposition indicated for Patient 1 to be admitted to telemetry (a floor in a hospital where patients undergo continuous cardiac monitoring), "With consult to cardio (cardiology)." Patient 1 was admitted to inpatient at 6:01 p.m. Patient 1 was under ED Services from 2:27 p.m. to 6:01 p.m.

A review of Patient 1's Medication Administration Record (MAR), dated 5/22/2022, indicated Patient 1 received Aspirin 325 milligram (mg, unit of measurement) by mouth at 3:22 p.m., Nitroglycerin ointment topical 2% one (1) inch on the skin at 3:32 p.m., and Morphine 4 mg intravenous (medication given directly into the vein) at 4:12 p.m.

A review of Patient 1's laboratory results, on 5/22/2022 at 4:12 p.m. (1 hour and 45 minutes after arrival in the ED), indicated elevated Troponin (a type of protein found in the muscles of the heart and elevated indicates muscle damage) 0.337 nanograms per milliliter (ng/ml, unit of measurement) (normal level is 0.03 ng/ml).There were no other troponin level ordered for follow up.

A review of Patient 1's Consultation completed by cardiology, entered at 5/22/2022 at 6 p.m. (three [3] hours and 33 minutes after Patient 1's arrival in the ED), indicated Patient 1's medical diagnoses included: chest pain, diabetes (a disease that occurs when blood glucose is high), hypertension (high blood pressure), and kidney transplant. The record indicated a plan for a possible cardiac catheterization (a procedure in which a thin, flexible tube (catheter) is guided through a blood vessel to the heart to diagnose or treat certain heart conditions, such as clogged arteries) in the morning and plan to contact Patient 1's regular cardiologist.

A review of Patient 1's Code Blue (a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest) record, dated 5/22/2022, indicated Code Blue was called at 7:35 p.m., indicated Patient 1 had no palpable (able to touch) pulse and no respiration. Patient 1 was pronounced dead at 8:01 p.m.

A review of Patient 1's Neurology (a medical specialty that deals with the disorders of the nervous system [includes the brain, spinal cord, and a complex network of nerves in the body]) Consultation Note dated 5/22/2022 at 7:59 p.m. titled indicated vital signs (V/S, measurements of the body's most basic functions) at 7 p.m. with BP 166/102 mmHg at sitting position, pulse 87 beats per minute, respirations 17 per minute on 2 liters oxygen with O2 at saturations 98 %. The record indicated Patient 1 became unresponsive and pulseless. Patient 1 had a generalized convulsion (a sudden, violent, irregular movement of a limb or of the body), and assessment for Patient 1 included post anoxic status epilepticus (seizure after lack of oxygen to the body).

During an interview with ED Physician (ED MD), on 6/28/2023at 1:40 p.m., ED MD stated when a patient with chest pain, who was evaluated in the ED, was stable, and the patient was not a STEMI (ST-elevation myocardial infarction, a type of heart attack that was more serious), the ED MD would consult with a cardiologist (staff cardiologist, heart doctor with privileges in the hospital). ED MD stated the hospital had no cardiologist on call for ED. The ED MD stated consult would be done by the staff cardiologist. EM MD stated if the facility staff cardiologist cannot come in to evaluate a patient with chest pain, then the patient would be transferred to higher level of care.

During an interview with Nursing Informatics 1 and concurrent record review of Patient 1's entire medical record for admission date 5/22/2022, on 6/28/2023 at 3:08 p.m., Nursing Informatics 1 stated Patient 1 had no other pain assessment (chest pain) since 5/22/2023 at 2:37 p.m. documented on Patient 1's Emergency Department Triage record. Nursing Informatics 1 stated Patient was under the care of the attending physician (MD 2) and consulted with the staff cardiologist (MD 3).

During an interview with Registered Nurse 4 (RN 4), on 6/28/2023 at 3:09 p.m., RN 4 stated Patient 1 with Non-STEMI was admitted to Telemetry (a floor in a hospital where patients undergo continuous cardiac monitoring)?or intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill patients). RN 4 stated for patient with chest pain were treated with Nitroglycerin sublingual (medication for chest pain given under the tongue for faster absorption and effectiveness) up to 3 doses every 5 minutes. RN 4 stated BP was not monitored before and after administration.

During an interview with CNO on 6/29/2022 at 2:05 pm, the CNO was asked for hospital policy for Non-STEMI, the CNO stated the hospital did not have a Non-STEMI policy.

A review of the facility policy and procedure titled Chest Pain, dated 7/2018 indicated, "All patients presenting with central chest pain tightness or other suggestive symptoms should be considered possible acute emergencies and should be placed under EKG monitoring without delay and evaluated by the emergency physician as soon as possible it included." The policy and procedure indicated patient to be on continuous cardiac monitoring, stat (immediately) 12 lead EKG (test that measures the complete electrical activity of the heart), and vital signs to be obtained. The policy and procedure indicated patient's had rhythm strip (heart monitoring) documentation and chest pain protocol included medication administration that included nitroglycerin sublingually, morphine IV, and aspirin. The policy and procedure indicated, "If an acute coronary (a term that describes a range of conditions related to sudden, reduced blood flow to the heart) episode remains suspected after the physician's evaluation the patient should be admitted to the intensive care unit."

A review of the facility's policy and procedure titled Triage Assessment and Reassessment, dated 12/2021, indicated patient emergency conditions are categorized under an emergency severity index (ESI) ESI level 2 indicated emergent conditions that are considered potential life threatening and included chest pain. ESI level 3 indicated urgent conditions that could potentially progress to a serious problem. Under the Section: Parameters of assessment and reassessment indicated" assessments and reassessments are a continuing process during patient stay in the emergency department documentations hourly as needed for assessment and reassessment and findings are determined by and included , Changes in Patient condition, and "Extended Stay in the ED stay in the Ed and our change in diagnosis."

Based on interview and record review the facility (General Acute Care Hospital 1, GACH 1) failed to ensure facility's Quality Assessment and Performance Improvement (QAPI) had a performance improvement activity for ensure:

1. Dialysis (a treatment for people whose kidneys are failing) patients treatment provided by Registered Nurse (RN) by one of one contract dialysis service (Company A) were scheduled and completed timely.

2. Dialysate (a solution consisting of water and chemicals [electrolytes, minerals in blood]) that passes through the artificial kidney [dialysis treatment] to remove excess fluids and waste products from the blood) water testing was evaluated for safe use by the facility dialysis contract service for one of one contract dialysis service (Company A) .

This deficient practice had the potential for care provided by the facility's dialysis contract service (Company A)
compassionate, high-quality care, and customer service focused service according to the facility's QAPI Plan 2022.

Findings:

1. During an interview with the Medical Director of Dialysis Services (MD 10) and Dialysis Manager, on 6/28/2023 at 11:00 a.m. . Dialysis Manager stated when a facility patient required dialysis, a call was made to the Command Center located at GACH 2 (sister hospital for GACH 1). Dialysis Manager stated GACH 2 coordinated all the dialysis schedule for GACH 1 dialysis patients' schedules that included coordinating emergency dialysis and daily dialysis schedule. Dialysis Manager stated the facility did not have a system to track and ensure facility's dialysis patients requiring dialysis received a dialysis treatment or if there was a delay in dialysis treatment for a scheduled patient.

During an interview with Dialysis Manager, on 6/30/23 at 4:15 p.m. Dialysis Manager was requested the list of dialysis patients for the month of June 2022 for evaluation of the daily patients receiving dialysis for any delays and ongoing tracking list of the facility dialysis patients. Dialysis Manager stated she was unable to provide a complete list of dialysis patients for June 2022.

A review of list of dialysis patients at the facility provided by Dialysis Manager, facility provide list of patients from 6/1/2023 to 6/17/2023.

2. During concurrent interview with the QAPI Manager and record review of facility QAPI studies, on 6/30/23 at 1:25 p.m., QAPI Manager stated there were no QAPI studies for dialysis services and no Quality Improvement (QI) projects oversight by the facility for evaluation of dialysate testing and contract dialysis services for dialysis for 2022 and 2023.

During an interview with Dialysis Manager, on 6/30/23 at 4:15 p.m. Dialysis Manager stated the dialysis contract service does all the dialysate water testing.

A review of the facility's QAPI Plan 2022 indicated the QAPI's purpose was designed to ensure compassionate, high-quality care, and customer service focused service. The QAPI plan will continually measure, assessed, and improve patient care hospital wide. The QAPI Plan indicated, "The directors/managers of all clinically and ancillary/support departments and services are responsible for implementing and coordinating performance improvement activities within their scope of services...Policies, procedures, training and guidelines describe how patient care needs are assessed and met."

Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to evaluate treatment and care provided to patient experiencing chest pain for one of 30 sampled patients (Patient 1). (Refer A - 0395).

2. The facility failed to ensure facility Registered Nurses (RN) had training to operate a dialysis (a treatment for people whose kidneys are failing) machine (turn of a machine) and provide dialysis treatment (return the blood and discconnect the patient) according to facility's dialysis contract service policy and procedure to discontinuation a dialysis treatment during an emergency for two (2) of two sampled nurses(Charge Nurse and Registered Nurse 8). (Refer A - 0398).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to evaluate treatment and care provided to patient experiencing chest pain for one of 30 sampled patients (Patient 1).

This deficient practice resulted to the delayed treatment for Patient 1's chest pain and eventual death.

Findings:

A review of Patient 1's Emergency Department Triage record, dated 5/22/2022 at 2:27 p.m., indicated Patient 1 had a complaint of "Sudden onset of mid-chest pain 5 hours ago." The record indicated Patient's chest pain was 9/10 (pain scale from 1 to 10; zero [0] indicating no pain and 10 for severe pain). Patient 1 was assigned an Emergency Severity Index (ESI, a five-level emergency triaging assessment, one [1] indicated urgent needs and five indicated least urgent) of 3. ESI 3 indicated urgent conditions that could potentially progress to a serious problem.

A review of Patient 1's electrocardiogram (ECG or EKG records the electrical signal from the heart to check for different heart conditions), dated 5/22/2023 time at 2:51 p.m.(24 minutes after admission) indicated Patient 1 was sinus rhythm (normal heart rhythm) with first degree AV (Anterior Ventricular) block (a condition of abnormally slow conduction through the AV node [generates an electrical signal to the lower heart chambers (ventricles) of the heart, causing them to contract or pump), possible left atrial enlargement (when one of your heart chambers gets bigger than normal), right bundle branch block (there's a delay or blockage along the pathway that electrical impulses travel to make the heart beat for the right side of the heart), and EKG was, "Abnormal." A review of Patient 1's entire record indicated the only cardiac rhythm documentation in Patient 1's entire medical record was the EKG at 2:51 p.m., Patient 1 was not placed on continuous cardiac monitoring.

A review of Patient 1's vital signs (V/S, measurements of the body's most basic functions) record, date 5/22/2022, indicated initial vital signs were at 2:42 p.m. (15 minutes after admission) with blood pressure (BP) 166/88 millimeters of mercury(mmHg, unit of measurement) (normal level is less than 120/80 mmHg), oxygen (O2) at saturation 93% (percentage) (normal level is between 95% and 100%) on O2 two (2) liters, pulse 83 beats per minute (normal level 60 to 100 beats per minute), and temperature at 97.8 degrees Fahrenheit (F, normal level between 97 degrees F and 99 degrees F). The second V/S was at 4 p.m. (1 hour and 18 minutes after the first recorded V/S), with BP at 152/86 mmHg, pulse 82 beats per minute, and respiration 17 per minute (normal level 12 to 18 breaths per minute). The third V/S was at 6 p.m. (2 hours after the second V/S) with temperature at 98.2 degrees F, pulse 92 beats per minute, respiration 17 per minute, and O2 saturation was 96 % on 2 liters O2. The V/S record had no pain assessment documented. The V/S record did not indicate V/S prior and after administering the Nitroglycerin ointment topical 2% at 3:32 p.m.

A review of Patient 1 Medication Administration Record ,(MAR), dated 5/22/2022, indicated Patient 1 received Aspirin 325 milligram (mg, unit of measurement) by mouth at 3:22 p.m., Nitroglycerin ointment topical 2% one (1) inch on the skin at 3:32 p.m., and Morphine 4 mg intravenous (medication given directly into the vein) at 4:12 p.m.

A review of Patient 1's Emergency Department History and Physical, dated 5/22/2022 indicated, Emergency Physician (ED MD)'s time of evaluation was at 3 p.m. The record indicated Patient 1 was treated with Aspirin (blood thinner medication), Nitroglycerin, and Morphine for chest pain. The record indicated Patient 1 was stable and diagnoses included Non-STEMI (Non-ST [a segment of the electrical signal from the heart to check for different heart conditions] Elevation Myocardial Infarction is a type of heart attack in which a minor artery of the heart is completely blocked or a major artery of the heart is partially blocked). Patient 1's disposition indicated for Patient 1 to be admitted to telemetry (a floor in a hospital where patients undergo continuous cardiac monitoring), "With consult to cardio (cardiology)." Patient 1 was admitted to inpatient at 6:01 p.m. Patient 1 was under ED Services from 2:27 p.m. to 6:01 p.m.


A review of Patient 1's Consultation completed by cardiology, entered at 5/22/2022 at 6 p.m. (three [3] hours and 33 minutes after Patient 1's arrival in the ED), indicated Patient 1's medical diagnoses included: chest pain, diabetes (a disease that?occurs when blood glucose is high), hypertension (high blood pressure), and kidney transplant. The record indicated a plan for a possible cardiac catheterization (a procedure in which a thin, flexible tube (catheter) is guided through a blood vessel to the heart to diagnose or treat certain heart conditions, such as clogged arteries)?in the morning and plan to contact Patient 1's regular cardiologist.

A review of Patient 1's Code Blue (a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest) record, dated 5/22/2022, indicated Code Blue was called at 7:35 p.m. indicated Patient 1 had no palpable pulse and no respiration. Patient 1 was pronounced dead at 8:01 p.m. (5 hours and 24 minutes after admission).

On 6/28/2023, at 3:08 AM, during concurrent interview with Nurse Informatics Analyst (Nurse. Info. 1) and record review of Patient 1's emergency department (ED) medical records, dated 5/22/2023, Nurse. Info. 1 stated Patient 1 arrived at the facility ED at 2:27 PM, was triaged with chest pain at 2:27 PM, and at 2:45 PM was place in a room, had a medical screening examination (MSE) by emergency department physician (medical doctor, MD 1) at 3:00 PM. Nurse. Info. 1 stated ED Nursing Form indicated the following:
1. Patient 1 presented in ED with chest pain for five hours at 2:40 p.m.
2. Physician Assistant evaluated Patient 1 at 3:10 p.m. with MD 1.
3. At 5:50 p.m., cardiologist (MD 3) examined the patient.
4. At 6:17 p.m., patient stated he was feeling better.
5. At 7 p.m., patient stated chest pain improved and denied shortness of breath. Nurses changed shift with report. Documentation did not indicate pain level.
6. At 7:20 p.m., patient was awake and oriented and denied pain. Plan to transfer patient to telemetry unit (a floor in a hospital where patients undergo continuous cardiac monitoring) when space was available.
7. At 7:32 p.m., patient's family member came out of the room and reported patient felt like he was going to faint. Patient was found unresponsive, with pulses and breathing. Respiratory therapist and physician called and notified.
8. At 7:35 p.m., Cardiopulmonary resuscitation (CPR - a lifesaving technique that useful in many emergencies, such as a heart attack, in which someone's breathing and/or heartbeat has stopped) began and Code Blue was called.
9. At 8:01 p.m., CPR was terminated. Patient's family member was at the bedside.

During an interview with Registered Nurse 4 (RN 4), on 6/28/2023 at 3:09 p.m., RN 4 stated Patient 1 with Non-STEMI was admitted to Telemetry (a floor in a hospital where patients undergo continuous cardiac monitoring) or intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill patients). RN 4 stated for patient with chest pain were treated with Nitroglycerin sublingual (medication for chest pain given under the tongue for faster absorption and effectiveness) up to 3 doses every 5 minutes. RN 4 stated Blood Pressure (BP) was not monitored before and after administration.

On 6/28/2023, at 3:35 p.m., during concurrent interview and record review of Patient 1's MAR, dated 5/22/2022, Nurse. Info. 2 stated there was no documentation after the medications were given to indicate the patient's response to the medications and the effectiveness of the medications.

On 6/28/2023, at 4:15 p.m., during interview with Nursing Director of emergency department (RN 6), RN 6 stated the following:
1. When a patient presents to the emergency department (ED) with chest pain, the triage nurse does a rapid assessment of the patient.
2. Then the patient gets an electrocardiogram (ECG or EKG - recording of the electrical signal from the heart to check for different heart conditions) done.
3. Afterwards, the EKG results are given to the ED provider to review, before getting filed.
4. If the patient is found to have a ST-Segment Elevation Myocardial Infarction (STEMI - the most severe type of heart attack), patient will get transferred to another facility for higher level of care for cardiology services because this facility does not have a catheterization laboratory (Cath lab - examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and its chambers, and to treat any abnormality found).


A review of facility's chest pain policy, dated March 2022, indicated the following:
1. Reference came from American College of Cardiology (ACC)/American Heart Association (AHA) Guideline Revision 2007
2. All patients with chest pains, tightness, or other suggestive symptoms, should be considered possible acute emergencies, and should be placed under EKG monitoring (cardiac monitoring) without delay, and evaluated by the emergency department (ED) physician, as soon as possible.
3. Implementation of oxygen at 4 liters - 6 liters by nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of help with breathing), establishment of a saline lock (a thin flexible tube placed in a vein of the hand or arm to get medicines through a vein), stat 12-lead EKG (electrocardiogram - representation of the heart's electrical activity recorded from electrodes on the body surface), obtain and record vital signs (measurements of the body's most basic functions - body temperature, pulse rate, breathing rate, blood pressure), obtain rhythm strip for documentation, and chest pain protocol.
4. Chest pain protocol included nitroglycerine (medication used to treat and prevent chest pain) under the tongue, and/or morphine sulphate 3 mg (milligrams) every five minutes by vein for four times, for pain relief, with systolic blood pressure greater than 90, and aspirin 80 mg oral.
5. Eligibility criteria included chest pain or chest pain equivalent syndrome consistent with acute myocardial infarction (AMI - heart attack) for less than 12 hours from symptoms began, EKG, new bundle branch block, troponin elevated (greater than 0.05), cardiogenic shock (cardiac shock - when your heart cannot pump enough blood and oxygen to the brain and other vital organs).

A review of facility's policy for Pain Management, dated 10/2016, indicated the following:
1. Purpose - for all patients to have access to the best level of pain relief that may be safely provided.
2. On admission, perform a baseline pain assessment and after any known pain producing event.
3. Assess all patients for pain level with routine vital signs, with reassessment within 30 minutes - 60 minutes after each pain management intervention.
4. Notify the physician for patients whose pain is unrelieved within the expected response time to the implemented intervention.

Based on interview and record review, the facility failed to ensure facility Registered Nurses (RN) had training to operate a dialysis (a treatment for people whose kidneys are failing) machine (turn of a machine) and provide dialysis treatment (return the blood and discconnect the patient) according to facility's dialysis contract service policy and procedure to discontinuation a dialysis treatment during an emergency for two for two (2) of two sampled nurses(Charge Nurse [CN] and RN 8).

The deficient practice had the potential for a facility nurse not able to safely turn off the dialysis machine in case of an emergency (a code blue [a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest] and the dialysis nurse was taking a bio-break or dialysis nurse became incapacitated).

Findings:

On 6/27/2023, at 2:45 p.m., during an interview Telemetry [a floor in a hospital where patients undergo continuous cardiac monitoring] CN stated the dialysis treatments were done by contracted dialysis nurses (End Stage Renal Disease Registered Nurse, ESRD RN). CN stated the facility nurses, including herself, did not receive training for dialysis machine and/or treatments. CN stated she did not know what to do with the dialysis machine, if the contracted ESRD RN becomes incapacitated.

During an interview, on 6/27/23, at 3:10 PM, Registered Nurse 8 (RN 8) stated no training had been provided for the nurses about safely turning off the dialysis machine and in case dialysis nurse became incapacitated during dialysis. RN 8 was providing care with Patient 21 (a dialysis patient).

A review of the Contracted Policy and procedure titled, "Emergency Discontinuation During Dialysis," dated 9/15/2018, indicated "The nursing staff (facility RN) at the contracted facility will receive in service training and instruction regarding how to return the blood to the machine and disconnect the dialysis patients safely in case of an emergency arises including if dialysis nurse becoming incapacitated." The trainings will be documented on the employee file, and the nursing staff will attend to dialysis and service at least quarterly and as needed."