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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure one of five patients (Patient #3) was assigned an appropriate Emergency Severity Index level facilitating a medical screening exam in order of priority and failed to ensure STAT laboratory values were received within 60 minutes of a physician order. (A1104)

Based on record review, facility policy review, and staff interview, the facility failed to ensure staff followed the facility policies related to STAT laboratory results within 60 minutes of the physician order and Emergency Severity Index triage level assignment. This affected Patient #3 and had the potential to affect all patients receiving care in the Emergency Department. The hospital census was 18.

Findings include:

Review of the medical record of Patient #3 revealed Emergency Medical Services (EMS) was called by a family member at 11:49 AM on 4/21/17 due to patient's complaints of severe back pain and increased weakness after a fall. According to the EMS record, although the patient denied any injuries, he/she was unable to stand on his/her own and had to be carried to the ambulance. A 4 lead electrocardiogram (EKG) at 12:03 PM noted sinus tachycardia with a heart rate of 150 beats per minute. It was further noted the patient had an elevated blood pressure of 170/90 and an elevated respiratory rate of 22 breaths per minute at this time. The patient complained of shortness of breath "worse than normal" with an initial oxygen saturation of 92% on room air. Oxygen at 4 liters per nasal cannula was applied and by 12:21 PM the patient's oxygen saturation improved to 96%. The patient's pain was assessed in the ambulance 10 on a 0-10 scale at 12:03 PM, 12:21 PM, and again at 12:30 PM.

1. The facility policy titled "Emergency Services Triage" (Policy No: Emergency Services-024), which was last reviewed and/or revised on 2/2017, stated all patients presenting to the Emergency Department for care will be seen on arrival by personnel qualified to determine the priority of care necessary. The priority with which persons seeking emergency care will be seen by the physician or provided a medical screening exam will be determined using triage classifications and guidelines based on ESI (Emergency Severity Index ) Five Level Triage System. The five level triage is based on patient acuity, severity of symptoms, the degree of risk for deterioration while waiting, and the need for additional resources. The ESI levels is described as follows:
An ESI Level I patient is critical and the condition is life threatening if not managed immediately.
An ESI Level II patient cannot wait for treatment and condition could rapidly deteriorate if treatment is delayed. Decision points for an ESI Level II included:
a. Is this a high risk situation.
b. Is the patient confused/lethargic/disoriented.
c. Is the patient in severe pain/distress.
An ESI Level 3 patient is stable, but treatment should be provided as soon as possible to relieve distress or pain.
An ESI Level 4 patient condition is low risk for deterioration while waiting, symptoms are less severe and patient can safely wait for treatment.
An ESI Level 5 patient is minimal to no risk for deterioration while waiting and could be safely evaluated and treated in the Urgent Care Center.

The ESI Acuity Algorithm was also reviewed. A Step B or Level II patient is a high risk situation where there is severe pain/distress determined by clinical observation and/or patient rating of greater than or equal to 7 on a 0-10 pain scale.

Further review of the medical record revealed the patient arrived to the Emergency Department at 12:38 PM. At 12:50 PM the patient's vital signs included a blood pressure of 195/72, a heart rate of 140 beats per minute, respirations of 22 breaths per minute, oxygen saturation at 92% with supplemental oxygen of 2 liters which was a reduction from the 4 liters initiated in the ambulance. At 1:05 PM, a staff nurse performed a triage assessment. The patient reported the back pain beginning with a fall three months prior but worsening after the fall that day. Upon presentation to the Emergency Department the patient continued to complain of severe back pain rating it a 10 on a 0-10 scale. It was further noted the patient also continued to complain of shortness of breath although the patient believed the shortness of breath was related to the back pain. Using the Emergency Severity Index (ESI) Five Level Triage System, a staff nurse determined the patient was a level 3 or urgent category.

At 1:15 PM a patient care assistant (PCA), was noted to reposition the patient for comfort. A note at this time stated "wait time explained" by the PCA. The medical record lacked documentation Emergency Department staff assessed the patient again until 2:05 PM when the physician performed his/her medical examination.
At 2:25 PM the physician placed numerous orders, including Troponin T level (Troponin T is a part of the troponin complex, which are proteins integral to the contraction of skeletal and heart muscles. Troponin T is useful in the laboratory diagnosis of heart attack because it is released into the bloodstream when damage to heart muscle occurs.), computed tomography scan (CT scan) of the abdomen, pelvis, and chest, 12 lead electrocardiogram, and 50 micrograms of fentanyl (narcotic used to treat severe pain) one time IV push for pain. All orders were placed with a STAT priority.

Results of the 12 lead EKG, performed immediately after ordered, at 4:25 PM, noted an abnormal EKG with sinus tachycardia with premature atrial complexes and a right bundle branch block.

The Medication Administration Record (MAR) noted the staff nurse administered the ordered fentanyl at 2:42 PM. One minute later, at 2:43 PM, the patient's vital signs included a blood pressure of 172/68, respirations of 26 breaths per minute, a heart rate of 132 beats per minute, and oxygen saturation of 91% with 2 liters of supplemental oxygen. Three minutes later, at 2:45 PM a nursing note stated the patient condition "deteriorated and patient more short of breath and more lethargic." The note further stated the physician and respiratory therapist (RT) were notified that the patient did not "look good" and there was concern about the patient's breathing. The RT's note stated: "Asked to come to the ED to assess patient. Upon assessment unable to obtain pulse. Patient diaphoretic and clammy. Patient cyanotic, lips blue and fingertips dark. Patient breathing 44 breaths per minute and heart rate of 136. Patient awake but non-verbal. Placed patient on 100% non-rebreather. Accompanied patient to CT scan."

The medical record revealed a code blue was called at 3:03 PM as staff were unable to obtain a blood pressure or pulse and patient wasn't breathing. Code blue documentation revealed cardiopulmonary resuscitation (CPR) was started at 3:04 PM. At 3:05 PM the documentation revealed 2 mg of Narcan was given. A repeat 12 lead EKG noted an acute myocardial infarction (heart attack). The patient could not be resuscitated and was pronounced dead at 3:42 PM.

The physician's note stated the following: "A code was called in CT. I immediately headed to CT and asked that Narcan be brought to reverse any negative effect fentanyl may have had on the patient. Per witnesses in the CT, the patient was talking and responsive to stimuli in the CT and then after completion of the CT when the patient was being moved back to the gurney, he/she stopped breathing and pulses were lost. There was a slight delay in starting CPR, but it was started in the CT. The patient was given 2 mg of Narcan and then transferred to a treatment room for further resuscitation."

Staff B, staff ED RN, was interviewed on 3/5/19 at 5:45 PM. A brief description of Patient #3, including the patient's age, sex, complaints of severe back pain of 10 on a 0-10 scale after a fall and shortness of breath, blood pressure of 195/72, and heart rate of 140 were provided. Staff B interrupted this surveyor before any additional information was provided and said: "That is a Level 2." He/She explained that based on the patient's age, sex, and unstable vital signs, he/she would have assigned the patient to a Level 2 which requires a medical examination by a physician within 15 minutes.

Staff A was interviewed on 3/5/19 at 5:50 PM. It was confirmed that based the facility protocol for assigning ESI level, the patient should have been assigned a level II due to the patient's continuous complaints of severe pain rated a 10 on a 0-10 scale and unstable vital signs.

2. The facility policy titled "STAT Testing" (Procedure Number: nvml.jtdmh.lab.108), initiated on 5/28/13, stated that tests required on a stat basis require a turnaround time within 60 minutes.

Review of the laboratory results revealed that Troponin T results were not provided to ED staff until 4:19 PM, 37 minutes after the patient's death and 114 minutes after STAT-ordered by the physician. The results indicated the reference range was 0.00-0.03 nanograms per milliter (ng/mL). According to the laboratory result the patient's Troponin T was noted to be "abnormally high" at 0.04 ng/mL.

Staff A, Director of Emergency, was interviewed on 3/5/19 at 4:00 PM. Staff A stated that the medical record lacked documentation of a stat Troponin T level within 60 minutes. The stat order was placed at 2:25 PM but results were not available until 4:19 PM.