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Based on the policy and procedure review, Emergency Department standing chest pain order review, medical record review, and staff and physician interviews, Emergency Department (ED) nursing staff failed to prevent a delay in obtaining a laboratory blood draw and administration of medication; and failied to follow policy and procedure for reassessment of an ED patient for 2 of 10 sampled ED patients (#20 and #15).

Findings included:

Review of a policy titled "ASSESSMENT -REASSESSMENT OF THE EMERGENCY DEPARTMENT PATIENT...POLICY...All patients presenting to the Emergency Department will be assessed and categorized using the Emergency Severity Index (ESI) 5 Level Triage System. The recorded data reflects assessment, planning, implementation and evaluation of the patient from admission through discharge, utilizing the nursing process, which is specific to their age and reason for visit....SUMMARY...To ensure that established criteria will be assessed and reassessed on all Emergency Department patients....INTERVENTION...A....Triage Assessment ...1....Upon entry to the Emergency Department, a visualization and determination of reason for visit is completed ....2...Triage documentation includes, at a minimum:...a....Documentation of chief complaint...d....Emergency Severity Index Acuity ...e....Presence of pain...f....Vital Signs ...3....Based on the reason for visit or anticipated time to provider assessment, the RN determines the need to initiate standing orders....4....Triage documentation is required for all patients....c....Initial Assessment ...1....Nursing assessment will be based on the chief complaint.....2....Upon completion of the initial assessment, a plan of care is formulated utilizing standards of care, standing orders, protocols and provider orders ....D....Reassessment...1...Reassessment of initial assessment findings are to be documented after interventions, change in patient condition, or according to provider orders. This includes a pain assessment after pain interventions...3....Vital signs will be reassessed every 4 hours...frequently based on patient condition, provider order, or event requirements....Vital sign frequency should align with relevant interventions and patient stability...4....Reassessment of vital signs will be documented within one hour of admission, discharge or transfer....E....Plan of Care
...1....Upon completion of the initial assessment, a plan of care is formulated utilizing standards of care, standing orders, protocols and provider orders....Appendix B: ED Documentation Guidelines...ED Patient...Vitals...Minimum Q4..."(every 4 hours)."

Review of a document titled " ED Adult Standing Chest Pain - Rapid ECG ... " (no date noted) revealed " ...Inclusion Criteria: ...Non-traumatic chest discomfort with coin use, congenital heart disease, history of CAD, or prior percutaneous intervention/cardiac surgery ...Patients over 30 YEARS and Older with any of the following: ...Non-traumatic chest discomfort ...Shortness of breath ...Non-traumatic arm, shoulder, or jaw pain ...Near syncope/syncope ...Palpitations ...Patients 45 YEARS and OLDER with any of the following above symptoms or with any of the following: ...Nausea/vomiting (without diarrhea) ...Upper abdominal pain (non-traumatic) ...Generalized/non-focal weakness ...Missed dialysis ...Chest discomfort may be pressure, aching, tightness, heaviness, burning, sharp, stabbing, or pleuritic ...Labs - For Patients 30 years and Older ...Troponin, High Sensitive ... " Review revealed no timeframe for initial Troponin draw and any following Troponin draws.

1. Review of the medical record revealed Patient #20 was a 74-year-old male who presented on 01/19/2023 at 1021 to the ED of Hospital A with a complaint of "Chest Pain." Review of the Triage note at 1025 revealed "Chest Pain (Pt [Patient] sts [states] woke up with chest pain, n/v [nausea/vomiting]." Review of the Patient Care Timeline revealed at 1025 an Acuity 2 was selected for Patient #20. Review of the ECG (electrocardiography -records the electrical signal from the heart) performed at 1026 revealed "Sinus rhythm; Moderate ST (represents electrically neutral area of the complex between ventricular contraction and relaxation) depression." Review revealed Orders were placed and acknowledged at 1026 for " ...Notify provider - Chest Pain/Shortness of Breath; Troponin, High Sensitive (blood work) ... Review of the Vital Signs at 1027 revealed "Resp (respirations): 17" at 1028 "Temp (temperature): 97.4; Heart Rate: 63; BP (blood pressure): 181/85, SpO2 (oxygen saturation): 100%." Review of the Provider note at 1045 revealed " ... HPI (history present illness): Patient 74-year-old gentleman with history of hyperlipidemia (high levels of lipids [fat particles] in the blood), PVD (peripheral vascular disease - circulatory condition with narrowed blood vessels and decrease blood flow to the limbs), hyperparathyroidism (condition where increase in the release of parathyroid hormone) who presents emergency department chest pain. (sic) Says it started about 6 AM. It did not wake him up. He is also feeling short of breath. He took 3 (three) sublingual nitros (nitroglycerin - medication to treat chest pain) without any relief. He is also endorsing nausea and vomited one time. ROS (review of systems): Neuro (neurological): Denies weakness; Heart: Denies palpitations ..." Review of the Patient Care Timeline revealed Patient #20 was placed in a room in the ED at 1120. Review of the Medication Administration Record revealed at 1203 (1 hour and 37 minutes after ordered) Patient #20 received Aspirin Chewable tablet (non-steroidal anti-inflammatory medication) 324 mg, Morphine injection (pain medication) 4 mg at 1207, Hydralazine injections (medication for high blood pressure) 10 mg at 1211, and Zofran injection (medication for nausea/vomiting) 4 mg at 1222. Review of the Troponin, High Sensitive Resulted at 1245 an "Abnormal Result. Collected: 1/19/2023 12:04 (1 hour and 38 minutes after ordered) Last updated: 1/19/2023 12:45 Status: Final Result Troponin, High Sensitive: 1,535 ... [Ref (reference) Range: < (less than) 20] ..." Review of the Patient Care Timeline revealed there was Provider Notification at 12:48 of the abnormal Troponin. Review of the ED Quick Update note at 1430 revealed "I went to this pt's room to draw a repeat trop (troponin) as well as give Zofran, mag, and hydralazine. While I was drawing the trop, the pt (patient) stated he was beginning to have chest pain and nausea again. I told him I had some Zofran for him and I would message the doctor regarding his chest pain. I took my rover phone out of my pocket to message (Provider name) when the pt suddenly became very pale and unresponsive. I checked for a carotid pulse and could not feel one, so I began CPR (cardiopulmonary resuscitation) while shouting for help. Help arrived within seconds and code narration began ..." Review of the Patient Care Timeline revealed the Code started at 1444 and the Time of Death was at 1543. Review of the Provider note at 1720 revealed " ... Patient hypertensive (high blood pressure) on arrival, improving with hydralazine, morphine and aspirin. Given characterization of pain, concern for ACS (acute coronary syndrome -condition related to sudden, reduced blood flow to the heart) or dissection (to cut or separate tissues). EKG (electrocardiogram -test that records your heart's electrical activity) with new sT depressions (indicates severe coronary damage) and troponin elevated 1500, consulted interventional cardiology 12:56 PM for concerning features as above who recommend reaching back out after CT (computed tomography - imaging that uses x-rays to create pictures of cross-sections of the body) imaging. CT called and patient taken emergently without evidence of dissection, noted to have thoracic aneurysm (a weakened area in the upper part of the largest artery in the body) without prior for comparison, no significant aortic aneurysm (a weakened area in the largest artery in the body) remaining after repair. Cardiology updated to evaluate at bedside ... Called emergently to bedside as patient began complaining of acute onset of worsening left-sided chest pain and within several minutes went into PEA (pulseless electrical activity-unable to feel a pulse, pt unresponsive, still have a wave on the heart monitor) arrest. On my evaluation, patient has had 1 round of CPR with return of spontaneous circulation but was unresponsive, irregular respirations, and equal breath sounds bilaterally before losing pulses again within the next minute ... Patient underwent prolonged resuscitation course ... Attempted bedside pericardiocentesis (procedure that involves puncturing the sac surrounding the heart to remove excess fluid) multiple times with continued aspiration (the action or process of withdrawing fluid, tissue, blood etc) of trace amount of dark fluid approximately 1 or 2 cc (cubic centimeters measuring volume). Critical care and cardiothoracic surgery arrived to bedside for further assistance. Unable to further aspirate the pericardial effusion (buildup of fluid in sac around the heart), ultrasound confirming significant amount of clot, and attempts ongoing with active CPR and resuscitation. Had several episodes of brief ROSC (return of spontaneous circulation) ... ongoing loss of pulses ... Cardiothoracic surgery performed cardiac window (removal of a small part of the sac around the heart to assist in removal of fluid from the sac) at bedside for further clot evacuation with no ROSC. Patient with fixed and dilated pupils, no palpable pulses, and prolonged resuscitation as above with significant interventions attempted as above without response. Time of death called. Family updated ... Diagnosis: 1. Deceased 2. Chest pain, unspecified type 3. Pericardial effusion; Disposition: Expired ..."

Interview on 04/27/2023 at 0900 with Registered Nurse (RN) #1 revealed she remembered Patient #20. Interview revealed RN #1 drew Patient #20's initial blood for Patient #20's labs and had medicated Patient #20. Interview revealed RN #1 continued with other task in the ED and when Patient #20 returned from having a CT scan, RN #1 noticed he had a second Troponin and medications ordered that had not been completed. Interview revealed RN #1 gathered supplies for the blood draw and the medications and went into Patient #20's room. Interview revealed Patient #20 said he was having "chest pain". Interview revealed RN #1 pulled her rover telephone out to send a secure message to the Provider when in the corner of her eye she noticed Patient #20 went "pale and unresponsive." Interview revealed RN #1 performed a sternal rub on Patient #20 with no response. Interview revealed RN #1 yelled for help and started CPR. Interview revealed RN #1 stayed in the room doing chest compressions until the Lucas machines (Lucas Chest Compression System used to perform chest compression during CPR) was placed.

Interview on 04/27/2023 at 0936 with RN #2 revealed she was the Triage Nurse on 01/19/2023 when Patient #20 arrived to the ED. Interview revealed Patient #20 presented to the ED with "chest pain, nausea, and vomiting". Interview revealed RN #2 performed the initial EKG and placed the standing orders for Patient #20 while he was in triage. Interview revealed the ED was full and RN #2 called the Charge Nurse on the radio to get a room for Patient #20. Interview revealed RN #2 continued with triaging other patients in the ED and did not draw the blood for the ordered labs for Patient #20.

Telephone/Zoom interview on 04/27/2023 at 1230 with Provider #4 revealed he was the Provider in Triage on 01/19/2023 when Patient #20 presented. Interview revealed Patient #20 woke up with chest pain that he said started around 6 am. Interview revealed Provider #4 reviewed the EKG, which showed no evidence of a STEMI (heart attack) and did not appear to be in distress. Interview revealed Patient #20 stayed in the Triage area so Provider #4 could keep an eye on him until a room was available in the ED. Interview revealed Provider #4 communicated to the charge nurse that Patient #20 needed a room. Interview revealed Provider #4 was not aware there was a delay in the blood being drawn for the lab work.

RN #8 was not available for interview upon request.



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2. A closed medical record review on 04/25/2023 for Patient #15 revealed, a 59-year-old female who presented to the ED on 02/13/2023 at 1628 with a complaint of left chest pain. Review of documentation revealed the "ED Provider Notes" dated "...02/13/23 2010..." revealed the patient visited the cardiologist earlier on the morning of 02/13/2023 and was advised to follow up at the hospital due to "...abnormal EKG (Electrocardiogram),...History of Present Illness:...." Patient #15 "...with a past medical history of HTN (High blood pressure), Fibromuscular dysplasia (narrowing of the arteries) who present to the emergency department for evaluation of EKG changes and Chest pain that started this AM (Morning)....Noted T wave inversions in septal leads. No shortness of breath, no cough, no fever." Continued medical record review revealed an EKG was completed 8 minutes after arrival at 1636 and the patient's vital signs were taken 11 minutes after arrival at 1639: oral "Temp 98.2 ..." degrees Fahrenheit, "...Heart Rate: 72...Resp: 20...BP: 172/81!...SpO2: 100%...(Room Air)" Review revealed triage began 18 minutes after arrival at 1647 and pain assessment performed 19 minutes after arrival at 1648 with chest pain at 3 out of (1-10) pain level. Review revealed at 1649, 20 minutes after arrival the patient's acuity was a 2 out of 5 (5 was the lowest), primary triage was completed, and RN (Registered Nurse) initiated the standard chest pain orders. Medical record review revealed the orders included: "...PIV (Peripheral IV)...ECG Lead...Repeat as needed...Lab - CBC (complete blood count) with Differential; Comprehensive Metabolic Panel (CMP); Troponin, High Sensitive...Imaging - XR Chest 2 Views..." Review revealed 26 minutes after arrival at 1654 insertion of a PIV, blood draw for CBC, CMP and Troponin was completed. At 1655, 1 minute after PIV insertion, the PIV site was assessed. Review revealed 5 minutes after the Troponin blood collection the lab received and released the blood sample at 1659. The lab received the blood sample 31 minutes after the patient's arrival at 1659. Continued medical record review revealed 38 minutes after arrival CXR (chest Xray) was initiated. at 17:06 and completed 43 minutes after arrival at 1711. Review revealed final Troponin results 31 minutes at 1731 after the lab blood sample was released and 1 hour and 3 minutes after the patient's arrival. Troponin results: "...High Sensitive <6 ng/L...Troponin, High Sensitive Interpretation: Normal..." Review revealed the patient had first provider evaluation 2 hours and 39 minutes after the Troponin results and 3 hours and 42 minutes after arrival. Patient #15 was placed in an ED room OZ4 1 hour and 34 minutes after evaluation and 5 hours and 16 minutes after arrival. Review revealed the 2nd Troponin was collected at 2209 with final results at 2301. The Troponin results 52 minutes after lab received the blood sample and 6 hours and 33 minutes after the patient's arrival. Review revealed the patient's PIV was discontinued pending discharge at 2345, 44 minutes after the second Troponin results, and 7 hours and 17 minutes after arrival. Medical record review revealed the patient was provided with an AVS (After Visit Summary) and discharged from ED at 2350, 7 hours and 17 minutes after arrival. Review revealed the initial Troponin was drawn at 1654 and 2nd Troponin was drawn at 2209. Review of document titled "ED Provider Notes" dated "...02/13/23 at 2010" revealed "...Medical Decision Making ..." revealed, "...ON clinical exam patient NAD (No Apparent Distress),...Vital signs reviewed by m ...Chart Reviewed cardiology not from today. Pt sent in for CP (Chest Pain) and concern for acute EKG changes. I foundn (sic) EKG in system from 9/8/2021 with the same appearance as today. I consulted with Cardiology...who viewed this, agree no acute changes....trop (Troponin) x 2 neg, (negative)...When I see the patient she is very irritated due to long wait times, understandably as she has been here for greater than 7 hours. I apologized,...Pt is discharged in stable condition" Review revealed the initial vital signs performed at 1639 and no other nursing documentation reassessment noted after PIV insertion, blood draws, ECG and 1 hour prior to discharge at 2350. Review revealed the named patient was in the ED for a total of 7 hours and 11 minutes and a nursing reassessment was not performed. Review revealed a nursing assessment was not performed prior to discharge.

Interview on 04/26/2023 at 1350 via telephone with an RN #1 assigned to Patient #15 on 02/13/2023 (ED Nurse Manager and Clinical Nurse Educator present) revealed she did not remember the patient. Interview revealed per policy reassessments were done after any intervention, as needed, a minimum of every four hours and one hour prior to discharge. The ED RN stated "yes the reassessment" should have been done per policy prior to discharge.

Interview on 04/26/2023 at 1407 with the ED Nurse Manager, RN #15 revealed only one assessment was done during the Patient #15's ED admission and the patient was not reassessed on 02/13/2023 per policy after intervention, every four hours and one hour prior to discharged.

NC00200022; NC00198539