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Based on records reviewed and interviews, the Condition of Participation (COP) for Governing Body was not met as evidenced by the hospital's failure to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 1 of 9 sampled patients presenting to the Emergency Department (ED) with chest pain (Patient #4).

Findings:

1. Standard: §482.12(f)(1) Emergency Services also known as A-0092 - Based on record reviews and interviews, the hospital failed to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 1 of 9 sampled patients presenting to the Emergency Department (ED) with chest pain (Patient #4). Please see A-0092 for details.

2. COP: §482.55 COP: Emergency Services also known as A-1100 - Based on records reviewed and interviews, the Condition of Participation for Emergency Services was not met as evidenced by the hospital's failure to provide care to a patient presenting with chest pain in accordance with current standards and policies for 1 of 9 sampled patients presenting to the Emergency Department (ED) with chest pain (Patient #4). Please see A-1100 for details.


The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on record reviews and interviews, the hospital failed to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 1 of 9 sampled patients presenting to the Emergency Department (ED) with chest pain (Patient #4).

Finding:

Based on record review and interviews, the hospital failed to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 1 of 9 sampled patients presenting to the ED with chest pain (Patient #4). See A-1100 for details.

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Based on record reviews and interviews, the hospital failed to ensure it was documented if patients had formulated an advance directive or if they wanted to formulate an advance directive for 10 of 21 sampled patients (Patient #3, #4, #5, #6, #7, #9, #10, #19, #20, and #21).

Findings:

The records for Patient #3, #4, #5, #6, #7, #9, and #10, who had presented to the Emergency Department, were reviewed. These patient records showed no evidence to indicate the patient was asked if he/she had an advance directive or if he/she would like to formulate an advance directive.

The hospital's Advance Directive Policy, dated 5/25/17, indicated the following:

- B. Outpatient: "For Primary Care Practices, the provider or their designee will make a best effort to ask patients over the age of 65 if they have an advanced directive. At the discretion of the provider, younger patients or patients in specialty practices diagnosed with a serious medical condition may also be asked about advanced directives."

- Under section Life Sustaining Treatment... Documentation Whether Patients Have Executed Advanced Directives A. As part of the admission process for all adult inpatients, the staff person involved will ask and document whether patient has executed an advanced directive; e.g., living will or durable health care power of attorney or POLST...C. If the patient does not have an advance directive and wishes additional information or wishes to execute an advance directive, the admission team member or the nursing staff will offer the patient the Maine Hospital Association's Health Care: Your Right to Choose" packet."

This policy did not address the inquiry of advance directives of patients who presented to the ED.

The hospital is required to provide written notice of its policies regarding the implementation of patients' rights to make decisions concerning medical care, such as the right to formulate advance directives.

On 3/7/19 at 9:20 AM, the Clinical Quality Registered Nurse confirmed there was no documentation that patients presenting to the ED had documentation in their records of being asked about advanced directives or offered the opportunity to formulate an advance directive. She indicated the Registrar and the Clinical Quality Department did not think the Emergency Department is an applicable department as all patients are full codes upon arrival and if the patient asks for the advanced directive staff offer the information according to policy.

On 3/7/19 at 2:09 PM, surveyors observed the ED Registration process for Patient #18. This patient was not asked about or offered advanced directive information.

On 3/7/19 at 2:09 PM, an interview was conducted with the Patient Access Specialist #1. The Patient Access Specialist confirmed Patient #18 was not offered an advanced directive during registration because he/she was not 35 or over. It is the Patient Access Specialist's preference as to who is asked about or offered an advanced directive.

On 3/7/19 at 2:24 PM, an interview conducted with the Patient Access Specialist #2 confirmed that sometimes when she does the registration in the assigned patient emergency room, she asks if the patient has a power of attorney or living will. Usually, when she registers at the registration window she asks or offers any patient 18 or over if they have an advanced directive and if not; she offers them the information.

On 3/7/19 at 12:05 PM, a surveyor interviewed Patient #20, who was in the ED. The patient was asked if he/she received the "Health Care: Your Right to Choose" booklet that contains information of Advanced Directives (surveyor held up the booklet) and the patient stated, "No, I haven't seen one of those".

On 3/7/19 12:10 PM, a surveyor interviewed Patient #21, who was in the ED. The patient was asked if he/she received the "Health Care: Your Right to Choose" booklet that contains information of Advanced Directives (surveyor held up the booklet) and the patient stated, "I've got a yellow folder before in the past, but not this time. I've never seen that booklet your holding up before, though."

On 3/7/19 at 12:22 PM, the surveyor interviewed Patient #19, who was in the ED. The patient was asked if he/she received the "Health Care: Your Right to Choose" booklet that contains information of Advanced Directives (surveyor held up the booklet) and the patient stated, "No, I didn't receive that, yet". This patient stated he/she entered the Emergency Department at approximately 8:00 AM.

On 3/11/19 at 2:35 PM, in an interview with the Director of Regulatory Compliance, the surveyor informed her that Patients #19, #20 and #21 were not provided with the "Health Care: Your Right to Choose" booklet that contains information of Advanced Directives, and the Director confirmed the finding.

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Based on record reviews and interview, the hospital failed to ensure medical records were accurate for 2 of 21 (Patient #4, and #5).

Findings:

1. The "Emergency Department Patient Summary", dated 1/22/19, which was given to the surveyor as part of this Patient #4's ED record, indicated "The following procedures and tests were performed during your ED visit". Laboratory Tests - "CBC Diff"(a complete blood count with differential); "Comprehen" (a comprehensive metabolic panel); and "Troponin"; Radiology Orders - "XR chest" (chest x-ray). There was no evidence in the patient's record that these tests were completed.

During an interview with Patient #4, via telephone on 3/5/19 at 3:07 PM, he/she stated that no tests other than an Electrocardiogram [EKG] were performed during the Emergency Department visit on 1/22/19.

On 3/7/19 at 3:20 PM, the Chief Quality Officer and Systems Director of Quality were interviewed. They stated that the Emergency Department documents get created as the care evolves and the information is prepopulated whether it happens or not. They stated that they need to work with Cerner (the Medical Record System) to correct this issue.

2. On 1/8/19 at 10:48 AM, the Emergency Department (ED) Provider put in three separate STAT (which means to be given immediately) orders for Patient #5 to receive Lactated Ringers (LR) 1,000 milliliters (ml) intravenously.

Documentation on Patient #5's Medical Administration Record indicated that the patient received 1000 mls (1 liter) of LR. However, the ED Provider documented that the patient received two liters of LR.

This patient record was inaccurate as in one place it indicated one liter of LR was given and in another place, it indicated two liters of LR was given.

Based on records reviewed and interviews, the Condition Participation for Emergency Services was not met as evidenced by the hospital's failure to provide care to a patient presenting with chest pain in accordance with current standards and policies for 1 of 9 sampled patients presenting to the Emergency Department (ED) with chest pain (Patient #4).

Finding:

It is standard practice for patients who seek care through the Emergency Department (ED) of a hospital for chest pain and an elevated blood pressure to receive a timely thorough evaluation/assessment, stabilizing treatment, and discharge to home or to previous living environment in a stable condition, admission to the hospital for continuing treatment, or transfer to another hospital for further treatment that the hospital is unable to provide.

On 1/22/19 at 5:13 PM, Patient #4, a 31 year old, presented to the ED with a complaint of "chest pain, dizzy".

On 1/22/19 at 5:20 PM, the Triage Registered Nurse (RN) documented the following:

- The patient's chief complaint was "CP [chest pain] and SOB [shortness of breath] since just prior to arrival. No other assoc [associated] sx [symptoms]".

- The patient's respiratory rate was 24 breaths per minute and his/her blood pressure was 201/134.

- The patient's weight was 528 pounds.

- The patient's chest pain was documented to be a "3" at rest on the numeric pain scale.

- The Emergency Severity Index (ESI) was "3-ED Urgent".

- Allergies and previous active diagnoses.

At 5:16 PM, an electrocardiogram (EKG) was ordered to be completed stat (immediately) because the patient was experiencing chest pain. At 5:20 PM, the EKG was completed. The reading, generated by the EKG machine, indicated the patient was in "sinus rhythm" which indicated this was a normal EKG. Documentation completed at 5:21 PM, indicated a Physician was notified of the EKG results.

At 7:09 PM or 7:10 PM, stat orders (orders to be completed immediately) were entered into the record by ED Physician #2 for the following: a chest x-ray, the medications Nitroglycerin (a medication for chest pain) and Metoprolol (medication for blood pressure) and blood work, including a troponin level (a lab test that is used to determine heart muscle damage).

At 7:15 PM, ED Nurse #5 documented, "Per registration, spoke with RN in pod to let them know that pt. [patient] is leaving department".

At 7:27 PM, ED Nurse #5 documented the following:

- Discharge Status: "stable"

- Disposition Date and Time: "1/22/19 1915" [7:15 PM]

- Disposition: "Left without being seen"

The "Emergency Department Patient Summary", which was given to the surveyor as part of this patient's ED record, indicated the following:

- ED Provider was ED Physician #5 who was "assigned" on 1/22/19 at "7:10 PM" and was unassigned on 1/22/19 at "7:13 PM".

- "The following procedures and tests were performed during your ED visit". Laboratory Tests - "CBC Diff"(a complete blood count with differential); "Comprehen" (a comprehensive metabolic panel); and "Troponin"; Radiology Orders - "XR chest" (chest x-ray).

The hospital's "Triage and Categorization of Patients Policy", revised 12/17, was reviewed and indicated the following:

- "Level 1: ED Resuscitation. Patient's presenting with need for immediate emergency care for loss/instability of vital life-sustaining functions or an acute change in level of consciousness to the point of being responsive only to painful stimuli or completely unresponsive."

- "Level 2: ED Emergent. Patients presenting with symptoms indicating a high-risk condition which could easily deteriorate, symptoms suggestive of a condition requiring time-sensitive treatment, an acute change in mental status from patient's baseline or severe pain/distress."

- "Level 3: ED Urgent. Patients presenting with symptoms and stable vital signs that, if predicted, the work-up and care would utilize 2 or more resources to render an ED disposition."

- "Level 4: ED Semi-Urgent. Patients presenting with symptoms that, if predicted, the work-up and care would require only 1 resource to render an ED disposition."

- "Level 5: Non-Urgent. Patients presenting with symptoms that, if predicted, would require no resource to render an ED disposition."

The hospital's "Chest Pain of Probable Cardiac Origin and Administration of Sublingual Nitroglycerine" policy, revised 9/17, was reviewed and indicated the following:

- "The Policy/Purpose Statement: To provide patient safety and to provide for the initiation of immediate care of the potential cardiac patient".

- "Upon determination through nursing assessment that a patient is experiencing chest pain and /or associated symptoms which may be of cardiac origin, the emergency nurse will:

a. Notify the Charge Nurse of the patient's condition and bring the patient to a room with cardiac monitoring capabilities. Nursing will notify the ED Provider (MD, PA [Physician Assistant], NP [Nurse Practitioner]) of the patient's arrival.

b. Place the patient in a position of comfort.

c. Obtain STAT 12 lead EKG within 5 minutes of arrival to the Emergency Department.

d. Attach the cardiac monitor to the patient. Record, interpret and document lead II rhythm strip. Consider instituting the cardiac 'Nursing Standing Orders'.

e. Attach the pulse oximeter to the patient. Document the oxygen saturation and administer supplemental oxygen if:
i. Oxygen saturation is below 92%, or if
ii. Chest pain is present.

f. Reassure the patient and explain procedures being performed.

g. Begin documenting pertinent history ...

h. Take full set of vital signs, document in the EMR and repeat as patient condition warrants.

i. Initiate venous access through an intermittent intravenous cap. Draw blood for lab testing.

j. If chest pain is present and AFTER conferring with the Emergency Department Provider, administer sublingual nitroglycerine. (IV ACCESS MUST BE ESTABLISHED PRIOR TO ADMINISTRATION OF SUBLINGUAL NITROGLYCERINE.)

k. Assist the Emergency Department Provider with patient exam.

l. Listen to and document breath sounds.

m. Administer analgesia, anti-dysrhythmic and other medications per provider order.

n. Obtain portable chest x-ray per Emergency Department Provider order.

p. Ensure that lab orders have been entered.

q. Continually document patient's response to interventions; notify the Emergency Department Provider of any unanticipated responses or deterioration in clinical condition.

r. Maintain communication with the patient's family, keeping them informed of the patient's condition. "


Based upon the hospital's "Triage and Categorization of Patient's Policy", this patient should have been triaged at a level 2 based on the patient's elevated blood pressure of 201/134; not a level 3.

There was no evidence in Patient's #4's medical record that indicated the following:

a. Between arrival at 5:15 PM and leaving at 7:15 PM, the patient was seen by a medical provider or the medical provider was consulted despite the patient's complaint of chest pain, elevated BP and increased respirations.

b. The nursing staff assessed the patient between 5:20 PM and 7:15 PM when the patient left.

c. Attached the cardiac monitor to the patient per the hospital's policy

d. Reassured the patient and explained procedures being performed per the hospital's policy

e. Initiated venous access through an intermittent intravenous cap and drew blood for lab testing per the hospital's policy.

f. Assessed breath sounds per the hospital's policy.

g. Administered medications per the provider's order.

h. Obtained the portable chest x-ray per the Provider's order.

i. Ensured that lab orders had been entered into the computer system.

j. The stat orders for labs (a complete blood count with differential; a comprehensive metabolic panel; and troponin level), medications (Nitroglycerin and Metoprolol), and chest x-ray were completed.

On 3/05/2019 at 3:07 PM, Patient #4 was interviewed via phone. The following information was obtained during this interview:

- The patient confirmed he/she presented to the ED around 5:15 PM on 1/22/19 after experiencing left arm pain and chest pain about 30 minutes before going to the ED.

- The patient described his/her symptoms as it if "felt like my heart was stopping then it would start up again double time ... it scared me".

- After an EKG was performed, he/she was sent back to the waiting room where he/she waited without being seen again for about an hour.

- After an hour, he/she and another patient in the waiting room were called and brought into the inner part of the ED at the same time. He/she and his/her spouse was asked to wait in the hallway.

- While standing in the hallway, for about three minutes, another staff member asked them if they needed help. The patient explained that he/she was told to wait in the hall by another staff member. This staff member took the patient and the patient's spouse to a room and stated that she would inform the nurse that he/she was in the room and someone would be in shortly.

- The patient stated that he/she and his/her spouse were in the room for about 45 minutes and no one came back in.

- While in the room, the patient stated he/she continued to have chest pain; he/she had not been shown where the call bell was; and he/she was not seen or examined by anyone.

- A little after 7:00 PM, the patient decided he/she had waited long enough without being seen; therefore, decided to leave. On the way out, the patient and the spouse stopped at the registration desk to let someone know they were leaving.

- Patient #4 stated the registration staff told him/her it was a "big liability" for them if he/she left without being seen. The patient explained the situation (i.e.: he/she had sat in an exam room for 45 minutes and no one had come in to see him/her).

- The patient expressed he/she felt where he/she had chest pain that she should have been seen and evaluated and he/she felt like they forgot about him/her in the exam room.

- The patient confirmed he/she did not have any labs drawn, a chest x-ray completed, or received any medications during his/her ED visit.

- The patient confirmed that his/her blood pressure had not been rechecked after the initial reading.

- The patient confirmed that no staff other than the triage nurse asked him/her again about his/her chest pain.

On 3/07/2019 at 3:05 PM, the ED Triage Nurse, who was on duty on 1/22/19, was interviewed. The following information was obtained during this interview:

- If a patient presents with chest pain, an EKG would be completed, vital signs would be completed, and the nurse would obtain the remaining required assessment information from the patient or family member.

- The surveyor asked about the chest pain protocol and he stated, "well, I'm sure an actual protocol exists somewhere deep in the computer system/files, but we go by what we think and compare their symptoms to the Triage Level guidelines we have ..." and he indicated these guidelines are posted in the triage rooms.

- He confirmed the EKG was completed "per chest pain protocol" and "if the Doctor was concerned about the EKG results the ED tech would have told me."

- He confirmed that the patient's "blood pressure was high but [his/her] heart rate was normal which made [him/her] a level 3 versus a level 2".

- The surveyor asked about the lab orders that are part of the chest pain protocol. He stated, "I could put the orders in under nursing protocols, by clicking on the 'Chest Pain' box and a handful of orders will populate, but that's only if I have the time, the Doctor's out back can do it too."

- He indicate that they are told "'PULL TO FULL' meaning if there is an empty bed we are going to put a body in it, no matter if there is a Doctor or Nurse available to see them ... they go on our computerized screen, that we all can see, with a blank space where the Provider and the Nurse are assigned, so that is how any of us know who still needs to be seen that is in a room and who already has an assigned caregiver. Whatever nurse becomes available would pick them up ... sometimes a provider sees the patient first ... they are not automatically assigned a specific nurse when they are brought back."

On 3/08/2019 at 10:00 AM, ED Nurse #6, was interviewed via phone. The following information was obtained during this interview:

- A patient will be placed on the computer board, which means they are in a room in the inner part of the ED waiting to be seen. The patient may or may not be assigned a nurse or provider when they are placed on the board.

- If a patient presents with chest pain, the registration staff alerts the Triage nurse who begins the triage process which would include an EKG being completed. The EKG reading is taken to the ED Provider by the staff who performed the EKG and this staff person informs the Provider with any additional information. The ED Provider would inform the staff person if the patient needed to come into the inner part of the ED who then communicates this information to the Triage Nurse.

- She confirmed that the Triage nurse can enter orders such as labs and x-ray to expediate the assessment process. If results were abnormal, such as an elevated Troponin, then the patient would be brought into the inner part of the ED right away.

- The surveyor shared Patient #4's scenario and she indicated that the patient should be triaged as a Level 2; that orders would be completed, and the patient would be brought into the inner part of the ED right away.

On 3/08/2019 at 10:30 AM, ED RN #5 was interviewed via phone. This surveyor asked her about the "Emergency Department Patient Summary" which she had printed on 1/22/19 at 7:27 PM. and the entry relation to the labs, x-ray, and medication being given. She stated, "that is an unfortunate thing about the patient summaries because anything that is ordered, given, and or done to a patient auto-populates to that summary ... even if it was not done or given".

On 3/08/2019 at 12:05 PM, ED Physician #2, who was the physician who entered orders into the patient's record, was interviewed via phone. She indicated the following:

- She never saw Patient #4.

- She "saw [he/she] was in a room without a nurse or provider signed up yet; I reviewed [his/her] triage; saw [his/her] elevated blood pressure and felt [he/she] needed Nitroglycerin to help rid the chest pain and get the blood pressure down; I ordered the Metoprolol PRN in case the blood pressure didn't lower enough, labs and x-rays to be done so the process could be started for [him/her]. "I was told soon after I put all those orders in that this patient had left without being seen."

- "I remember feeling bad because I was not told about this patient, I just happened to choose [him/ her] to help start things along if I could. If a nurse would have come to me to let me know [he/she] had these symptoms and wanted to leave I would have at least gone to see [him/her] quickly, no matter how busy, and talk to [him/her] and try to convince [him/her] to stay so we could get these tests done, make [him/her] feel better ... we needed to get [his/her] blood pressure down and get a Troponin level for sure."


This patient presented to the ED on 1/22/19 at 5:13 PM with chest pain and his/her blood pressure was 201/134. The patient, after waiting two hours and two minutes, left without being seen (7:15 PM). The triage nurse identified the patient as a level 3 despite his/her elevated blood pressure; protocols, which two nurses indicated could be initiated, were not; the hospital's "Chest Pain of Probable Cardiac Origin and Administration of Sublingual Nitroglycerine" policy was not followed; the patient was not reassessed after the initial triage assessment despite his/her elevated blood pressure; and the patient was never seen by an ED Provider in the two hour and two minutes he/she was in the ED.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.