HospitalInspections.org

Based on policy review, hospital document review, medical record review from Nursing Home (NH) #1, and interview, the hospital delayed moving the patients from Emergency Medical Services (EMS) stretcher and EMS oversight to emergency department (ED) bed and ED staff oversight and care. The hospital failed to assess the patients' condition upon arrival to be prioritized based on presenting signs and symptoms for 8 of 25 (Patient #1, 3, 4, 6, 13, 23, 24 and 25) sampled patients.

The findings included:

1. Review of the hospital's "TRIAGE ASSESSMENT OF PATIENTS BY EMERGENCY SEVERITY INDEX (ESI)" policy revealed, "...PURPOSE...Determine patient acuity...Identify severity of illness or injury...Ensure patients with highest acuity are seen first...Determine number of expected resources to reach a disposition decision...Determine placement in appropriate treatment areas...POLICY...When EMS arrives with a patient and no beds are available, the patient will receive a documented ESI Triage assessment by a licensed RN [Registered Nurse] to determine assignment of the patient. All EMS patients are to be triaged and assessment discussed with a provider before being placed in the waiting room due to bed availability in the department. Discussion should be documented in the EMR [electronic medical record]..."

Review of the hospital's "Emergency Medical Treatment and Patient Transfer Policy" revealed, "Definitions...Ambulance Parking occurs when hospital staff delays the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS by refusing to release EMS staff or equipment and preventing EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney..."

Review of the hospital's "The EMTALA [Emergency Medical Treatment and Active Labor Act] Medical Screening Stabilization Policy" revealed, "...Once a patient presents to the Dedicated Emergency Department of the hospital, whether by ambulance or otherwise, the hospital has an obligation to see the patient. A hospital's EMTALA obligations begin when the patient presents at the hospital's Dedicated Emergency Department on hospital property, or is picked up a Hospital-owned ambulance, and a request is made for examination or treatment of an emergency medical condition. Patients arriving via ambulance meet this requirement when ambulance staff requests treatment from hospital staff. Ambulance Parking is not appropriate and could result in an EMTALA violation..."

2. Review of Nursing Home (NH) #1's medical record for Patient #1 revealed she was a 72 year old resident of a nursing home. Patient #1 had diagnoses that included Alzheimer's Disease, Schizoaffective Disorder, Anxiety Disorder, Gastro-Esophageal Reflux Disease, and Hypertension.

Patient #1 sustained a fall from her bed on 9/20/18 at the nursing home. The NH Certified Nurse Aide reported the fall to the charge nurse who assessed the patient and asked the facility treatment nurse to complete a full assessment.

The NH treatment nurse documented the following injuries for Patient #1:
Bruise to right eye.
Hematoma above right eye measuring 1.5 X 4 centimeters (cm).
Small cuts on both the upper and lower lip.
A 0.3 X 0.3 abrasion to the right knee.
Small laceration to the 5th digit measuring 0.2 X 0.1 cm.
An abrasion to the right side of the nose measuring 0.5 X 1.5 X 0.1 cm.
A 1 X 1 cm skin tear to the right little finger.
A small red mark on the left ear.
Bruising to the right elbow measuring 1 X 0.5 cm.
The nose swollen and bruised.

The nursing home called for EMS to transport the resident to an ED for assessment of her injuries.

Review of EMS #1's Patient Care Report revealed EMS #1 arrived at the nursing home at 2:40 PM and left with Patient #1 at 3:00 PM.

EMS #1 documented the Neuro/Mental status as "alert, altered mental status, normal for this patient, confused..."

Vital signs documented by EMS at 2:55 PM were:
Normal Sinus Rhythm, blood pressure (BP) 104/64.
Pulse 72, Respiration rate - 12, O2 Sat - 89 (O2 saturation is defined as blood oxygen levels with the normal being 95 - 100 %).
Glucose- 123.
Glasgow Coma Scale - 15 (The Glasgow Coma Scale is a common scoring system used to describe a person's level of consciousness. A score of 8 or less indicates severe head injury; 9-12 indicates moderate head injury and 13-15 indicates mild head injury).

Vital signs documented by EMS at 3:10 PM were:
Normal Sinus Rhythm.
BP- 129/95.
Pulse- 80.
Respirations-12.
Glucose- 92.
Glasgow Coma Scale- 15.
EMS arrived at the hospital's emergency department at 3:46 PM.

The EMS #1 narrative report revealed, "Responded Emergent to [name of nursing home] for Pt [patient] fell. Upon arrival found Pt supine in bed c/o [complaints of] generalized pain. Staff stated Pt fell off bed at roughly 1355 (1:55 PM) and was placed back in it...decided to send Pt to ER [Emergency Room]. Pt was chronically confused so was unable to tell us where she hurt. Pt did have some swelling to her upper lip and had a small cut to nose. Assessed Pt vitals, Pt AAO [alert and oriented] X [times] 3, Pearl (sic) [pupils equal and reactive to light]...Resp [respirations] non labored, pulse strong and regular...O2 [oxygen] sat [saturation] increased to 93%, no other change in Pt status..."
EMS documented they arrived at the hospital ED at 3:46 PM.

There was no documentation on the hospital's ED record that the hospital staff assessed and triaged Patient #1 upon arrival to the ED with EMS.

The EMS staff documented, "While waiting for bed at [named Hospital] ER [emergency room] noted Pt had a sudden decrease in LOC [level of consciousness]. Pt went into agnal [agonal] respirations. Staff started CPR [cardiopulmonary resuscitation] in hallway. Moved to bed 8 with [named Hospital] staff running code. Gave report to nurse [Nurse #1], Returned to service."

Review of the hospital's ED record for Patient #1 revealed the ED staff documented Patient #1 presented to the hospital's ED at 4:13 PM (27 minutes after the actual arrival time documented by EMS #1) and was triaged by Nurse #2 at 4:15 PM (29 minutes after the actual arrival time documented by EMS #1).

The chief complaint documented by Hospital Nurse #2 was "Pt. sent from nsg [nursing] home, EMS said she slid out of bed and moved back into bed with wincing movements at nsg home. During transport baseline mentation confused with slight grimacing. While in ER hallway pt coded."

Physican #1 documented he performed a medical screening examination (MSE) at 5:22 PM (1 hour and 26 minutes after the patient had arrived in the ED and 52 minutes after the patient had expired in the ED) The MSE revealed "...The patient presents in cardiac arrest. The onset was 5 minutes ago. Witnessed arrest yes by nurse...Initial cardiac rhythm Asystole [total cessation of the electrical activity of the heart]. Pre-arrival Treatment none. Preceding symptoms fall at nursing facility...Patient brought in from nursing facility due to fall and altered level of consciousness. Patient was near baseline upon arrival to ED but didn't have significant head injury. Pt was being wheeled to the room when she was found to have sudden cardiac arrest and was transported to room 8. The [there] was a full code and CPR initiated...Patient was initially given 1 mg [milligram] of epinephrine...with no return of spontaneous circulation. Concern for intracranial hemorrhage or possible head injury."

The hospital's CPR record for Patient #1 revealed the following:
At 4:10 PM (3 minutes prior to documented Hospital arrival time) 1 milligram of Epinephrine was administered and CPR was resumed at 4:13 PM.

At 4:32 PM the patient was in asystole.

At 4:34 [sic] PM a cardiac ultrasound was performed per Physician #1.

At 4:34 [sic] PM Patient #1 expired.

The facility delayed moving the patient from EMS stretcher and EMS oversight to ED bed and ED staff oversight and care. The facility failed to assess the patient's condition upon arrival to prioritize based on the presenting signs and symptoms.

3. Medical record review for Patient #3 revealed a Patient Care Record dated 9/20/18 by EMS #1. Patient #3 was a 31 year old male brought to the hospital ED by EMS after suffering a panic attack that was first thought to be a seizure at his primary care physician office. Patient #3 was transported to the hospital on 9/20/18, and EMS #1 documented they arrived at the hospital's ED at 3:15 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #3 was triaged with an ESI rating of 3 at 3:38 PM (23 minutes after documented time of arrival by EMS #1).

4. Medical record review for Patient #4 revealed a Patient Care Record dated 9/20/18 by EMS #2. Patient #4 was a 63 year old male brought to the hospital ED by EMS after falling from an 8 foot ladder onto concrete at home. Patient #4 complained of pain to his left lower back, flank and hip and pain to his left scapula. Patient #4 had multiple abrasions and a laceration to the bottom of his right big toe. Patient #4 was transported to the hospital on 9/20/18, and EMS #2 documented they arrived at the hospital's ED at 3:23 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #4 was triaged with an ESI rating of 3 at 3:46 PM (23 minutes after documented time of arrival by EMS #2).

5. Medical record review for Patient #6 revealed a Patient Care Record dated 9/20/18 by EMS #2. Patient #6 was a 26 year old male brought to the hospital ED by EMS with complaint of sexual assault. Patient #6 reported he had an accident at work in June 2018 which resulted in fractures of left ankle, hip and wrist. Patient #6 reported his friends had been forcing drugs down his throat and raped him 3 days ago. Patient #6 was seated in a wheelchair but was able to stand, pivot and lie down on the stretcher. Patient #6 was transported to the hospital on 9/20/18, and EMS #2 documented they arrived at the hospital's ED at 3:52 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #6 was triaged with an ESI rating of 3 at 4:04 PM (12 minutes after documented time of arrival by EMS #2).

6. Medical record review for Patient #13 revealed a Patient Care Record dated 6/27/18 by EMS #2. Patient #13 was a 77 year old female brought to the hospital ED by EMS for decrease in consciousness and low blood sugar. Patient #13 was administered glucagon by EMS. Patient #13 was transported to the hospital on 6/27/18, and EMS #2 documented they arrived at the hospital's ED at 1:40 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #13 was triaged with an ESI rating of 3 at 1:58 PM (18 minutes after documented time of arrival by EMS #2).

7. Medical record review for Patient #23 revealed a Patient Care Record dated 9/21/18 by EMS #2. Patient #23 was a 30 year old female involved in a motor vehicle crash who initially did not wish to seek medical treatment but called EMS back to the scene to transport her to the ED. Patient #23 was transported to the hospital by EMS #2 on 9/21/18, and EMS #2 documented they arrived at the hospital's ED at 12:06 PM.

There was no documentation the patient was assessed or triaged by the ED staff upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #23 was triaged with an ESI rating of 3 at 12:23 PM (17 minutes after documented time of arrival by EMS #2).

8. Medical record review for Patient #24 revealed a Patient Care Record dated 9/23/18 by EMS #2. Patient #24 was a 4 month old male with vomiting and lethargy picked up by EMS #2 at his home. Patient #24 was transported to the hospital by EMS #2 on 9/23/18, and EMS #2 documented they arrived at the hospital's ED at 2:03 PM. The EMS record further revealed, "...delay at [named hospital] secondary to no bed available..."

There was no documentation the patient was assessed or triaged by the ED staff upon arrival to the ED via EMS.

The ED record documented Patient #24 was triaged with an ESI rating of 4 at 2:27 PM (24 minutes after documented time of arrival by EMS #2).

9. Medical record review for Patient #25 revealed a Patient Care Record dated 9/20/18 by EMS #2. Patient #25 was a 44 year old female with a history of asthma picked up by EMS #2 at her physician's office for an asthma attack. Patient #25 was transported to the hospital by EMS #2 on 9/20/18, and EMS #2 documented they arrived at the hospital's ED at 2:44 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED via EMS per hospital policy.

The ED record documented Patient #25 was triaged with an ESI rating of 3 at 3:07 PM (23 minutes after documented time of arrival by EMS #2).

10. During an interview in the ED hallway on 10/1/18 at 11:50 AM, the ED Director verified that prior to the changes implemented in the ED on 9/27/18, if several ambulances arrived at the same time and no ED rooms were available, the patients would remain in the hallway with EMS personnel until a room became available. She stated the ED charge nurse had been primarily responsible for performing the initial assessment of ambulance patients when they arrived. She stated they had identified there were times when the charge nurse was not available to perform the assessment, and there was delay in triage documentation.

During an interview in the conference room with the ED Director on 10/2/18 at 9:07 AM, she was asked to describe the old method (prior to 9/27/18) of triage/assessment for ambulance arrivals to the ED. She stated, "old method was patient arrives, charge nurse greets patient and EMS...clarifies chief complaint, quick eyeball assessment...if stable EMS will stay with patient..." She verified there had been times when EMS remained with patients in the hallway until an ED room became available and triage could be performed, if the ED was full. The ED Director was asked specifically about Patient #1 who expired in the ED on 9/20/18. She verified the triage assessment was documented at 4:15 PM but the first care documented was at 4:10 PM on the code sheet. She further verified the arrival time documented by EMS was 3:46 PM. She stated she could not speak as to why the delay occurred. She verified there was nothing in the medical record that documented the patient was assessed prior to the initiation of CPR due to Patient #1's non- responsiveness (at 4:10 PM). She also verified the patient was documented as presenting to the ED at 4:13 (27 minutes after the EMS documented arrival time). She stated the previous process was to register the patient at the time triage was initiated.

During a phone interview on 10/2/18 at 11:10 AM, the Charge Nurse who was on duty when Patient #1 expired in the ED stated, "...we have a very busy ER...we did have to park [patients] on the wall [EMS entrance] and wait for a room...hospital is responsible...but patients were under EMS supervision [until a room was available]..."

During an interview in the conference room with ED Nurse #2 on 10/2/18 at 11:21 AM, she stated the process when Patient #1 presented to the ED on 9/20/18 was for EMS to stay with patients in the hallway until a room was available. She stated there were instances when more than one ambulance would arrive at the same time, and the ED was full with no rooms available. She stated it was not uncommon for EMS to stay and monitor patients until a room became available, and the nurse could perform triage.

During an interview in the conference room with ED Nurse #1 on 10/2/18 at 11:28 AM, she verified prior to 9/27/18 the process was to have EMS stay with patients if the ED was full and no rooms were available. She verified the ED staff relied on EMS personnel to let them know if the patient condition worsened. She verified there were times when several ambulances arrived at the same time and no rooms were available, and she had witnessed EMS lined up in the hallway with patients on EMS stretchers.

During an interview in the conference room with the Chief Nursing Officer (CNO) on 10/2/18 at 11:41 AM, she verified the delay on assessment for Patient #1 was not acceptable but stated she was uncertain what caused the delay. She stated the old process was for the Charge Nurse to perform an assessment on EMS arrivals if there were no ED rooms available. She did verify for Patient #1 there was nothing documented by a charge nurse; therefore, there was no documented assessment prior to the initiation of the code at 4:10 PM.

During a phone interview on 10/3/18 at 11:46 AM, Emergency Medical Technician/Paramedic (EMT/P) #1 confirmed he transported Patient #1 to the hospital ED on 9/20/18. EMT/P #1 confirmed he waited with Patient #1 in the hallway of the ED for about 20-30 minutes before Patient #1 was triaged by an ED nurse. EMT/P #1 stated he had transported patients to the ED before and had to wait a significant amount of time in the ED hallway before an ED nurse triaged the patient. EMT/P #1 stated EMS waiting in the ED hallway happened quite often.

11. The ED Director provided hospital documents kept in a binder in the ED which revealed the plan established by the hospital to address the concerns identified by the findings of a complaint investigation.

The "CHARGE NURSE MEETING MINUTES" dated 9/27/18 revealed the outline of an ED staff meeting to address the ED's deficient practice. Interventions established by the hospital to address the delay of care in the ED.

The bullet point summary of the hospital's interventions revealed, "...Upon EMS arrival, EMS will be immediately directed to open beds; the ED triage room (12, 13, 21, 27, 36) or hall triage (based on EMS radio report and current status)...RN will meet EMS at assigned location for stable patients and complete the following...Quick reg [register] patient (capture time of arrival)...Transition patient to ED bed/chair...Triage patient...Receive report from EMS...Release EMS...RN will meet EMS at assigned location for unstable patient and complete the following...Quick register the patient (capture time of arrival)...Transition patient to ED bed/chair...Provide lifesaving interventions...Triage patient...Receive report from EMS...Release EMS..." The ED Director provided a flow chart of this new procedure implemented by the ED to address patients who arrived to the ED via EMS.

The "EMS Triage Log Sheet ...TIMES" dated 9/26/18-10/1/18 revealed the times of arrival, registration, triage and seen by provider and room number were logged for patients who arrived to the ED via EMS.

During an interview in the ED hallway on 10/1/18 at 11:40 AM, the ED Director stated the process to address patients who arrived via EMS to the ED has changed since the incident was identified last week. The ED Director stated the ED now has one nurse assigned to perform EMS triage. The ED Director stated the hospital changed 5 of the ED rooms to triage only rooms (12, 13, 21, 27 and 36) for patients who arrived via EMS to the ED. Room 12 and 13 were at the entrance of the ambulance bay of the ED, and Room 21, 27 and 36 were in three separate pods around the ED. The ED Director stated when EMS arrived to the ED, the nurse would greet the patient when EMS came through the door and escort the patient to one of the new triage rooms. The nurse would then quick register the patient, triage the patient, get report from EMS and then release EMS. The ED Director stated if all the triage rooms were full, the nurse would follow the same procedure in the ED hallway. The ED Director stated if the triage nurse was unavailable, the nurse assigned to the pod the patient was taken to was to immediately go to the triage room in the pod to register and triage the patient.

During an interview in the conference room on 10/2/18 at 9:06 AM, the ED Director stated the hospital developed and implemented the plan to address the delay in care by 9/27/18 and have started tracking 100% of all patients who arrived to the ED via EMS. The ED Director stated the ED would continue to track all EMS patients for the foreseeable future until they could see the staff was sustaining the plan. The ED Director stated she would report the findings of the tracking to the CNO who would then report the findings to the executive team.

During a phone interview on 10/2/18 at 11:08 AM, ED Nurse #3 stated the process to address patients arriving to the ED via EMS has changed. Nurse #3 stated the ED now had 5 triage rooms (12, 13, 21, 27 and 36) and a dedicated EMS triage nurse. ED Nurse #3 stated she had not witnessed ambulance parking since the hospital implemented the plan.

During a phone interview on 10/2/18 at 11:21 AM, ED Nurse #2 confirmed the process to address patients arriving to the ED via EMS has changed. ED Nurse #2 stated the ED now had a dedicated EMS triage nurse and 5 dedicated triage rooms. ED Nurse #2 stated patients arriving to the ED via EMS were immediately triaged, and they were no longer waiting in the hallway.

During an interview in the conference room on 10/2/18 at 11:27 AM, ED Nurse #1 stated the ED had a new process to eliminate the EMS wait time to triage. ED Nurse #1 stated the ED now had a designated EMS triage nurse. ED Nurse #1 stated she had not witnessed any patients waiting in the hallway with EMS since the hospital implemented the new process.

During a phone interview on 10/2/18 at 11:33 AM, the ED Medical Director stated the hospital designated five new EMS triage rooms and a nurse designated for EMS triage to address the findings of the Immediate Jeopardy identified during the complaint investigation. The ED Medical Director stated the ED took ownership of the patient upon arrival and assumed responsibility for the care of the patient.

During an interview in the conference room on 10/2/18 at 11:48 AM, the CNO stated the hospital now had a designated EMS triage nurse to immediately triage and assume care of the patient who arrived via EMS. The CNO stated the hospital identified the ED needed more staff in the ED, and the hospital was working toward establishing staffing patterns to provide nurses to triage patients immediately. The CNO stated staff were trained to do a quick registration and begin immediately charting on the patient. The CNO stated the ED Director was auditing 100% of medical records from patients who arrived to the ED via EMS. The CNO stated the ED Director would report the findings to her, and she would then report the information to the executive team. The CNO stated she would report the findings to the Medical Executive Committee, Quality Improvement and the Governing Body. The CNO stated the ED Director would continue to audit 100% for an indefinite period of time.

During an interview in the conference room on 10/2/18 at 12:00 PM, the Chief Quality Officer (CQO) stated she developed the plan with the CNO to address delay in care and ambulance parking. The CQO stated the ED Director would monitor 100% of patients who arrived to the ED via EMS and report any outliers. The CQO stated outlier would be any patient whose time from arrival to triage was greater than 10 minutes. The CQO stated the charge nurse was to document the time of arrival on the EMS triage log sheet. The CQO stated the ED Director would continue to monitor 100% of all patients arriving to the ED via EMS for a period of three months and then would periodically spot check to validate compliance. The CQO stated the CNO would report the findings to the executive team (Chief Executive Officer, Chief Financial Officer, Assistant Chief Executive Officer, Chief Quality Officer and Chief Nursing Officer) at their weekly meetings.