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Based on interviews and record review, the facility failed to implement emergency medical treatment in accordance with facility policy for 1 of 3 medical records reviewed for patients with chest pain (Patient #1)

Findings include:

Facility Policies:

According to the policy titled Adult Electrocardiogram, all stat (immediate) electrocardiogram (EKG) exams (a test which records the electrical signal from the heart to identify different heart conditions) must have a preliminary interpretation by a physician/LIP within 30 minutes; for suspected acute myocardial infarction (AMI; a heart attack) 10 minutes is required.

According to the policy titled Chest Pain Protocol - ED, any patient meeting the standardized written criteria will have an EKG completed and reviewed by a physician within 10 minutes of arrival to the ED. Walk-in patients complaining of chest pain or exhibiting chest pain equivalent symptoms (identified in the standardized written criteria for immediate EKG) should be immediately given an EKG. These patients will receive an immediate assessment by the providers.

1. The facility failed to complete timely interventions and nursing assessments of a patient who entered the facility emergency department (ED) with a complaint of chest pain and shortness of breath while experiencing a myocardial infarction, (MI; commonly known as a heart attack).

Record review

a. A medical record review was completed for Patient #1 who arrived at the ED on 10/28/20 at 10:12 a.m. Technician (Tech #1) entered Patient #1's complaint into the electronic health record (EHR) as shortness of breath. Five minutes later at 10:17 a.m., Tech #1 updated Patient #1's chief complaint to include chest pain, which started 20 minutes prior with a pain rating of 6 out of 10, 10 being the worst pain possible.

At 10:23 a.m., an EKG was obtained and revealed an abnormal reading. On review of Patient #1's medical record there was no evidence the EKG was evaluated by a provider. This was in contrast to facility protocol which required a provider to review all patient EKG's and sign off on the review.

At 11:01 a.m., Patient #1 was taken back to a bed in the ED, which was 45 minutes after arrival to the ED with complaints of chest pain and shortness of breath. At 11:05 a.m., Registered Nurse (RN #2) documented Patient #1's symptoms as central chest pain and pressure 10 out of 10.

At 11:10 a.m., an hour after Patient #1 arrived with chest pain, he was assessed by physician assistant (PA #3), who wrote an order for staff to obtain lab work and administer aspirin. This was in contrast to facility policy which read the patient would receive an immediate assessment by the providers.

At 11:15 a.m., labs were obtained from Patient #1 to assess a troponin level (a measurement of a cardiac protein used to detect heart injury).

At 12:21 p.m., two hours after Patient #1 arrived with chest pain, the troponin lab work resulted at 0.062 which was elevated from the normal range of 0 - 0.045.

At 12:40 p.m., PA #3 was notified of the elevated troponin level by the charge nurse and PA #3 ordered a repeat troponin level and EKG.

At 12:57 p.m., two hours and 40 minutes after Patient #1 arrived with chest pain, PA #3 ordered a cardiology consultation for a Non-ST-elevation myocardial infarction (NSTEMI; heart attack).

At 1:25 p.m., PA #3 documented she discussed Patient #1 with Provider #4. PA #3 documented Provider #4 agreed Patient #1's EKG was abnormal and recommended the patient be treated with nitroglycerin and a heparin drip (nitroglycerin: a medicine used to open blood vessels to improve blood flow and heparin: a medication to prevent blood clots.

At 1:33 p.m., three hours and 15 minutes after Patient #1 arrived with chest pain and one hour after receiving abnormal lab results related to patent's MI (heart attack), Patient #1 received medications to treat Patient #1's heart attack.

At 1:37 p.m., the second troponin level resulted at 0.901, which was elevated from the previous result of 0.062.

At 1:51 p.m., Patient #1 left the ED for an emergent cardiac catheterization for a NSTEMI (a heart attack). According to the report from the cardiac catheterization, Patient #1 had two vessels in his heart which were 100% blocked.

Interviews:

b. An interview conducted with a cardiologist (Provider #4) on 11/18/20 at 10:27 a.m. Provider #4 stated that chest pain is the most significant determinant of risk associated with heart damage and mortality. Provider #4 stated the administration of aspirin reduces mortality and procedural issues for patients suffering from reduced blood flow to the heart, acute coronary syndrome (ACS), as happened to patient #1. After reviewing patient #1's chart, Provider #4 stated that given Patient #1's chest pain rating and EKG, ideally staff would administer aspirin and request a cardiology consult for Patient #1. Provider #4 stated patient #1 would be not be considered stable, and considering the combination of patient #1's EKG results and chest pain rating, patient #1 would be considered high risk even without meeting criteria for STEMI, an EKG reading that indicates a nearly total or total blockage of blood to the muscles of the heart (a heart attack).

c. An interview was conducted with interventional cardiologist (Provider #5) on 11/18/20 at 9:21 a.m. Provider #5 treated Patient #1 by performing a cardiac catheterization (a procedure in which a long thin tube is inserted in a vein and continues until the tube reaches the heart) used for diagnostic purposes. Provider #5 stated that Patient #1's condition was emergent due to Patient #1's ongoing chest pain and EKG changes. Provider #5 stated that a cardiology consult should have been called before 1:15 p.m. due to the ongoing chest pain, and although patient #1's EKG results did not indicate STEMI, the EKG results were also not normal. Provider #5 stated that if the ED consulted cardiology sooner, ED staff would have begun treatment sooner.

d. An interview was conducted with ED Provider (Provider #6) on 11/18/20 at 12:12 p.m. Provider #6 stated providers who worked in the ED were expected to review, sign and write the time on the EKG results to ensure that a medical doctor or physician assistant had reviewed the results to ensure patient safety. Provider #6 stated a collaborative, or a number of tests which included blood tests and a chest X-ray (collab) should still be ordered for a patient if symptoms such as chest pain are present. After review of Patient #1's chart, Provider #6 stated that the EKG results were not normal, but did not meet the requirement for STEMI. Provider #6 stated that with the combination of chest pain and shortness of breath, the goal would be to get the patient a room in the ED as soon as possible. Provider #6 stated that if a patient's symptoms included chest pain along with shortness of breath, the patient should have been prioritized to be treated sooner upon admission to the ED.

e. An interview was conducted with a Critical Care Technician (Tech #1) on 11/17/20 at 4:22 p.m. Tech #1 stated patients who complained of chest pain should have an EKG performed within 10 minutes of staff notification about the patient's chest pain.

f. An interview was conducted with Registered Nurse (RN #2) on 11/17/20 at 2:56 p.m. RN #2 stated patients who presented with chest pain should have an EKG performed within 10 minutes of stating complaint and the results of the EKG should be reviewed and signed by a provider with the date and time. Additionally, a chest x-ray and blood samples should be taken to complete a series of tests even if there are no beds available in the ED. RN #2 explained that it was important to begin tests and procedures within 10 minutes because delays in treatment could lead to heart damage.