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Based on medical record review, policy review, document review, and interviews, it was determined that clinical staff failed to follow policies and procedures governing the care provided in the emergency department.

Medical record review revealed Patients #1, Patient #2, and Patient #3 arrived in the emergency department with the complaint of chest pain, were triaged with an Emergency Severity Index level 2 (emergent-30-minute vital signs required), and sent back to the waiting room. Emergency department staff did not place Patient #1, Patient #2, or Patient #3 on a cardiac monitor, vital signs were not obtained every 30-minutes, an electrocardiogram (EKG) was not obtained (Patient #3 only), blood work including a troponin level was not obtained (Patient #3 only), and an IV access was not started per facility policy.

On 03/20/24 at 01:41 PM, an Immediate Jeopardy was identified for the CoP of Emergency Services. The facility implemented immediate interventions that included updating policies & procedures with staff education related to the monitoring of patients who must wait in the waiting room before being placed in the emergency department treatment area. Vital sign frequency audits were implemented and will be reviewed by the Nursing Quality Office and presented at the Nursing Practice Quality and Safety Steering Committee.

On 03/20/24 at 06:41 PM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews.

Cross Reference:

482.55 (a) (3) Emergency Services.

Based on medical record review, policy review and interview, the facility failed to follow policies governing the care provided in the emergency department:
1.Staff are not providing ongoing and continuing assessment of the care provided in the emergency department for cardiac patients.
2.Staff did not follow the policy for patients who leave without being seen for Patient #1.
Failure to follow established policies has the potential for a delay and/or lack of identification of an adverse patient event.

Findings #1:

Review of the policy " Emergency Department Triage and Documentation "dated 11/15/12 indicated that all patients presenting to the emergency department for care will be triaged and seen by medical providers according to the severity of their illness/injury. A triage severity category will be assigned to each patient using the five-level "Emergency Severity Index (ESI)," after the initial nursing assessment and interview. If the patient's medical status changes, the assigned triage category will change. Category level two: (Unstable) is a life-threatening condition that may deteriorate or with symptoms requiring time sensitive interventions. An example is a patient with chest pain, age 25 and greater, with severe shortness of breath and severe pain.
-All patients in these categories (category 2) will be taken immediately to the treatment area. A registered nurse is directly responsible for care of all category one and two patients, including assessments and reassessments.
-All patients placed on the cardiac monitor will have an initial rhythm strip read and attached to the patient's medical record.
-Vital signs (blood pressure, apical pulse, respiratory rate) and patient assessment for all category level one and level two patients must be documented at least every one-half hour unless less frequently ordered by the physician. Vital signs and reassessment will be documented more frequently than every one-half hour at the nurse's discretion or physician order depending on the patient's physical condition.

Review of the policy "Cardiac Monitoring" dated 07/27/18, indicated that cardiac monitoring is required in the emergency department based on presenting symptoms.

Review of the policy "Specific Treatment Guidelines-Emergency Department," dated 09/22/21 indicated that any patient who presents with suspicious chest pain or an abnormal rhythm, the nursing staff will do the following:
-Monitor the ABC's (airway, breathing and circulation).
-Immediately contact the emergency department physician.
-Establish an IV (intravenous access).
-Begin oxygen therapy, only if oxygen saturation is below 90%.
-Do an EKG (electrocardiogram).
-Establish cardiac monitoring.

Review of the emergency department medical record dated 01/09/24 for Patient #1 revealed the following:
-At 11:05 AM, Patient #1 presented to the emergency department with the complaint of chest pain.
-At 11:13 AM, vital signs were completed. The blood pressure was 173/88 with an oxygen saturation (percent of oxygen in the blood) of 98%. Patient #1's pain level was reported at five out of ten (one indicating no pain, 10 indicating the worst pain).
-At 11:22 AM, Staff (I), Triage Nurse documented that Patient #1 presented with chest pain which radiated into the neck and down both arms. Patient #1 denied shortness of breath, vomiting, fever and chills however reported nausea. Patient #1 took chewable aspirin, 324 mg prior to arriving to the emergency department. Patient #1 was assigned an Emergency Severity Index (ESI-measurement of illness severity) of two.
-At 12:45 PM, Staff (H), Nurse Practitioner documented that 30 minutes prior to arrival to the emergency department, Patient #1 noted sudden onset of centralized chest pain with heaviness that radiated to both the right and left arm. Patient #1 denied recent illness, was not coughing and/or did not have hemoptysis (cough producing blood). Patient #1 did not have a history of cardiac disease but identified a family history of cardiac disease. Orders were placed for an electrocardiogram (EKG-test to check heart rhythm), chest x-ray, and bloodwork including a troponin level (test to determine a cardiac attack).
- At 12:45 PM, the electrocardiogram revealed minimal inferior ST elevations (possible indication of a heart attack).
-At 12:55 PM, the chest x-ray revealed that Patient #1's lungs were clear and there was no sign of pleural effusion (accumulation of fluid in the cavity surrounding the lungs), pneumothorax (collection of air outside of the lung but within the cavity surrounding the lung) or acute osseous abnormalities (bone abnormalities). No definite acute cardiopulmonary disease was identified.
-At 03:12 PM, Patient #1 was discharged from the system with a discharge disposition of left without being seen.
-At 03:15 PM, a troponin result of 34 (normal range per facility criteria) was documented.
(Patient #1 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, and an IV access was not started per facility policy).

Review of the emergency department medical record for Patient #2 dated 03/19/24 revealed the following:
-At 09:16 AM, Patient #2 presented to the emergency department with complaints of dizziness, chest pain, and nausea. Patient #2 has a history of depression, hypertension (high blood pressure), Multinodular Goiter (an enlarged thyroid caused by multiple thyroid nodules), Sickle Cell Trait (an inherited blood disorder), Migraine, Iron Deficiency, and Hashimoto's Thyroiditis (the immune system causes the death of the cells in the thyroid that make hormone).
-At 09:45 AM, an electrocardiogram (EKG-test to record the electrical signals in the heart) was performed.
-At 09:46 AM, Patient #2 was triaged. Vital signs were obtained with a blood pressure of 122/77, respirations of 18 breaths per minute, a temporal (side of the head) temperature of 97.7 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 97%, a heart rate of 87 beats per minute, and chest pain of eight out of ten (score of one the least pain, 10 the worse pain). An emergent or an Emergency Severity Index of two (emergency: could become life threatening) was assigned. Patient #2 was returned to the emergency department waiting room.
-At 11:09 AM, repeat vital signs were obtained with a blood pressure of 131/73, respirations of 14 breaths per minute, oxygen saturation of 98%, and a heart rate of 79 beats per minute.
-At 12:43 PM, Patient #2 was moved from the waiting room to emergency department hallway bed five.
-At 12:45 PM, a medical screening examination was completed on Patient #2. The physician ordered continuous telemetry (cardiac monitoring), a covid/influenza test, and a blood work, including a troponin level (test to determine a cardiac attack).
-At 01:03 PM, the nursing documented that Patient #2 had mid chest pain that radiated to the left side and under the breast.
-At 02:00 PM, Patient #2's lying blood pressure was 127/66.
-At 02:02 PM, Patient #2's sitting blood pressure was 122/78.
-At 02:03 PM, Patient #2's standing blood pressure was 119/76.
-At 02:31 PM, an electrocardiogram was performed.
-At 02:38 PM, Patient #2 was moved from the waiting room to emergency department hallway bed 12.
At 03:21 PM, Patient #2's vital signs were obtained with a blood pressure of 125/70, respirations 20 breaths per minute, a temperature of 98.2 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 98%, and a heart rate of 72 beats per minute.
-At 04:00 PM, Patient #2's vital signs were obtained with a blood pressure of 138/79, oxygen saturation of 98%, and a heart rate of 77 beats per minute.
-At 04:55 PM, Patient #2 was discharged from the emergency department with an after-visit summary report and was instructed to follow-up with their primary medical provider as soon as possible or return to the emergency department for any worsening or concerning symptoms.
(Patient #2 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, and an IV access was not started per facility policy).

Review of the emergency department medical record for Patient #3 dated 03/19/24 revealed the following:
-At 12:36 PM, Patient #3 arrived in the emergency department with a complaint of chest pain, flank pain, and blood in the urine. Patient #3 had a history of atrial fibrillation (irregular heart rhythm) status post cardioversion (returns heartbeat to normal rhythm), aortic aneurysm (a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and torso), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Patient #3 was anticoagulated (a substance used to prevent and treat blood clots in the blood vessels and heart).
-At 12:55 PM, Patient #3 was triaged. An emergent or an Emergency Severity Index of two (emergency: could become life threatening) was assigned. Vital signs were obtained with a blood pressure of 141/101, respirations of 20 breaths per minute, a temporal temperature of 97.5 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 95%, a heart rate of 91 beats per minute, and four out of 10 chest pain. Triage was completed and Patient #3 was returned to the emergency department waiting room.
-At 01:55 PM, Patient was taken from the waiting room to emergency department room five.
-At 02:13 PM, a medical screening examination was conducted by the physician with a differential diagnosis of decompensated heart failure (a structural or functional change in the heart leading to the inability to pump blood) from atrial fibrillation (abnormal heartbeat). The physician also ordered bloodwork and urine laboratory studies for Patient #3, including obtaining a troponin level, and an electrocardiogram. (There is no indication in the medical record that this was completed or reviewed by a physician).
-At 02:44 PM, blood was collected for labs.
-At 03:34 PM, urine was collected via straight catheterization, for an urinalysis.
-At 03:30 PM, vital signs were obtained with a blood pressure of 117/85, respirations of 24 breaths per minute, oxygen saturation of 93%, and a heart rate of 112 beats per minute.
-At 03:56 PM, vital signs were obtained with a blood pressure of 125/82, respirations of 21 breaths per minute, oxygen saturation of 91%, and a heart rate of 104 beats per minute.
-At 06:00 PM, vital signs were obtained with a blood pressure of 118/79, oxygen saturation of 93%, and a heart rate of 92 beats per minute.
-At 07:19 PM, Patient #3 was discharged from the emergency department with an after-visit summary report instructing Patient #3 to follow-up with primary medical provider as soon as possible or return to the emergency department for any worsening or concerning symptoms.
(Patient #3 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, an EKG was not obtained, blood work including a Troponin level was not obtained per physician order, and an IV access was not started per facility policy).

Interview on 03/18/24 at 02:08 PM with Staff (I), Triage Nurse, revealed that patients presenting with chest pain are triaged and electrocardiogram is done. An Emergency Severity Index (ESI) level 2 requires additional resources of care which include assessments to be done every hour to two hours and to quickly hook a patient on to a cardiac monitor.

Interview on 03/20/24 at 09:51 AM with Staff (M), Nurse Practitioner, revealed that quick examinations are done on patients on cardiac monitor to decide what to order. Patients seen by the triage nurse who has chest pains will have an electrocardiogram set up before being seen by a provider.

Findings #2:

Review of the policy "Signing Out Against Medical Advice," dated 10/18/23 indicated that patients may not be detained in the hospital against their wishes. The patient must be asked by the provider to sign the "Refusal of Care" form. If the patient does not wait for the physician, or the patient refuses to sign the form, the physician, and a witness, or two witnesses (Thompson Health Associates) will sign the form. When a patient leaves against medical advice, the nurse manager/nursing supervisor must be notified immediately. Patient will be discharged from computer system with a reason code of against medical advice.

Review on 03/20/24 of the emergency department medical record dated 01/09/24 for Patient #1 revealed the following:
-At 11:05 AM, Patient #1 presented to the emergency department with complaint of chest pain.
-At 03:12 PM, Patient #1 was discharged from the electronic medical record system with a discharge disposition of left without being seen. (The medical record had no indication of when the patient left the hospital. No leave without being seen or leaving against medical advice documentation was found in the medical record).

Interview on 03/18/24 at 02:19 PM with Staff (G), Attending Emergency Department Physician, revealed that staff speak to patients that may want to leave against medical advice about the implications and the need to stay to receive medical care. If they still insist on leaving, they are given a form to sign denoting that they have opted to leave against medical advice. Staff (G) stated that staff would follow up and call a patient who had an elevated troponin level who left without being seen by a provider, after test is conducted, to convince them to come back in or to seek immediate medical care somewhere else.