HospitalInspections.org

Based on policy review, medical record review, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to obtain an electrocardiogram (EKG), administer oxygen, and initiate cardiac monitoring and intravenous access per policy on 1 of 2 sampled patients that presented to the Emergency Department with complaints of chest pain (Patient #4).

The findings include:

Review of current hospital policy entitled "Chest Pain" dated 12/2009 revealed, "Emergency Department (ED) patients presenting with chest pain will be evaluated as soon as possible. If the patient meets Triage Criteria for a patient with Urgent - Chest Pain, do the following:...4. Page EKG (electrocardiogram staff) STAT (immediately). If EKG not available in the department, initiate the EKG. 5. After completion of the EKG have the ED Provider review and document time...7. Place the patient on Cardiac monitor, O2 @ 2L via NC (administer oxygen at 2 liters/minute via nasal cannula), and start IV (intravenous line)....Note: In the event the Triage Nurse or Primary Care Nurse assigned to the room cannot immediately initiate the above outlined actions, it is the responsibility of the Charge Nurse to ensure they are being done until another nurse is available. **The EKG is to be done within 10 minutes of arrival to the ED....If there are no rooms available, the EKG may be performed in the Triage room, the patient may be placed in Stretcher Triage where the EKG will be done. In the event there are no beds in the ED and no beds in Stretcher Triage, the Charge Nurse will triage a patient out of a room in the ED and place in a hall bed."

Review of current hospital policy entitled "Triage - Emergency" dated 12/2009 revealed, "...When (Emergency Severity Index - ESI) Level II condition is identified, the triage process stops, the patient is taken directly to a room and immediate physician intervention requested...."

Closed medical record review for Patient #4 revealed a 47 year-old male that presented to the ED on 05/10/2011 at 1229. Review of the triage nurse's assessment documented at 1240 revealed, "C/O (complains of) chest pain x 3 days intermittent. Today feels worse. Increased fatigue and malaise. Had cardiac cath(eterization) and stent placement x 2 on 5/5/11. Consulted (cardiologist) who advised him to come to ED. + SOB (positive shortness of breath). No nausea....Pain location: Chest . Description: Pressure, Tightness. Intensity: 8 (on a scale of 0 - 10, with 10 being the most intense pain)....Triage (ESI) Level: 2." Record review revealed an EKG was performed by an EKG technician at 1358 (1 hour and 18 minutes after the triage nurse noted the patient complained of chest pain). Record review revealed the ED physician signed the EKG at 1400 and noted "NSR (normal sinus rhythm). 0 (no) acute (changes)". Record review revealed documentation the patient was placed in an ED treatment room at 1403 (1 hour and 23 minutes after the patient complained of chest pain and the triage nurse found the patient to be an ESI Level 2). Record review revealed documentation cardiac monitoring was initiated and oxygen was administered at 2 liters/minute via nasal cannula at 1416 (1 hour and 36 minutes after the patient complained of chest pain). Record review revealed the first documented evidence the patient had an intravenous line was at 1546, when he received intravenous pain medication (3 hours and 6 minutes after the patient complained of chest pain). Record review revealed the patient was admitted with a diagnosis of acute chest pain. Further record review revealed on 05/11/2011 the patient was transferred to another acute care hospital with plans to undergo an interventional cardiac catheterization.

Telephone interview on 06/16/2011 at 0950 with the nurse that did the triage assessment on Patient #4 on 05/10/2011 revealed any patient that comes into the ED with complaints of chest pain should have an EKG done within 30 minutes of arrival. Interview revealed, "In triage during the day you call the EKG tech and they come do it. If other patients are waiting (to be triaged) you can move the patient to the chair at the registration desk to wait for the EKG." Interview revealed if the EKG tech was not available then the nurse could do the EKG herself. The surveyor read the nurse's notes from Patient #4's record to the nurse. Interview revealed, "I assigned him (ESI) level 2 because he was having chest pain and was that fresh out of a cath and stent placement....Those (coronary artery) vessels can re-occlude pretty fast....I think I called the charge nurse to let her know and I called EKG....I guess I probably put him at the registration desk to wait for EKG....I don't recall if the EKG was done before he went to a room."

Interview on 06/16/2011 at 1140 with the EKG tech that did Patient #4's EKG on 05/10/2011 at 1358 revealed the EKG tech covers the whole hospital. Interview revealed when an EKG is needed in the ED, ED staff call the tech directly. Interview revealed, "We go immediately to the ED if they call for an EKG. If I am busy with another patient, I tell them and they tell me if they are going to do the EKG....Usually patients are in triage when I do EKGs in the ED." Interview revealed the EKG tech did not recall Patient #4 or when she was called to do the EKG. Interview revealed the EKG tech reviewed the patient's medical record. Interview revealed the patient was in ED treatment room CT4 when the EKG was done.

Interview on 06/16/2011 at 1100 with the 05/10/2011 charge nurse revealed the nurse did not recall the named patient. Interview revealed the charge nurse reviewed the patient's medical record. Interview revealed the nurse did not remember being called about the patient. Interview revealed, "If I had known I would have brought him back (to the treatment area) because he had a cath with stents a couple of days before and his physician advised him to come to the ER."

Interview on 06/16/2011 at 0920 with the Clinical Coordinator of Performance Improvement in the ED revealed an EKG should be done within 10 minutes of arrival when a patient presents with complaints of chest pain. Interview revealed chest pain protocol should be implemented in triage if the patient couldn't be taken directly to a treatment room. Interview revealed if an EKG tech was unavailable to do the EKG then either a nursing assistant or a nurse, who has been trained and had competency validated, could do the EKG. Interview revealed the nurse that triaged Patient #4 on 05/10/2011 could do EKGs. Interview confirmed there was no available documentation an EKG was performed prior to 1358 (1 hour and 18 minutes after the triage nurse noted the patient complained of chest pain). Interview confirmed there was no available documentation that chest pain protocol (including oxygen, IV, and cardiac monitoring) was done in triage. Interview revealed, "I don't know why the EKG was not done sooner."

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