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Based on interview and record review, the facility failed to meet the emergency needs of 5 of 11 sampled patients who presented to the Emergency department (ED) (Patient #'s 1, 2, 4, 7, and 8).

Patient #2 who presented to the ED after not being dialzyed for a week. Patient #2 had an elevated blood sugar on presentation and did not receive Insulin unitl 4 hours later. Patient #2 had other critical lab values and the recommendation was made for admission and a consult with a Nephrologist. Patient #2 was not dialyzed until 9 hours after presenting to the ED.

Patient #8 presented to the ED with nausea/vomiting and severe pain. Patient #8 was found to have a critically low potassium level and did not receive treatment for over 3.5 hours after report of the critical value. Patient #8 had two sets of physician orders on the record which did not correlate when it came to treatment for the elevated potassium.One order did not give the freqency of how many doses of Potassium to administer and another order asked that 3 doses be administered. Patient #8 only had documentation of one dose being administered while in the ED.


Patient #'s 1,2, 4, 7 and 8 had ED physician orders that were not timed, dated or signed. There was no way to tell in some cases if treatment was being done timely,if staff were following up timely to lab results and if admitting orders for other departments were being implemented timely.

Refer to tag A1103 for additional information.

Based on interview and record review, the facility failed to ensure that the Emergency Department (ED) was fully integrated into other services in 5 of 11 sampled patients (Patient #'s 1, 2, 4, 7, and 8).

Patient #2 who presented to the ED after not being dialzyed for a week. Patient #2 had an elevated blood sugar on presentation and did not receive Insulin unitl 4 hours later. Patient #2 had other critical lab values and the recommendation was made for admission and a consult with a Nephrologist. Patient #2 was not dialyzed until 9 hours after presenting to the ED.

Patient #8 presented to the ED with nausea/vomiting and severe pain. Patient #8 was found to have a critically low potassium level and did not receive treatment for over 3.5 hours after report of the critical value. Patient #8 had two sets of physician orders on the record which did not correlate when it came to treatment for the elevated potassium.One order did not give the freqency of how many doses of Potassium to administer and another order asked that 3 doses be administered. Patient #8 only had documentation of one dose being administered while in the ED.


Patient #'s 1,2, 4, 7 and 8 had ED physician orders that were not timed, dated or signed. There was no way to tell in some cases if treatment was being done timely,if staff were following up timely to lab results and if admitting orders for other departments were being implemented timely.




This deficient practice had the likelihood to cause harm to all patients presenting to the ED.





Findings include:





Review of the clinical record of Patient #2 revealed she was a 43-year-old female who presented on 05/02/2018 at 5:09 a.m. Patient #2 was triaged at 5:22 a.m. and the chief complaint was general weakness. According to the assessment Patient #2 had not had hemodialysis in 1 week and was assessed as having a moderate pain level of 7 out of 10 (0 meaning no pain and 10 meaning severe pain). Patient #2 was documented as having an elevated fasting blood sugar of 357.


Review of the "Daily Focus Assessment Report" at 8:49 a.m. revealed Patient #2 had the following critical lab values:

Blood urea nitrogen of 143 with reference ranges being 6.0-17.0;
Creatine of 16.1 with reference ranges being 0.4-1.2;
Potassium of 6.3 with reference ranges being 3.5-5.0.

Review of physician progress notes at 8:55 a.m. revealed Patient #2 remained in the ED and has been admitted to the hospitalist, with consult to the Nephrologist.

Review of the "Daily Focus Assessment Report" at 9:34 a.m., revealed Patient #2 was given 10 units of Regular insulin and this was for a blood sugar of 279 which was taken at 9:29 a.m.

This was the first documented dosage of insulin given (4 hours after the triage assessment).


Review of ED physician orders on Patient #2 revealed one page which had two different sets of orders written on it. There was no signature after each set of orders nor time to indicate when they were written.

The first set of orders on the page included the Regular insulin10 units IV (intravenous) x 1. A nurse documented on the orders that the medication was administered at 9:33 a.m. for a blood sugar of 279. This was not for the blood sugar reading on presentation to the ED of 357.

The second set of orders on the page revealed Patient #2 had diagnoses of altered mental status, increased potassium, increased troponin, urinary tract infection and increased glucose. There were orders written on the set to admit the patient and for a consult for Hemodialysis with a nephrologist. There was no time as to when these orders were written.

Review of physician progress notes at 11:04 a.m., revealed Patient #2 would be admitted to Telemetry. Nephrology had already been consulted and will be dialyzed ..." Kayxelate 60 grams will be given stat and K level will be monitored."

Review of the "Daily Focus Assessment Report" at 1:30 p.m., revealed Patient #2 was transferred to the Medical/surgical unit at 1:30 pm.

Review of physician progress notes at 2:18 p.m., revealed some of the following documentation:

"treatment for hyperkalemia given, will plan ASAP HD with 2k bath ..."


At 3:25 p.m., Patient #2 was transported to dialysis for a treatment over 9 hours after presenting to the ED.


During an interview on 05/04/2018 after 9:00 a.m., Staff # 15 confirmed the documentation.



Review of the clinical record of Patient #8 revealed she was a 56-year-old female who presented to the ED on 04/23/2018 at 11:39 a.m.. Patient #8 was triaged at 11:43 a.m., and presented with complaints of nausea/vomiting and a severe pain level of 8 (0 meaning no pain and 10 meaning severe pain).

Review of lab reports dated 04/23/2018, 1:30 p.m. revealed the following critical labs results:

Sodium level of 134 with reference ranges being 137-145;
Potassium level of 2.5 with reference ranges being 3.5-5.0.

According to documentation on the bottom of the report, the lab results was called to the ED at 1:55 p.m.


Review of Patient #8's ED physician's orders revealed four different orders for treatment and medications written on one page. There were orders written on the one page at 12:22 p.m., 1:04 pm., and 3:23 p.m. and the last set was not timed by the physician, but they were reviewed by nursing at 5:40 p.m.

Review of the last orders on the page revealed Patient #8 had diagnoses which included gastroenteritis, hypokalemia, and migraine headache. One of the orders on the form was for the potassium supplement (K Lyte 25 milliequillivents by mouth). The order was incomplete and did not include how often to administer the medication.

There was no way to tell when the order for the potassium was written.

The physician signed the bottom of the order page at 1:13 p.m. There was no way to tell which orders were written at this time. This time did not correlate with the last timed order on the page which was at 3:23 p.m..

Another set of physician orders were found which were dated 04/23/2018 at 4:45 p.m. These orders were for admission to the Medical surgical unit and there was another order for "KLyte 25 MEQ PO q 4 (hours) x 3 doses."

Review of the ED "Daily Focus Assessment Report" dated 04/23/2018 revealed the following:

At 5:52 p.m. (over 3.5 hours after report of the critical value), Patient #8 received the potassium supplement K Lyte 25 milliequillent (MEQ) by mouth.

At 6:00 p.m. there was a nursing rounding status/observation.

Review of the ED "Daily Focus Assessment Report" dated 04/24/2018 at 0050 revealed documentations that Patient #8 was transferred to the Medical surgical unit (over 6 hours after receiving one dose of potassium).

There was no documentation of any more doses of Potassium being administered while in the ED.

During an interview on 05/03/2018 after 11:00 a.m., Staff #'s 5 and 15 confirmed the documentation.





Review of the clinical record on Patient #4 revealed she was 26-year-old female who presented to the ED on 04/21/2018 at 3:46 a.m. Patient #4 was triaged at 3:56 a.m. and had complaints of left side pain. Patient #4 was assessed as having a pain level of 6 out of 10 (0 meaning no pain and 10 meaning severe pain).

Review of physician orders revealed an order for the pain medication Dilaudid 1 milligram IV. There were orders for other medications, lab and treatments.

The physician failed to sign off on the orders. The orders were electronically signed off on 04/27/2018 (6 days later) by the physician.

Review of the "Daily Focus Assessment Report" dated 04/21/2018 revealed Patient #4 received the Dilaudid at 6:40 a.m. (over 2.5 hours after presenting).





39801


Review of Patient #1's emergency record revealed the following:

Patient #1 presented to the Emergency Department (ED) at 3:34 am with a chief complaint of MVA (Motor Vehicle Accident). Patient #1 was triaged at 4:15 am. Patient was given Emergency Severity Index (ESI) level of 2 and was assessed at having a pain level of 9 (0 meaning no pain and 10 meaning severe pain).

Patient#1 was medically screened at 3:40 am. Patient #1 went to radiology at 4:00 am and returned to the ED room at 4:45 am.

Review of the "ED Trauma flow sheet" revealed morphine 4 mg and zofran 4 mg given at 4:45 am intravenously.

Review of the "Physician H&P" revealed the following notation:
"morphine 4 mg IV now and Zofran 4 mg IV now". There was no date, time, or physician signature on the notation. Review of the CPOE (Computer Physician Order Entry) did not reveal a physician order that correlated with the notation. The original "physician H&P" document was signed by a physician at 0315. The was no documentation to determine if the order of morphine and Zofran was from that physician or another physician.

Staff member with initials JL noted medications at 4:45 am, there was no date listed. The medications were given at 4:45 am.


Review of Patient #7's ED record revealed the following:

Patient #7 presented to the ED at 4:18 am with a chief complaint of Chest pressure. Patient#7 was triaged at 4:18 am with. Patient #7 was given an ESI level of 3 and was assessed at having a pain level of 2 (0 meaning no pain and 10 meaning severe pain).

Patient #7 was medically screened at 4:05 am.

Review of the ED "Physician H&P" showed the following notations under medications:
"4:55 am Zofran 4 mg IV, Morphine 4 mg IV, NTG (Nitroglycerin) 1-inch patch". There was no date or signature. The signature line was blank on the document. There no documentation to determine if the order of morphine, zofran, and NTG were from a physician. Review of the CPOE (Computer Physician Order Entry) did not reveal a physician order that correlated with the notation.

Staff member with the initials SS, RN noted the medications at 7:19 am, there was no date listed. The medications were given at 7:19 am.