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Based on record review, interview, and policy review, it was determined, the facility failed to ensure care and treatment was provided in a safe setting and according to standard of practice for 1 of 4 sampled patients (Patient #1). The patient presented to the Emergency Department and was triaged as needing emergent treatment, the facility was experiencing a volume surge in the department and the patient's diagnosis, diagnostic studies and treatment was delayed, resulting in the patient leaving the facility against medical advice. The patient subsequently died at home.

The findings included:

Facility policy titled "Patient's Rights and Responsibilities" dated 10/15/20 documents "Patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment."

Clinical record review conducted on 01/30/23 revealed Patient #1 presented to the Emergency Department (ED) on 01/02/23 at 12:35 PM with chief complaint of weakness, pain in the shoulders and chest and general malaise.

The patient was triaged at 1:15 PM as emergent with an Emergency Severity Index (ESI) of 2, Emergent. Vital signs included elevated heart rate at 126 beats per minute and low blood pressure, 99/64.

The record indicates orders for an Electrocardiogram (EKG), chest x-ray and STAT (immediate) blood work including Troponin levels was ordered at 1:18 PM.

The Physician Assistant documents at 1:19 PM "94 year old female presents to the ED complaining of pain behind the left shoulder and into the chest. Patient also has general malaise, shortness of breath. Patient states she has not been sleeping well due to the pain in her left shoulder and back region."

Interview with the Triage Nurse on 01/31/23 at 8:30 AM revealed after the triage process was completed, Patient #1 was asked to return to the lobby, the department was at overcapacity and there were no available beds.

Paper copy of the EKG completed on 01/02/23 at 1:22 PM revealed abnormal results and a stamp noted NO STEMI (ST elevation myocardial infarction).

The triage nurse documents at 3:10 PM, the patient's son went to the triage desk and stated he was going to take his mother home. He stated she had an appointment in the morning and can have the blood work done at this time. The nurse noted the patient was encouraged to stay for further evaluation. The patient's son declined and left the emergency department.

At 4:49 PM, the physician reviews the EKG again and documents abnormal results and positive answer to STEMI.
The charge nurse documents at 5:10 PM attempts to reach the patient at home to return to the ED.

Interview with The Triage Nurse conducted on 01/31/23 at 8:30 AM, revealed she was the triage nurse on duty on 01/02/23. It was a rough day, she was the only triage nurse with one technician, there were a line of patients waiting and recalls Patient #1. The patient complained of shoulder pain and weakness, she did the EKG and asked her to sit back out in the lobby. She then took the EKG to the provider for review and does not recall being instructed to place Patient #1 in a room immediately. Later during her shift, she spoke to the patient's son, she explained they were busy, and they were putting orders in for labs, and she was having a x-ray done as well, and kept them updated. a while later, the son approached the desk and wanted to leave AMA (against medical advice), relaying the patient was tired of sitting in the ED. The nurse apologized and told them she is due to see the physician. At the time, she did not have any AMA forms printed for them to sign, and the patient and son left the unit. When she finally got time to catch up her charting is when she found out the patient had a STEMI and the charge nurse was calling for her return.
The nurse was asked what had she learned from this event and explained she learned they need more help on triage, at least two nurses and better communication with the back.

Interview with The ED Physician conducted on 01/31/23 at 9:29 AM revealed the physician acknowledged deviations from the patient's care. The first time he reviewed the EKG, he had concerns regarding ischemia, but was not sure if the patient's fast heart rate attributed to the changes in the EKG; so he asked the triage nurse to place the patient in a room and he would come and see her. The Physician confirmed the EKG was not labeled as a positive STEMI at that time and also verified he did not see the patient. It was a very busy day, the department was over capacity and the blood work was not completed. If the blood work was done, maybe the Troponin would be elevated and actions may have been taken sooner. In addition, when the patient decided to leave against medical advice, he was not made aware, sometimes a conversation with the physician and taking the opportunity to do a reassessment would get different results.
The physician recalls the EKG technician brought back the EKG results and at that time he confirmed the reading as a positive STEMI. The physician then asked the nurse where the patient was and was advised they had left. He instructed the nurse to call them back in. Eventually they were able to reach the household and were told the patient had coded, he is not sure whether at the house or in the ambulance.

The facility investigated the event and the plan of correction failed to include immediate and effective corrective measures to minimize the risk of reoccurrence. (Refer to A286)

Based on clinical record review, interview and review of the Performance Improvement Plan, it was determined, the facility failed to implement preventive actions and mechanisms to minimize risk of injury to patients. The deficient practice is evidenced by: Failure to develop corrective action addressing the root cause of 1 of 1 adverse incident reviewed, resulting in delay in care and subsequent patient's death; failure to implement immediate mechanism to address patient care flow in the emergency department during surge times and failure to identify all factors contributing to the event.

The findings included:

Clinical record review conducted on 01/30/23 revealed Patient #1 presented to the Emergency Department on 01/02/23 at 12:35 PM with chief complaint of weakness, pain in the shoulders and chest and general malaise. The patient was triaged as 1:15 PM as emergent with an Emergency Severity Index (ESI) of 2.
The record indicates orders for an Electrocardiogram (EKG), chest x-ray and STAT blood work including Troponin levels was ordered at 1:18 PM.
The patient was instructed to return to the lobby, as no beds were available in the department.
The EKG completed on 01/02/23 at 1:22 PM revealed abnormal results and was stamped as NO STEMI (ST elevation myocardial infarction) by the physician.

The EKG technician identified the EKG was abnormal and at 4:49 PM, the physician reviews the EKG again, and documents abnormal results with positive STEMI and efforts to reach the patient were initiated.

Patient #1 had left the ED, Against Medical Advice (AMA), the staff attempted to reach the patient at home and learned the patient had expired.

Interview with the Triage Nurse conducted on 01/31/23 at 8:30 AM indicates the delay in care was due to patient surge, volume, staffing and not following the AMA policy.

Interview with the ED physician conducted on 01/31/23 at 9:29 AM validates there was a delay in identifying the STEMI, delay in obtaining ordered blood work, there were concerns regarding staffing during surge times, and the staff did not follow the AMA policy for notifying the physician that the patient was leaving, all contributing factors to the delay in care.

The facility investigated and reported the adverse event and developed a plan of correction.

Review of the facility investigation and corrective actions revealed the following concerns:
The investigation did not identify all the barriers and factors that contributed to the adverse event.
The action plan did not include department wide education.
The action plan did not address staffing strategies during patient surges and when the ED is overcapacity.
The plan did not address a process to ensure diagnostic studies are completed timely during patient surges.
The plan did not address reassessment of patients with ESI 2, that are waiting in the lobby pending bed placement.
The tracer developed as a monitoring tool to sustain compliance with the facility surge plan and to minimize reoccurrence of the event did not address how the facility is going to monitor the provision of timely care for patients with ESI 2 when the ED is over capacity.

Interview with The Director of Quality and The Risk Manager conducted on 01/31/23 at 12:25 PM revealed the process for reducing adverse events and reoccurrence includes the completion of the root cause analysis and implementing corrective measures. The facility follows joint commission standards, corrective actions are implemented within thirty to forty five days from the event.
The surveyor explained the concerns regarding the correction plan involving Patient #1. The facility first measure describes education to clinical leaders to ensure physicians are informed that there are ESI level 2 patients in the lobby for bed placement. The education did not include physicians or staff nurses.
The second measure addressed validation of initiating the Overcapacity Plan via tracers and door to triage times. The facility provided a copy of the Tracer Observation Form created to monitor compliance. The tracer did not address patients with an ESI of 2, waiting in the lobby for bed placement.
The corrective action does not specifically address how the ED is going to improve the process for ensuring diagnostic orders are completed timely, even for those patients not bedded.
The corrective action does not address how the nursing staff reassesses patients in the lobby with abnormal vital signs.
The investigation and corrective action did not address staffing constrains when the ED is at over capacity.

The Director and Risk Manager acknowledged the provided correction plan did not address the key point documented above. Then explained the facility process for this review is ongoing and further action plans are typically developed after the weekly meetings as other issues may arise. Even later, when the enterprise reviews the event, they may add additional measures. The Director explained at times, the staff does not put forward all the pertinent information, and later conversations bring out other areas of concerns and then additional plan of action would be discussed and implemented as warranted.

Based on record review, policy review and interview, it was determined, the facility failed to ensure policies and procedures for determining emergency severity index were accurately developed and implemented, when triaging patients presenting to the facility seeking emergency care.

The findings included:


Review of the Emergency Department (ED) central logs dated 01/30/23, 01/23/23, 01/18/23, and 01/02/23 revealed multiple patients who presented to the ED, were triaged with acuity levels of 3H (high) and 3L (low).

Facility policy titled "Emergency Department Severity Index Triage (ESI)" approved 02/08/22 documents:
"This policy is intended as a guideline only and failure to follow the policy may or may not be a breach in the current clinical standard of care. It is not intended to replace professional judgment in patient care or administrative matters.
PURPOSE
The purpose of this policy is to establish guidelines to define the use of the ESI tool within the IRMC Emergency Department.
POLICY
It is the policy of IRMC to identify patient's need for care or treatment upon presentation to the ED. IRMC utilizes the ESI tool as a triage assessment guide.
o ESI triage integrates a five level acuity scoring system based on presenting acuity and utilization of resources needed to care for the patients.
o The benefits of the ESI tool include rapid identification of patients that need immediate lifesaving resources and interventions.
o ESI also enables rapid sorting of patients into groups with meaningful differences in projected care and resource needs.
o Acuity level descriptions are communicated to all care providers by the triage RN or triage team as determined by subjective and objective data collection.
It is the policy of IRMC that comprehensive data collection is limited during the triage process and that collection of data does not delay a Medical Screening Exam (MSE) or delivery of care and/or interventions.
It is also the policy that the primary and secondary assessment data and vital signs may be documented by the triage RN or the primary RN.
The ED triage team consists of qualified ED personnel with documented ESI training and essential assessment skills and experience. It is recommended that the Triage RN stationed in the ED lobby have a minimum of six months Emergency Nursing practice. In addition, the RN assigned to the ED lobby point of entry will be currently certified in Advanced Cardiac Life support (ACLS) and be certified in Pediatric Advanced Life Support (PALS).
PROCEDURE
A. The Assistant Nurse Manager and the triage RN and triage team are stationed at points of entry into the Emergency Department.
B. Patients that present to the ED by ambulance or via the ED lobby entrance are assessed by experienced ED RN and ED triage team and are rapidly designated to exam rooms if there is immediate life threatening condition. The ED team consists of RN's, ED Techs and/or ED Paramedics and Advanced Practice Clinicians (APC).
C. ESI Level I patients need immediate intervention and are considered unstable. Examples of Level I ESI patients may include but are not limited to:
1. Cardiac arrest
2. Respiratory arrest
3. Severe respiratory arrest
4. Critically injured trauma patient
5. Overdose with a respiratory rate of 6
6. Anaphylactic shock
7. Pediatric decrease level of consciousness, loss of tone, hypoventilation, hypoperfusion
8. Chest pain with hypotension, paleness and diaphoresis
9. Imminent Delivery
D. The decision to assign Level ESI 2 is based on pertinent subjective and objective information. The patient's medical history, current medications and patient age will be considered. Examples of Level 2 ESI patients may include but are not limited to the following:
1. New onset lethargy, confusion or disorientation
2. High risk situation such as conditions that may easily deteriorate or may require time sensitive treatment.
3. Severe acute pain or distress.
4. Abnormal vital signs associated with clinical presentation
5. Acute psychiatric event
6. Pediatric respiratory distress, tachypnea, tachycardia, retractions
7. Severe pain or distress (the RN is not required to assign a level 2 rating for patients that self-report pain of 7/10 or greater and are determined by the triage RN to be safe to wait.).
E. The decision to assign Level ESI 3 is based on the assessment that the patient is stable and is not at a high risk for deterioration, but it is predicted that the patient needs several resources to reach a disposition decision. Resources include lab and radiology diagnostic studies, procedures such as IV hydration, IV medications, nebulized medications and possible specialty consultations. Additional resources include simple laceration repairs, foley catheterizations and Procedural
F. The decision to assign Level ESI 4 is based on the assessment that the patient is stable and the predicated amount of resources required is one resource.
G. Assessment of Patient vital signs may be considered in assigning a triage Level if parameters are outside of normal range and are significant and meaningful to the presenting patient presentation and assessment according to current ENA standards.
H. The Triage RN in with the Assistant Nurse Manager and/or Triage team will determine the allocation and placement of patients into bed assignments taking into consideration the patient acuity, staff availability, and complexity of the nursing and physician assignment.
l. The triage members including the triage RN's and Paramedics and Techs will prioritize their triage tasks when multiple walk in patients patient's arrive at once.
J. ED exam rooms may be reserved by the Assistant Nurse Manager when awaiting Level I and Level 2 patients from Emergency Medical Services (EMS)."

The policy failed to determine and specify the criteria for ESI 3H (high) and ESI 3L (low).

Interview with The Accreditation Coordinator on 01/31/23 at approximately 2:33 PM regarding how the ED staff assigns acuity level of 3H and 3L, revealed he was not sure and will email the ED manager for clarification. The Coordinator presented an email from the manager explaining ESI 3H is like a ESI 2 but with stable vital signs or depending on the complaint and a level 3L is not as acute. The Coordinator acknowledged the facility does not have a policy or procedure establishing the criteria when assigning acuity level of 3H or 3L.