HospitalInspections.org

Based on medical record review, staff interviews, and review of the facility's incident reports, it was determined that the facility failed to provide a safe setting in the Emergency Department for one of ten sampled patients (Patient #9). The facility had a census of 31 patients in the Emergency Department at the time of the investigation.

Findings include:

The medical record of Patient #9 was reviewed on 02/17/12. The patient was admitted to the Emergency Department on 10/04/11 at 01:56 P.M. with complaints of a sudden onset of chest pain. According to the History and Physical of the Interventional Cardiologist (Staff H) the patient had a history of a myocardial infarction (MI) in 2008. An MI occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely damaging the heart muscle. The patient described the current chest pain as equivalent to the pain experienced in 2008. The electrocardiogram (EKG) showed an acute MI. The Emergency Department Physician (Staff D) documented in a progress note that the Cardiac Catheter Lab was notified of an impending emergency case. Staff D further indicated that the Emergency Department Staff Nurse (Staff C) was given a verbal order to give the patient 81 milligrams of aspirin but that Staff C refused to follow the order, stating that Staff D needed to first, place the order in the computer. Staff D documented that orders for a Heparin bolus and 300 mg of Plavix were also verbally given to Staff C. It was further documented that Staff C also refused to give these medications. The patient was emergently transferred to the Cardiac Catheter lab at 02:15 P.M. where the ordered medications were given and a stent was successfully placed.

The Manager of the Emergency Department (Staff F) was interviewed on 02/17/12 at 01:30 P.M. and asked about this incident. Staff F stated, "I remember this incident and this was a safety issue because the nurse could've given the wrong dose or even the wrong medication with the way the doctor was barking those orders." Although Staff F denied being present when the event occurred, Staff F reported that staff C unsuccessfully attempted to calm Staff D down. Staff F denied that any follow-up to this incident was completed.

Staff C and E were interviewed on 02/17/12 at 03:59 P.M. Staff E provided a copy of an email written by Staff C. The email described the incident that occurred on 10/04/11. The email indicated that Staff D asked Staff C to administer Heparin, aspirin, Morphine, Plavix, Metoprolol, and a Nitroglycerin drip. Staff C told Staff D that the medications needed to be put into the computer so that the correct medications and dosages were given. It was noted in the email that Staff D said, "No, I will not. This is an emergency, you will do what I say." During the interview Staff C stated: "I felt that it was unsafe to try to triage a patient on top of taking verbal orders." Staff C further explained that Staff D was speaking in a loud tone. Staff E indicated that the census in the Emergency Department on 10/04/11 was 38 with only 27 available beds. Staff E stated, "Because the census was so high that day, all the beds were full and I'm sure the other patients nearby could hear the commotion." Staff E indicated that Staff D was terminated of his services on "either 10/08/11 or 10/09/11. Staff E also denied that any follow-up to this incident was completed.

Based on tour of the Emergency Department and interview with the Emergency Department Manager (Staff F), the facility failed to ensure that the physical environment of the Emergency Department was maintained in a manner that assured the well-being of the patients.

Findings include:

The Emergency Department was toured on 02/16/12 at 02:35 P.M. Drops of a clear liquid substance were noted on the floor in Room 1, leading into the hall and then into Room 5. There was no "Caution Wet Floor" sign noted to alert those walking in that area. Peeling paint was noted on the soffit below the ceiling in Room 12. Thick clumps of dust with black specks were noted as a surveyor's hand wiped over the surface of a cabinet shelf inside Room 12. Five drinking cups were noted stacked upside down on the first shelf of the cabinet. Chipped wood was also noted along the door frames of the doors of Rooms 12, creating a sharp edge. The non-skid safety strips at the rear entrance to the Emergency Department were noted to be peeling off. These facts were verified with Staff F on 02/16/12 at approximately 03:45 P.M.