HospitalInspections.org

Based on observation, interview, and record review, the hospital staff failed to:

1. Follow its Standardized Procedure to check patients' blood sugars at the time of triage when two of 27 patients arrived in the Emergency Department (ED) via ambulance with chief complaint of high or low blood sugar (20 and 12). This failure caused delay in receiving timely medical screening examinations and stabilizing treatment by a physician or other qualified medical personnel as soon as possible.

2. Assume full responsibility of providing timely medical screening examination and stabilizing treatment to one of 27 patients (20) who arrived the ED via ambulance. Patient 20 had high blood sugar and was left on an ambulance stretcher on Emergency Medical Technician's (EMT) watch in the ED hallway for four hours. Patient 20 had a cardiopulmonary arrest (a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and other vital organs) and died due to severe Diabetic Ketoacidosis (a life-threatening medical condition). The failure of timely caring for patients on "Wall Time" may have contributed to Patient 20's death and could cause immediate and potential harm to all future patients.

Diabetic Ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the glucose (sugar) they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Because the cells cannot receive sugar for energy, the body begins to break down fat and muscle for energy. When this happens, ketones (the by-products of broken down fat in the bodies, too much of it in your blood is really bad for health). This can cause the chemical imbalance called diabetic ketoacidosis.

Wall Time is the time delayed in the transfer process that occurs when the patient remains on the ambulance gurney for an extended period of time, preventing ambulance crews from returning to service in a timely manner.

3. Implement its policy and procedure on "VOLUME CONTINGENCY PLAN" when the ED was saturated which caused delay of providing medical screening examination and stabilizing treatments to one of 27 sampled patients (20). This failure had led to Patient 20's death and had the potential to delay life-saving treatment to all future patients.

The hospital uses the Emergency Severity Index (ESI) as a tool to categorize patients acuity and resource needs. The ESI yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). Level 1 requires immediate life-saving interventions. Level 2 generally requires placement and treatment initiated rapidly. Level 3 requires two or more resources. Level 4 likely requires one resource, and Level 5 likely requires no resources. Resources can be specialty consultation, IV fluids, injections, laboratory tests, or x-rays.

Findings:

1a. The ED record for Patient 20 was reviewed on 11/28/16 with the Manager of Quality and Patient Safety (MQ) and the Director of Clinical Risk and Regulatory Affairs (DCR). Patient 20 visited the emergency room a total of five times between 2/29/16 to 3/2/16. The description of each visit is listed below:

a. First Visit-2/29/16-Patient 20 was brought to the ED via an ambulance at 6:47 PM for chief complaint of blood sugar 69 (normal blood sugar is 70-100) in the field. Patient 20 was triaged at level 3. The triage nurse did not check her blood sugar at the time of triage. Patient 20 did not have her blood sugar checked until 10:56 PM, four hours after the triage. At this time, her blood sugar was 36. Orange juice was given and blood sugar was re-checked at 12:47 AM with a result of 211. Patient 20 was discharged at 1:20 AM.

b. Second Visit-3/1/16-Patient 20 walked in the ED with chief complaint of chest pains and headaches at 3:54 AM, about two and half hours after she was discharged. Physician Assistant (PA) 1 documented Patient 20 was seen earlier for low blood sugar but did not have her blood sugar re-checked. Patient 20 was diagnosed with depression and anxiety. Patient 20 was discharged on 3/1/16 at 6:04 AM.

c. Third Visit-3/1/16-Patient 20 walked in at 1:50 PM complaining of high sugar and had not been taking medications for months. She was triaged at Level 5. The triage nurse did not check her blood sugar at the time of triage. At 2:51 PM, in the fast track area, Patient 20's blood sugar was 423. Urine Glucose Dip (Urine Glucose Dipstick is a glucose urine test measures the amount of sugar in a urine sample) showed positive for sugar and acetone. There was no documentation this was communicated to PA 2. Patient 20 was discharged at 4:16 PM.

d. Fourth Visit-3/1/16-Patient 20 walked in at 10:21 PM complaining of headaches and vomiting. She was triaged at Level 4. She left without being seen by a qualified medical provider. An ED staff documented the discharge time was 4:21 AM on 3/2/16. No blood sugar was done during this visit.

e. Fifth Visit-3/2/16-Patient 20 was brought in by an ambulance at 1:10 PM after the patient was found to have altered level of consciousness in the field. Patient 20 presenting complaints were nausea, vomiting with high blood sugar. The MQ stated a reading of high blood sugar indicated the blood sugar was 600 or above. Patient 20 was triaged at 1:24 PM at Level 2. The triage nurse did not check Patient 20's blood sugar but did document the patient had abnormal breathing at the time of triage. The MQ stated, at 3 PM, one and half hours after the patient was triaged, the then ED Manager called a physician to evaluate the patient. The physician ordered some laboratory tests to be done. At 5:28 PM, the critical laboratory test results were released. Patient 20's blood sugar was 1090 and Potassium was 8.1 (normal value is 3.7 to 5.2). Patient 20 was immediately placed in a room and stabilizing treatment was attempted. Cardiopulmonary resuscitation was initiated at 6:05 PM. Patient 20 did not survive the resuscitation. Patient 20's discharge diagnose was acute severe diabetic ketoacidosis.

1b. During a review of the clinical record for Patient 12 with the Quality Clinical Safety Coordinator (QCSC) 2, on 11/30/16, at 9 AM, the document titled "Emergency Record" dated 10/5/16, indicated Patient 12 had a past medical history of Diabetes Type II (a problem with the body that causes blood glucose [sugar] levels to rise higher than normal). Patient 12 arrived at the ED by private car on 10/5/16, at 4:16 PM, complaining of "high blood sugar, nausea, SOB (Shortness of Breath), and headache." Patient 12 was screened by the Fast Track Triage Registered Nurse at 4:19 PM, no blood glucose test was performed. The clinical record indicated Patient 12 was placed on a gurney and placed in the "Blue Zone" hallway for one hour and 47 minutes. Patient 12's blood glucose was obtained at 7:05 PM, three hours after she was triaged. Blood glucose resulted to be at 509. Medical diagnosis indicated a Mild DKA. QCSC 2 confirmed the finding.

During an interview with Triage Registered Nurse (TRN) 3, on 11/30/16, at 10:49 AM, she stated patients complaining of high blood sugar and with a history of diabetes should be tested for blood glucose. TRN 3 stated it was within her scope of practice to obtain a blood glucose test but did not have the device. TRN 3 stated, "We can, but we would have to walk all the way to Red or Blue zone to get a glucometer (device used to determined blood concentration)."

During an interview with TRN 4, on 11/30/16, at 11:10 AM, she stated, "If I have time, I will check blood sugar. I would have to get a glucose machine." She stated she would have to walk to one of the two nurses stations (Red or Blue Zone) to get a glucose monitoring device to check a patient's blood sugar.

During an interview with the Emergency Department Director (DES) on 11/30/16, at 11:30 AM, she stated the triage nurses "do not have a Glucometer (glucose monitoring device) with them. They have to go to one of the nurses stations to get it when needed."

During a subsequent interview with the DES on 11/30/16, at 4:43 PM, she stated, "We realized that blood sugar checks are not being done in a timely manner... We will implement it back to where fast track will be able to have a glucometer on hand."

The hospital policy and procedure titled "Emergency Department Standardized Procedure", undated, indicated "5. Blood Glucose Monitoring with Accucheck (Glucose monitoring device) Inform System- a. Patient presents with signs and symptoms of hyper- (high blood sugar) or hypoglycemia. b. Patient has past medical history of diabetes..."

2. The initial complaint contained concerns of a patient (20) brought to the ED by ambulance with a chief complaint of high blood sugar was not assigned to a licensed nurse due to nurse staffing shortage. The complainant alleged the death of the patient was a result of lack of proper staffing, monitoring, and resources.

During an initial tour of the hospital's ED on 11/28/16, at 3:07 PM, accompanied by the MQ and the DES, it was noted there were 12 patients in the hallway of the Blue Zone and Red Zone, on ambulance stretchers with EMTs standing next to them. During a concurrent interview, the MQ stated both Red and Blue Zones are for patients classified as Level 1 and Level 2. These patients on ambulance stretchers were waiting to be placed in a bed in these two zones. The MQ stated these patients were on "Wall Time" on EMT's watch and were not assigned to a licensed nurse until they were transferred to an ED bed. She did not clarify who (EMT or the hospital) was responsible for the monitoring and assessment of these patients.

The ED records for Patient 20 was reviewed on 11/28/16. Patient 20 visited the ED a total of five times; one visit on 2/29/16, three visits on 3/1/16, and the last visit on 3/2/16. All of the visits were related to her complaint of low or high blood sugars except the second visit. She was treated for chest pains and headaches in the second visit on 3/1/16.

In her last visit, on 3/2/16, Patient 20 arrived to the ED via an ambulance at 1:10 PM after she was found to have altered level of consciousness in the field. Patient 20's blood sugar in the field was "high." Patient 20 presenting complaints were nausea, vomiting with high blood sugar. The MQ stated a reading of "high" blood sugar indicated the blood sugar was 600 or above. Patient 20 was triaged at 1:24 PM at Level 2. She was then left on the ambulance stretcher with the EMT from 1:24 PM to 5:28 PM (four hours Wall Time). The ED staff did not re-check Patient 20's blood sugar during the Wall Time. The MQ stated, at 3 PM, one and half hours after the patient was triaged, the ED Manager called a physician to evaluate Patient 20. The physician ordered some laboratory tests to be done. Again, there was not a licensed nurse assigned to monitor and assess her emergent medical condition. Patient 20 was left in the hallway with the EMT until 5:28 PM, four hours after she was triaged, when the critical blood test results were released. Patient 20's blood sugar was 1090 and Potassium was 8.1. Patient 20 was immediately placed in a room at 5:28 PM. Cardiopulmonary resuscitation was initiated at 6:05 PM. Patient 20 did not survive the resuscitation. Patient 20's clinical impression read, "Acute severe diabetic ketoacidosis, Hyperkalemia (high Potassium), Pulmonary (lungs) bleeding, Cardiopulmonary Arrest."

During an interview with the MQ and the DES on 11/28/16, at 5 PM, the MQ stated Patient 20 was not assigned to a licensed nurse to monitor and assess her condition when she was on "Wall Time." The DES stated Level 2 patients should be seen as soon as possible. They both indicated the hospital ED has faced severe challenges in high patient volume and shortage of licensed nurses.

During an interview on 11/29/16, at 8:30 AM, the MQ clarified the responsibility of monitoring and assessing of patients on "Wall Time" would be the staff at the ED, not the EMTs. She explained the day Patient 20 arrived the ED, there was excessive sick calls in the inpatient area resulting in delays of moving ED patients to inpatient areas which caused congestion in the ED. The DES stated after the incident, she went to the Chief Nursing Officer (CNO) requesting assistance. The CNO instructed all inpatient nursing staff to take one extra patient and agreed to change licensed vocational nurses' hours in the ED to ensure 24-hour coverage.

During an and interview with EMT 1, on 11/28/16, at 3:30 PM, he was observed standing next to a patient lying on an ambulance stretcher in the blue zone hallway. EMT 1 stated he was waiting for staff to transfer the patient to a hospital gurney. EMT 1 stated, "We (EMT) cannot take off without our gurney." EMT 1 stated, the wait time could take hours. EMT 1 stated he would look at the patient's breathing but would not perform vital signs or perform assessment during the wait time.

During an interview with TRN 2, on 11/29/16, at 2:07 PM, she stated it was the responsibility of the assigned triage nurse to monitor patients on Wall Time. TRN 2 stated, "I don't see or monitor patients until they are assigned to a room."

During an interview on 11/29/16, at 2:27 PM, Registered Nurse (RN) 1 stated it was the ambulance triage nurse's responsibility to keep an eye on the patients on "Wall Time." This nurse will continue to monitor the patients and notify the MD (physician) of any changes.

During an interview on 11/30/16, at 10:53 AM, with ED technician (EDT) 1, EDT 1 stated the patients remaining on the ambulance stretcher "were not assigned to a nurse. They have EMT on the side." EDT 2 stated, "Yes, our triage nurse is taking care of them." At 11:10 AM, TRN 4 was interviewed. She stated she was also the ambulance triage nurse but it was difficult to be the triage nurse and monitor patients on "Wall Time." She stated, "There was no time to do patient care. I have to triage patients and make sure all the patients waiting in hallway will be seen." She pointed at a chart holder on the wall and stated, "This (chart holder) could be full." The chart holder could hold about 15 patient records.

During an interview with the CNO on 11/30/16, at 3:15 PM, he stated the hospital had been challenged with a high number of ED visits and short of staffing. But the hospital continued to try to hire more traveling nurses and licensed vocational nurses. The CNO did not offer any solutions to ensure "Wall Time" patients were provided timely medical screening examination and stabilizing treatments.

3. The "Emergency Department Ambulance Wall Time" log from 5/2016 to 10/2016 was reviewed on 11/28/16. The average "Wall Time" per patient was 71 minutes in 5/2016, 95 minutes in 6/2016, 74 minutes in 7/2016, 58 minutes in 8/2016, 62 minutes in 9/2016, and 54 minutes in 10/2016. Within these six months, there were 38 days the hospital had "Wall Time" of 100 minutes or over, seven days with "Wall Time" of 150 minutes or over. The day, 3/2/16, when Patient 20 visited the ED, the average "Wall Time" was over three hours. The hospital's surge plan was requested. The DCR provided a copy of "VOLUME CONTINGENCY PLAN," revised on 11/6/08, the hospital would use in case of a surge in patient volume.

On 11/29/16, the hospital's "VOLUME CONTINGENCY PLAN" policy and procedure was reviewed with the MQ, the DES, and the DCR. A concurrent interview was conducted on 11/30/16, at 2:40 PM. The DES stated she was not aware of such a plan had existed until yesterday when the survey team requested it. The MQ and DCR both stated, "We had the plan but no surge plan was implemented on 3/2/16." During a subsequent interview on 11/30/16, at 10 AM, the MQ and the DCR stated on 3/2/16, the hospital should have activated Level Orange as indicated on the "Volume Contingency Plan." Level Orange in the hospital's "VOLUME CONTINGENCY PLAN" included but not limited to: "HS (house supervisor) to notify chief of staff and medical directors of need for round to assess for potential discharges; Evaluate elective procedures and surgeries to for impact on patient flow; All available beds in the hospital will be used for admissions, regardless of service assignment, if medically appropriate to the care of the patient; Additional Daily Bed Briefing meetings; pm (evening); with Level Orange High Occupancy Team Members in attendance."

During an interview with the CNO, on 11/30/16, at 3:15 PM, he stated the hospital had been challenged with a high number of ED visits and short of staffing. The ED cannot turn patients away or divert ambulance to another facility. He stated, "And we implemented the surge plan yesterday to get patients out of ED."