HospitalInspections.org

Based on document review and interview, it was determined the facility failed to analyze and implement corrective measures to reduce the number of patients who returned to the Emergency Department (ED) within 72 hours.

Findings include:

The document titled "Clinical Quality and Patient Safety Performance Improvement Plan 2023" states, "the Clinical Quality and Patient Safety Performance Improvement Program oversees activities of all hospital and patient services (inpatient, outpatient, and ambulatory) to enhance quality and safety of patient care, to identify actual and potential problems concerning patient care and clinical performance and, develop and implement strategies to prevent harm. The program includes but, is not limited to development and recommendation of proposed courses of action to address identified problems and the use of established mechanisms to implement corrective actions to identified problems."

1. Review of Medical record #1 identified a 20-year-old who presented to the ED on 9/17/23 with multiple symptoms such as tachycardia, headache, chills, fever, and body aches, and 9/18/23 with complaints shortness of breath while walking and worsening symptoms. The patient was discharged from the ED on 9/18/23 and was found deceased in his dormitory on 9/22/23.

There was no documentation that the facility identified any deficiencies in the care provided to the patient for the second visit and implemented any measures to improve the quality of care provided to the patient.

2. The surveyor requested data of patients who returned to the ED within 72 hours from 9/17- 9/26/23. The facility presented a list with approximately 64 patients. Review of the list identified cases with multiple revisits.
For example: Patient #22 returned to the ED six (6) times between 9/17 - 9/24/23, within an 8-day interval; Patient #23 returned to the ED seven (7) times between 9/17 - 9/22/23, within a 6-day interval.


3. Review of the document titled "ED Dashboard 2023," revealed the following data of geriatric admissions after 72 hour return visits to the ED:

April 2023 - 37.8%
May 2023 - 36.9%
June 2023 - 37.0%
July 2023 - 36.8%
August 2023 - 36.6%
September 2023 - 37.8%

There was no target or goals for the 72-hour patient returns to the ED documented on the dashboard or in the ED minutes. There was no documentation in the Committee of Quality Improvement (CQI) ED minutes or the Quality Performance Improvement Committee minutes, that the data was discussed, analyzed or that any measures were taken to minimize 72-hour patient returns to the ED.

This was confirmed with Staff A, Interim Director of the ED, on 10/30/23 at 1:55 PM, who also stated, reviews of patient returns are done only for patients who expire, are admitted or taken to the operating room.

Based on medical record review, document review and interview, in one (1) of 40 medical records reviewed, it was determined the hospital failed to review abnormal laboratory values and reassess a patient prior to discharging the patient from the Emergency Department (ED). This was identified in MR #1.

This failure may have placed the patient at risk for serious harm or death.

Findings include:

The facility's policy titled "Pain Management", reviewed 11/2022 states, "all patients have the right to appropriate assessment, management, treatment modalities and education regarding their pain. All patients will be screened and assessed for pain on admission, routinely at regular intervals, with each new report of pain, taking into consideration procedures or interventions performed as part of the patient's care. Patients will have their pain assessed before and after pharmacological/non-pharmacological intervention."

Review of MR #1 identified a 20-year-old patient who presented to the Pediatric Emergency Department (ED) on 9/17/23 at 7:26 PM. Triage note documented a throbbing headache behind the eyes, sore neck, and chills x two (2) days. The patient had last taken Advil three (3) hours prior to arrival to the ED. The patient's vital signs at 7:30 PM were temperature 99.5F (normal range 97-99), heart rate (HR) 114 (normal range 60-100), respiratory rate (RR) 16 (normal range 12-20), B/P-113/78 (normal range 90-120/50-90) and oxygen saturation was 99% (normal range 96-100).

There is no numerical assessment of the patient's pain or comfort level upon arrival to the ED.

A 7:47 PM the physician (MD) noted the patient presents for several symptoms including headache, chills, fever, and body aches. Of note the patient tested COVID + three (3) weeks prior. Reports additional sick contacts over the past few weeks. Also has appetite change and myalgia (pain in the muscle[s]). Assessments were done and the doctor noted the patient's appearance is not ill-appearing. The patient was given Zofran 4 mgs (a medication that prevents nausea and vomiting...) and Tylenol 650 mg orally at 8:35 PM. COVID, Influenza A and B, and Respiratory Syncytial Virus (RSV) PCR tests were done, and all were negative.
At 9:57 PM the patient's RR was 14 and a pain level of 4/10 was documented.
The patient was discharged from the ED at 10:07 PM that night. A 10:08 PM documentation shows the patient's HR was 99. The discharge diagnosis was Acute Viral Syndrome.

The patient returned to the Pediatric ED on 9/18/23 at 8:21 PM, less than 24 hours after discharge, with complaint of shortness of breath while walking. In addition, the patient complained of fever, chills, body aches, headache, dehydration, nausea and vomiting, onset three (3) days ago. The patient's temperate was 100.6F, HR 126, RR 18, B/P 114/66 and oxygen saturation was 97%.

No numerical assessment of the patient's pain or comfort level upon arrival was documented.

At 10:04 PM The MD documented, the patient was seen here yesterday, and he returned because he was feeling worse. Now along with his body aches, headaches and fever he has been nauseous and throwing up. He threw up 5-6 times today. He is having a hard time tolerating oral liquids and solids. Also, complaints of headache and shortness of breath with walking. Feeling sick since Saturday. Patient meets the protocol for the Sepsis Inflammatory Response Syndrome. The MD's plan was for labs, Sepsis bolus of 1 liter of Normal Saline, EKG, hold off on antibiotics until labs returned, no chest x-ray at this time. Will reassess after initial fluid bolus.

The patient was given one (1) liter of saline bolus at 9:19 PM. Motrin was given at 10:00 PM and another bolus at 10:33 PM after the patient reported to the MD at 10:31 PM that he is feeling better but dehydrated. The patient's vital signs at 10:32 PM was HR 110 and at 10:40 PM the temperature was 99.9F, HR 106, RR 16, B/P 119/70 and oxygen saturation was 98%.

A physician (MD) documented at 10:31 PM "Patient reassessed. Reports feeling better. Says he's dehydrated. No lactate. Electrolytes wnl (within normal limits). Will give another fluid bag and d/c (discharge). Patient agreeable to d/c."

The patient was discharged on 9/18/23 at 11:12 PM. The discharge diagnosis was Viral Syndrome.


Lab tests showed multiple abnormal results including but not limited to low red blood cells (RBC) of 3.63 (normal range 4.5-6.0), low Hematocrit 32.5 (normal range 42.0-52.0), low Hemoglobin 11.0 (normal range 13.9-16.3), low platelets 85 (normal range 150-450), low lymphocyte % 5.8 (normal range 15.0-50), low lymphocyte # was 0.4 (normal range 1.0-4.5) elevated blood sugar 131 (normal range 60-100), low calcium 7.6 (normal range 8.5-10.5), abnormal blood gases including but not limited to low PC02 - 37 (normal range 42-48), O2 sat (venous) 84.7 (normal range 70-75), high POCA HHB (Deoxyhemoglobin) 15.0 (normal range 0.0-5.0), low Methemoglobinemia (Meth HGB-a condition with life-threatening potential) 0.2 (normal range 0.4-1.50), low oxyhemoglobin 83.1 (normal range 94.0-99.0) and high Base Excess (BE) 3.1(normal range 0-2). Abnormal urinalysis included moderate blood in the urine, trace leukocytes esterase (normal results - negative), white blood cell 14 (normal range 0-5) and the appearance was cloudy (normal results - clear).

There was no documentation that any of the abnormal lab values, patient's shortness and tachycardia was addressed or discussed with the patient for follow-up with his doctor. A planned EKG was not ordered or performed despite the patient's rapid heart rate on both visits. There was no documentation which indicated why the EKG was not done. There was no provider reassessment of the patient after the second bolus of fluid was administered. There was no documentation that any provider assessed/reassessed the patient's pain level (numerical value) or level of discomfort throughout each ED visit.

These findings were shared with Staff B, VP Quality and Regulatory Affairs on 11/1/23 at 4:00 PM.