HospitalInspections.org

Based on record review, interview and policy review, the hospital failed to furnish emergency services to meet the needs of patients according to acceptable standards of practice; failed to properly assess chest pain and/or timely treating patients complaining of chest pain; failed to ensure laboratory orders were obtained; and failed to immediately notify the physician of critical laboratory values.

Failure to furnish emergency services, properly assess chest pain, obtain laboratory testing and failure to immediately notify the physician of critical laboratory values resulted in Immediate Jeopardy.

See A1104

Based on record review, interview and policy review, the hospital failed to furnish emergency services to meet the needs of patients according to acceptable standards of practice; failed to properly assess chest pain and/or timely treating patients complaining of chest pain; failed to ensure laboratory orders were obtained; and failed to immediately notify the physician of critical laboratory values. This affected four (Patients #1, #2, #5 and #9) of ten medical records reviewed. The census was 31.

Findings include:

1. Record review revealed Patient #1 presented to the emergency department (ED) on 12/04/21 at 9:54 A.M. complaining of chest pain and shortness of breath. Patient #1 was called for triage at 9:58 A.M. by Staff C. Staff C documented that the patient reported chest pain across the upper chest that started at 7:00 A.M., shortness of breath, numbness and tingling to both arms. The pain severity was documented as a five on a one to ten scale, with 10 being the worst pain. An electrocardiogram. (ECG) was obtained at 10:00 A.M., which showed possible left atrial enlargement, anterior infarct and was an abnormal ECG. Patient #1's vital signs at 10:06 A.M. were heart rate of 64 beats per minute, respirations 17 breaths per minute, oxygen saturation of 94 percent and blood pressure of 173/110 millimeters of mercury (mm/Hg). Triage was completed at 10:06 A.M. and. Patient #1 was sent back to the waiting area. At 10:08 A.M. a troponin (enzyme test to detect a heart attack) high sensitivity, complete blood count (CBC), basic metabolic panel (BMP) and chest X-ray were ordered. At 10:32 A.M. all lab specimens were drawn as ordered. The abnormal CBC results were reported at 10:51 A.M. The abnormal BMP results were reported at 11:08 A.M. and was abnormal. The troponin I high sensitivity results were reported at 11:24 A.M. as critical with a value of 159 nanograms per liter (ng/L). (Normal troponin level is below 0.04 ng/L.) The laboratory staff, Staff F, reported the critical result to the nurse, Staff D. Staff D did not notify the physician until 19 minutes later at 11:43 A.M. At 11:45 P.M., a physician assistant ordered a repeat troponin high sensitivity. At 11:53 A.M., 12:13 P.M. and 12:31 P.M., Staff O attempted to call the patient from the waiting area with no response. At 1:08 P.M.., it was documented the patient left the hospital against medical advice (AMA).

Review of the hospital complaint investigation revealed Patient #1's family member submitted a complaint to the patient feedback website on 12/04/21 at 5:24 P.M. Patient #1's family member stated she and Patient #1 arrived to the hospital ED on 12/04/21 because the patient was experiencing chest pain. Patient #1 rated the pain an eight on a one to ten scale and complained of numbness and tingling to both arms. Patient' #1's family member stated she asked politely to be seen right away as the patient was experiencing symptoms of a myocardial infarction. ECG and vital signs were obtained. Patient #1's family member then requested imaging and laboratory tests, specifically a troponin level. The laboratory tests were drawn, and Patient #1 was sent back to the lobby to wait. Patient #1's family member documented in the complaint to the hospital that "We waited over an hour and a half and still had not seen lab results or a physician." Patient #1's family member drove Patient #1 to another area hospital and Patient #1 was treated at the other hospital within five minutes. Patient #1's family member documented Patient #1 had a heart attack and needed coronary artery bypass surgery.

Review of the results of the hospital's investigation revealed Staff A contacted Patient #1's family member, who stated the ED technician completed a "quick stroke assessment" and Patient #1 was asked to sit in the lobby. Patient #1's family member intervened and asked for the ECG. The ECG was completed and reviewed by the physician and did not indicate a myocardial infarction (heart attack). Patient #1 started to look pale in the lobby, so Patient #1's family member requested the troponin be checked. Troponin was drawn. Patient #1 and the family member waited another hour, until Patient #1 could wait no longer. The family member drove the patient to a neighboring hospital. The neighboring hospital explained that if Patient #1 had waited any longer, he could have needed cardiopulmonary resuscitation (CPR) due to the extent of the coronary artery occlusion.

The hospital's complaint investigation results contained a statement from Staff L, the ED physician, dated 12/07/21. Staff L reviewed Patient #1's ECG and did not not show a need for immediate treatment. Staff L spoke with another physician, Staff P, who stated they remembered being told about Patient #1's critical Troponin and stated Staff Q asked for the patient to be brought back next. Staff M stated staff must have gotten overwhelmed with Ambulance admissions, so Patient #1 could not be brought back for treatment. Staff D documented on 12/04/21 at 11:43 A.M. the physician was notified of the critical troponin level. Staff D attempted to call Patient #1 back at 11:53 A.M., 12:13 P.M. and 12:41 P.M. with no response. On 12/04/21 at 4:45 P.M., a "Left Without Being Seen" form was completed. Staff F, the Operations Laboratory Manager, revealed he called Staff D on 12/04/22 at 11:24 A.M. with the critical troponin result for Patient #1. Staff F stated an order for a CBC, Troponin and BMP for Patient #1 was placed on 12/04/21 at 10:08 A.M. and the labs were drawn at 10:32 A.M. The specimens arrived to the lab at 10:41 A.M.. The CBC resulted at 10:51 A.M., the BMP at 11:08 A.M. and the troponin resulted at 11:22 A.M.. Staff D did not notify a physician of the critical troponin level physician until 11:43 A.M.. An entry by Staff N, a physician, documented concern with the timing of the call back time for the critical troponin level. The investigation documented the concern was resolved to Patient #1's family member's satisfaction and the complaint was closed as of 01/06/22.

Review of the hospital policy titled "Critical Tests and Critical Results/Values" revealed critical tests are those that require rapid communication of the results. Failure to promptly report a critical test result may impact the patient's treatment. Critical results are abnormal results which fall significantly outside of pre-established parameters and have been determined to pose significant risk to the patient. Failure to promptly report critical results may put the patient's life in jeopardy. Time frames for performance of critical tests are dependent upon the type of test and patient preparation. Each diagnostic area with identified critical tests will establish an acceptable length of time between ordering the critical test, performance of the test and availability of results. Critical results are to be called to the licensed caregiver within one hour from the time the critical value is known and validated to the reporting of the result to the licensed caregiver who can act upon the results. Receiving staff must complete a read back and this must be documented. Verbal or phone notification of the physician or licensed independent practitioner must be documented in the patient's medical record. This must be documented in the flow sheets. If the nurse or diagnostic area is unable to contact the physician with the critical test or result, the individual is to contact their manager and follow the chain of command. For electrocardiograms (EKG) in the emergency department, the results should be immediately handed to the patient's nurse. The nurse then notifies the physician of the critical value. A troponin high sensitivity greater than 99 is considered critical and staff is instructed to "call initial abnormal value per patient encounter" to the licensed caregiver within one hour.

During interview on 01/26/22 at 11:01 A.M., Staff F stated all emergency department laboratory orders are "STAT" orders. Staff F stated critical lab results are flagged and the nurse is called directly with the results. Staff F stated the electronic medical record (EMR) will hold the critical lab result until laboratory staff acknowledge and document the critical results were reported to.

During interview on 01/25/22 at 1:15 P.M., Staff A stated staff must notify the physician immediately of critical lab values. Staff A stated Staff D was not available for interview at this time. Staff A stated all laboratory orders in the ED are STAT. Staff A stated STAT troponins should be drawn and the physician notified of the results within one hour. Critical results should be reported to the physician immediately. Staff A stated Staff D waited 19 minutes before notifying the physician of Patient #1's critical troponin level because she was waiting on the physician to come out of a room with another patient. The nurse can only notify the physician. They cannot notify mid-level providers such as nurse practitioners or physician assistants. Staff A verified the nurse did not notify the physician of the critical troponin result for 19 minutes. Staff A further verified that the nurse did not follow the hospital policy titled "Critical Tests and Critical Results/Values" by notifying the manager or follow the chain of command when she was unable to immediately notify the physician of the critical troponin level.

During interview on 01/25/22 at 3:59 P.M., Staff A verified on 12/02/21, the ED had two physicians and one mid-level provider on duty at the time Patient #1 was waiting to be treated.

2. Record review revealed Patient #2 presented to the ED after a visit to the orthopedic physician for extreme right hip pain. The patient arrived to the ED on 01/11/22 at 6:07 P.M.. The patient had history of cancer. Triage started at 6:21 P.M. and the patient stated he/she was continuously having the worst pain possible. The patient rated the pain as a ten on a one to ten scale. Patient #1 had started taking Fentanyl 12.5 mcg on 01/10/22 for pain control. Patient #2 complained of intermittent nausea and vomiting. The patient was placed in an ED room at 6:25 P.M.. At 8:13 P.M. orders were placed to admit the patient to an inpatient bed but the patient remained in the ED. At 8:52 P.M., the right hip pain was reassessed as an eight on a one to ten scale. There was no documentation of alternative pain interventions, or the administration of medication for pain, nausea or vomiting was offered until 10:48 P.M.. On 01/12/22 at 2:34 A.M. the patient was transferred from the ED to an inpatient bed.

During interview on 01/25/22 at 4:50 P.M., Staff A verified Patient #2's pain was not assessed or managed timely. .

3. Record review revealed Patient #5 presented to ED on 01/08/22 at 9:30 P.M. complaining of worsening back and side pain for the past two days. Vital signs were obtained at 9:45 P.M.. The vitals signs were within normal limits except for Patient #5's blood pressure, which was 130/89 mm/Hg. Triage was completed at 9:47 P.M.. Patient #5's pain was never assessed using a scale to get a baseline pain level. The nurse only documented the location of the patient's pain. There were no pain interventions provided. On 01/09/22 at 1:22 A.M. the hospital transferred the patient from an ED room to "off the floor." The patient was discharged at 2:51 P.M..
On 01/11/22, Patient #5 submitted a complaint stating the wait time was over four hours when experiencing sharp pain.

During interview on 01/25/22 at 9:26 A.M., Staff B verified the above findings.

4. Record review revealed Patient #9 presented to the ED on 12/05/21 at 2:18 P.M. complaining of weakness and dehydration. Vital signs were obtained at 2:38 P.M. and all were within normal limits. Patient #9 complained of back pain of a seven on a one to ten scale. Triage was completed at 2:39 P.M. At 2:40 P.M. laboratory orders for a CBC and BMP were placed. At 5:45 P.M., Patient #9 signed a release for leaving before medical screening. The laboratory tests were never drawn and Patient #9's pain was never reassessed or treated.

During interview on 01/26/22 at 9:45 A.M., Staff B verified the above findings.

Review of the hospital policy titled "Pain Management" revealed patients will be assessed for pain on admission to the emergency room. Nursing assessment and the use of an appropriate pain scale will guide pain management. Outcome monitoring occurs on an ongoing basis. Monitoring includes the initial pain assessment and pain reassessment. Pain management includes pharmacological and non-pharmacological intervention. Both options should be offered. Pain is assessed and documented for all patients using scales consistent with the patients age, condition and ability to understand.