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Based on review of the medical record for patient #1 and other hospital documentation, and interviews with the Quality Staff and the Emergency Department (ED) Chair the governing body failed to ensure that emergency services were provided to patient #1 in accordance with his/her needs when he/she presented with severe chest pain, was inaccurately triaged, and then waited two and a half hours for urgent intervention. The governing body also failed to ensure that Quality Assessment Performance Improvement (QAPI) processes adequately reviewed and investigated the adverse event in order to develop any corrective actions to protect other patients from other similar events. This was evident for 1 of 10 patients reviewed during survey.

The findings include

Review of the medical record revealed that patient #1 presented at the hospital emergency department during the evening of 3/17/15 with severe chest pain (rated by the patient as 10/10). The patient was triaged at an Emergency Severity Index (ESI) level of 3 by the triage nurse and was placed in the ED waiting room to wait to be seen by a physician. The ESI is a tool used by emergency departments to triage the severity classification of a patient ranging from ESI-1 (most urgent) to ESI-5 (least urgent). An ESI of 3 would reflect a stable patient not in extreme pain who was safe to wait to be seen. Because patient #1 was triaged at ESI 3 he was not seen by the physician for 2.5 hours and was not provided oxygen until nearly four hours after his/her initial presentation to the ED. Less than a half-hour after finally receiving oxygen, the medical record revealed that patient #1 collapsed, had no pulse, and required CPR. The record revealed that patient #1 was eventually (after a CT scan was obtained to rule out a head bleed from a fall sustained in the treatment area) taken to the cardiac catheterization lab, received a stent for an occluded artery and balloon pump placement, then was transferred to ICU. The record revealed that patient #1 never returned to his prior baseline status and then expired later that same day.

During an interview with the ED Chair on 9/10/2015 it was revealed that he was not aware of care issues regarding patient #1 and he had not been included in or made aware of any investigations regarding the care of patient #1. The evaluation of the care scenario for patient #1 prior to the catheterization lab being notified was not sent through the ED and Quality/Patient Safety staff and the ST Elevation Myocardial Infarction (STEMI) review committee, to the governing body.

Reference Federal Tag A0286, F1100 and F2408

Based on review of 10 patient medical records, and review of the hospital's policies and procedures it was determined that patient #1 was left unattended by staff in an unprotected environment and sustained a fall.

Medical record documentation on 3/18/15 at 1:05AM revealed that patient #1 was left unattended, sitting on the side of a stretcher with the side rails down. The patient experienced a medical emergency, became unresponsive, and fell forward onto the floor sustaining a head laceration.

Review of the hospital's 'Fall Precaution Patient Care Guideline', at risk patients are not to be left unattended in treatment areas and that nurses should consider keeping top bedrails up. Patient #1 would have been deemed a high fall risk due to his reporting symptoms on arrival to the Emergency Department and due to his past medical history which included an unsteady gait.

Failure of staff to provide a safe environment may lead to potential harm or injury for all patients.

Based on staff interviews (with the Accreditation Manager and the Patient Safety Officer on 9/8/15 and 9/10/15) and review of medical record and other documentation, it was determined that the hospital failed to ensure an effective Quality Assessment process was followed when patient #1 suffered a serious preventable adverse event but the event was not identified, investigated and addressed as required in the Federal regulations.

Review of the medical record revealed that patient #1 presented at the hospital emergency department during the evening of 3/17/15 with severe chest pain (rated by the patient as 10/10). The patient was triaged at an Emergency Severity Index (ESI) level of 3 by the triage nurse and was placed in the ED waiting room to wait to be seen by a physician. The ESI is a tool used by emergency departments to triage the severity classification of a patient ranging from ESI-1 (most urgent) to ESI-5 (least urgent). An ESI of 3 would reflect a stable patient not in extreme pain who was safe to wait to be seen. Because the patient was triaged at ESI 3 he was not seen by the physician for 2.5 hours and patient #1 was not provided oxygen until nearly four hours after his/her initial presentation to the ED. Less than a half-hour after finally receiving oxygen, the medical record revealed that patient #1 collapsed, had no pulse, and required CPR. The record revealed that patient #1 was eventually taken to the cardiac catheterization lab (after obtaining a CT scan for a head injury due to a fall in the treatment area) and received a stent for an occluded artery and balloon pump placement, then was transferred to ICU. The record revealed that patient #1 never returned to his prior baseline status and then expired later that same day.

Review of hospital documentation revealed that the fall was identified and that the ED nursing director documented that a "review was completed" on a fall investigation report sheet. The ED director did not document any detailed findings and outcomes of the investigation. The patient safety and quality department did not ensure that the manager completed the investigative details of the delay in treatment leading to the adverse event and the Quality Department failed to thoroughly investigate the concern.

Review of the patient safety/fall data revealed that three falls occurred during March 2015. The report failed to indicate the severity of fall or fall with serious injury for patient #1. The report showed "0" fall severity or fall with serious injury for the month of March, which did not accurately reflect the outcome of the fall for patient #1. The patient sustained a head laceration with excessive bleeding due to the fall. Cardiac catheterization lab records indicated that blood thinning medication (Integrilin) had to be stopped due to excessive bleeding of Patient #1's head laceration. At no point in the investigation was it identified that this patient with the dire symptom of severe chest pain waited over four hours before collapsing with an ultimately fatal cardiac condition.

Interview with the Patient Safety Officer on 9/10/15 revealed that the ED nursing director who completed the investigation is no longer employed at the hospital and there are no documents to indicate pertinent findings or details of the investigation or even that the investigation had been completed. The Accreditation Manager confirmed during the same interview that she had no information about the incident prior to the 9/8/15 survey and that cardiac arrests occurring in the ED were not all tracked and reviewed by patient safety and quality assurance staff. Also, no morbidity/mortality review had been completed.

The interview with the Patient Safety Officer and the ED Department Chair on 9/10/15 also revealed that the STEMI review committee (a committee that reviews patients suffering heart attacks or cardiac events) did review the medical record and cardiac events for patient #1. During this interview it was revealed that this STEMI review did not include all the events occurring in the ED prior to the patient being transferred to the cardiac catheterization lab. The review focused on the events occurring once the cardiac consultation was requested after the patient was found in cardiac arrest and subsequently transferred to the catheterization lab.

Patient #1 expired in the hospital on 3/18/15. On 9/10/15 when the survey was conducted, no hospital QAPI systems had identified the serious preventable adverse event of a delay in treatment, no report had ever been filed as required under the State Patient Safety program requirements, and no substantive review of the delay in treatment that lead to the patient cardiac event, collapse and bleeding event had ever been done.
Reference A0092 and A1100

Based on medical record review, staff interviews and hospital document review, hospital staff failed to:
1- Properly triage and assign appropriate Emergency Severity Index score (ESI).
2- Perform a timely medical screening exam.
3- Provide urgent interventions timely for a patient with severe chest pain (notifying physician, obtaining orders for medications, applying oxygen, placing patient on a cardiac monitor)
4- Reassess the patient for changing/deteriorating medical condition.
5- Follow hospital care guidelines and protocols for a patient reporting chest pains.

Patient #1 arrived to the Emergency Department (ED) during the evening of 3/17/15 reporting chest pain and nausea at registration. Patient #1 was promptly was triaged by the ED nurse. The triage nurse documented that the patient continued to report chest pain 10/10 with "chest uneasiness, nausea, and shortness of breath". Vital signs were obtained during triage and indicated an elevated blood pressure and low oxygen saturations of 92% on room air. A 12 lead EKG was obtained, which revealed abnormalities that indicated possible cardiac injury. About 45 minutes after arriving in the emergency department, blood was obtained from the patient and sent to the lab.

Although initial assessment was done and diagnostic labs were drawn, the triage staff inaccurately assigned an Emergency Severity Index (ESI) level of 3 for patient #1's condition and he/she was placed in the ED waiting room to wait to be seen by a physician. The ESI is a tool used by emergency departments to triage the severity classification of a patient ranging from ESI-1 (most urgent) to ESI-5 (least urgent). An ESI of 3 would reflect a stable patient not in extreme pain who was safe to wait to be seen. Because the patient was triaged at ESI 3 he was not seen by the physician for 2.5 hours and patient #1 and was not provided oxygen until nearly four hours after his/her initial presentation to the ED. Interview with the clinical resource nurse on the morning of 09/08/15 revealed that a patient reporting severe pain should be scored as an ESI-2 requiring immediate medical attention and intervention, should be placed on a cardiac monitor with oxygen applied, and should be seated in the intake area of triage with constant monitoring of the patient. Medical record review with the clinical resource nurse confirmed that there was no documentation of cardiac monitoring, oxygen placement, or medication for chest pain for patient #1 initiated at the time of triage.

About two and a half hours after arrival in the ED, patient #1 was taken from the waiting room to the intake triage area by the physician who then performed the first physician examination. The record revealed that a decision was then made to then admit the patient about three hours after the patient ' s initial presentation in the ED. The patient was then taken to a treatment room at where the second set of vital signs was obtained and the patient's chest pain was reassessed. Documentation by staff indicated that the patient was not placed on oxygen until approximately four hours after arriving in the ED. The nurse administered 0.4mg nitroglycerin (a medication used to treat chest pains) under the patient's tongue with no relief of chest pain and a second 12 lead EKG was obtained about the same time the patient received the oxygen.

Shortly after the patient received the oxygen and nitroglycerin the nurse documented in a progress note that she left the treatment room with the patient sitting on the side of the stretcher to show the physician the new EKG; however, other documentation at this time stated that the patient was sitting on the stretcher with the side rails up. Medical record documentation indicated that patient #1 then collapsed, fell to the floor, was unresponsive, had no palpable pulse, and that CPR was initiated.

The hospital's patient care guidelines and protocols for a patient reporting chest pains in the ED lists specific nursing interventions. These interventions include taking the patient directly to the treatment area and notifying the physician that the patient is having active chest pains, applying oxygen, attaching the patient to a cardiac monitor, establishing an IV, and administering medications. According to these guidelines the patient would have been placed on bedrest and had vital signs obtained at least every 15 minutes for 1 hour, then every hour, and frequent reassessment of the patient's degree of pain.

A physician consultation report on 3/18 indicated that when the patient collapsed he/she apparently "had a ventricular fibrillation arrest. The subsequent EKG... showed acute inferior lateral wall . " Patient #1 was rushed to the catheterization lab where an occluded artery was stented (a surgical intervention to open an occluded artery), and the patient went to the ICU but was " not doing too well... is intubated... blood pressure was also on the very low side, 60s over 30 at most.. " Patient #1 expired later the same day that he/she had been transferred into the ICU and the day after his/her initial presentation in the ED.

Reference Federal Tags A 0142 and A0286