HospitalInspections.org

Based on observation and a review of clinical records, the director of the nursing service failed to be ensure effective operation of the nursing service. Hospital policies and procedures were not followed by nursing staff, as evidenced by the nursing staff's failure to properly assess, reassess, and notify the physician of changes in the patient's status and the patient's physical decline.

Findings:

Review of the clinical record for patient #1, a 32-year-old male, revealed that patient #1 was brought into the emergency department of MCH on 8-23-19 at 7:38 am. Patient #1 was brought to the ED by ambulance, in the custody of the Odessa Police Department on an emergency detention order. Patient #1 had called 911 from a church parking lot and stated that he felt homicidal. The patient arrived in the triage area via wheelchair and stated to the triage nurse (staff #6) that he had taken "at least 10 flexeril 10 mg at 0630". He stated that he had also been drinking beer the previous evening. Patient #1's GCS [Glasgow coma score] was 15. He was classified as an ESI II and wheeled to an ED examination room.

Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI: "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."

During triage, the patient's vital signs were as follows:
* Blood pressure 150/123 mmHg
* Pulse 149 bpm
* Temperature 98.2° Fahrenheit
* Respirations 24 breath/minute
* O2 Saturation 99% on room air

An EKG performed at 7:58 am indicated sinus tachycardia. Urine toxicology (collected at 8:39 am) indicated a presumptive positive reading for cocaine, benzodiazepines and tricyclic antidepressants. His blood alcohol level (collected at 7:51 am) was 0.230%.

The medication administration record indicated the following:
*8:45 am
°Ativan 2 mg IM [intramuscular]
°Haldol 5 mg IM
°Benadryl 50 mg IM

*9:21 am
°Haldol 5 mg IM

The patient was found to be in asystole at 9:47 and ACLS protocol was initiated. The patient expired and was pronounced dead at 10:04 am.

A review of the Vital Sign Flowsheet indicated that the patient's vital signs were assessed at the following times:
*7:41 am
°Blood pressure 150/123 mmHg
°Pulse 123 bpm

*7:48 am
°Blood pressure 123/100 mmHg
°Pulse 164 bpm

*8:01 am
°Blood pressure 145/92 mmHg
°Pulse 145 bpm

*9:26 am
°Blood pressure 194/191 mmHg
°Pulse 195 bpm

*9:31 am
°Blood pressure 145/124 mmHg
°Pulse 192 bpm

*9:46 am
°Blood pressure 170/113 mmHg
°Pulse 155 bpm

Facility policy ED-6850-015 titled "Assessment and Reassessment of Emergency Department Patients" states, in part:

"Policy Statement:
Initial Vital Signs and Assessment will be documented in the Emergency Department (ED) Medical Records. Patients in the ED will be reassessed including vital signs, according to charting guidelines and Standards of Practice/Care.

Procedure:
1. All patients will be assessed upon arrival to the ED.

2. Documentation of vital signs and reassessment will be made as follows:
...
ESI Level 2: As with ESI Level 1, vital signs should be reassessed no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable, and at least 30 minutes prior to disposition.
...
3. Vital signs will be taken 30 minutes after the administration of narcotics, vital signs will taken(sic) 5 minutes after the administration of sub-lingual nitroglycerin. Vital signs will be taken 30 minutes post administration of oral vasoactive medications."


Facility policy ED-6850-108 titled "Overdose and Poisonings - Management Of" states, in part:

"Policy Statement:

Provide immediate appropriate care for patients that have been subjected to harmful agents, whether ingested, absorbed or inhaled.

Procedure:
1. Assess adequacy of airway and establish if necessary.
...
6. Report any change in condition or vital signs to the physician immediately."


Facility policy ED-6850-170 titled "Emergency Department Record" states, in part:
" ...
2. Nurse's Notes
...
D. Repeat vital signs according to ESI standards and document in the medical record."


Facility policy ED-6850-110 titled "Patients - Nursing Management of Patients Who Are Emotionally Ill or Who Are Under the Influence of Drugs or Alcohol or Become Difficult to Manage" states, in part:

"Policy Statement:
Emergency Department staff will attempt to maintain optimum safety, privacy and preservation of personal dignity of the disoriented, uncooperative, combative, or intoxicated patient, while rendering medical care.
Procedure:
...
2. Assess airway, breathing, and circulation. Initiate interventions as indicated.
...
5. Monitor vital signs and level of consciousness.
...
8. Notify physician of patient status."


Facility policy ED-6850-007 titled "Admission - Patients to the Emergency Department" states, in part:

"Procedure:
...
4. Emergency Physicians are immediately notified of critical patients, abnormal vital signs(sic) change in vital signs, deterioration/change of patient condition, and abnormal assessment findings."

According to professional reference site www.heart.org:

* Normal blood pressure - Systolic reading (top number) less than 120; Diastolic reading (bottom number) less than 80
* High Blood Pressure Stage II - Systolic reading 140 or higher; Diastolic reading 90 or higher
* Hypertensive Crisis - Systolic reading higher than 180; Diastolic reading higher than 120


According to professional reference site www.webmd.com:

* Normal blood pressure - Systolic reading less than 120 AND Diastolic reading less than 80
* Elevated blood pressure - Systolic reading 120-129 AND Diastolic reading less than 80
* High Blood Pressure Stage I - Systolic reading 130-139 OR Diastolic reading 80-89
* High Blood Pressure Stage II - Systolic reading 140 or higher OR Diastolic reading 90 or higher
* Hypertensive Crisis - Systolic reading higher than 180 AND/OR Diastolic reading higher than 120

**Both references state that a "hypertensive crisis" is a medical emergency and that care should be sought immediately.


According to professional reference site www.mayoclinic.org, "A normal resting heart rate for adults ranges from 60 to 100 beats per minute. Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness."


According to professional reference site www.webmd.com, "A normal resting heart rate is usually 60-100 beats per minute. Your number may vary. Children tend to have higher resting heart rates than adults."


A review of the clinical record for patient #1 revealed no documentation that nursing staff had monitored the patient appropriately following administration of narcotic medication nor had nursing staff notified the treating physician of critical changes in the patient's status.

Based on observation, review of the clinical record, and an interview with staff, the hospital failed to provide patient #1 with an appropriate medical screening examination within the capability of the hospital's emergency department, as review of camera footage revealed an incomplete screening exam that did not coincide with the exam noted in the clinical record.

Findings:

Review of the clinical record for [patient #1], a 32-year-old male, revealed that [patient #1] was brought into the emergency department of MCH on 8-23-19 at 7:38 am. The patient was brought to the ED by ambulance, in the custody of the Odessa Police Department on an emergency detention order. The patient had called 911 from a church parking lot and stated that he felt homicidal. The patient arrived in the triage area via wheelchair and stated to the triage nurse (staff #6) that he had taken "at least 10 flexeril 10 mg at 0630". He stated that he had also been drinking beer the previous evening. Patient #1's GCS [Glasgow coma score] was 15. He was classified as an ESI II and wheeled to an ED examination room.


Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI: "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."


During triage, patient #1's vital signs were as follows:
* Blood pressure 150/123 mmHg
* Pulse 149 bpm
* Temperature 98.2° Fahrenheit
* Respirations 24 breath/minute
* O2 Saturation 99% on room air

The patient's height was 5'10" tall and his weight was documented as 289 lbs with a BMI [body mass index] of 41.9. The patient stated that he used smokeless tobacco daily and denied having any allergies.


A review of the clinical record reveals staff #5's (resident physician) encounter with [patient #1] at 7:48 am. The encounter states the following:

"History of present illness: 32-year-old male presents to the emergency department with the police department. Brought in for resisting arrest. Was found in the parking lot of a church in his car saying he was homicidal. Subsequently resisted arrest. Multiple please(sic) officers present. Question of overdose on cyclobenzaprine [flexeril]. Patient states he took a handful but unable to quantify. Patient not answering questions. Denies injury anywhere. Denies pain.

General Appearance: Well developed, well-nourished, alert, agitated

HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light, extraocular muscles intact. Pharynx normal. No oral lesions. Moist mucous membranes.

Neck: Normal inspection, no thyromegaly, no lymphadenopathy. Neck supple.

Respiratory: chest nontender. No respiratory distress. Breath sounds clear and equal bilaterally.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Strong distal pulses with good perfusion.

Abdomen: Soft, nontender, nondistended. No organomegaly. No palpable masses. Normal bowel sounds.

Back: Normal inspection, no CVA tenderness.

Skin: Warm, dry, intact with normal color and no rash. No embolic lesions. No petechiae.

Extremities: Nontender, full range of motion, no calf tenderness. No pedal edema.

Neuro: Awake, alert, oriented x 4. Cranial nerves II through XII grossly intact. Motor and sensation grossly intact. Mood and affect normal."


Following this recorded encounter, the clinical record contained an "Attending Attestation" written by staff #4, which stated:

"The patient was independently seen, interviewed, and examined by me. I agree with the assessment and care plan as documented by [staff #5]. [Patient #1] initially arrived extremely agitated requiring multiple officers (nearly ten officers) to restrain patient for several minutes. Yelling at staff and kicking and punching. After failure of verbal instructions failed, physical restraints were applied to protect patient from self (he pulled out his initial IV) and to protect staff. Patient given Benadryl, Haldol, Ativan. Continued to be combative. Subsequently given another dose of Haldol. Nurse was present in room and entire time throughout ED course. Patient remained with a pulse ox[imetry] in the 90s on 2 L nasal cannula for several minutes. Nurse witnessed pulse ox suddenly decreased to 70s. I was notified immediately and entered the room and patient was being bagged. I witnessed bradycardia down to 50s and then to 0. ACLS started immediately. See nursing notes for details PED --> Asystole. I suspect patient had cardiac arrest due to cocaine, ethanol (cocaethylene), benzodiazepines (UDS was before ED Ativan). Extreme catecholamine surge from agitation coupled with drugs likely led to cardiac arres which led to apnea. Unsuccessful resuscitation. Pronounced [dead] 10:04 AM. No family present."


A review of the Patient Summary Report indicated the following key activities:
* 7:38 am - Triage
* 7:44 am - RN Exam
* 7:44 am - Seen by ED Physician
* 7:49 am - EKG performed


In a review of footage from the arresting officer's bodycam[era], the following events were noted:

* 7:38 am - Patient #1 arrives in triage via wheelchair

* 7:44 am - Patient is wheeled to a treatment room in the ED and transfers himself from the wheelchair to the bed. Hospital staff (identified by staff #3 as a registered nurse) is present in the room.

* 7:45 am - Officers begin the process of cuffing the patient's hands and feet to the gurney. The patient has a leather belt around his waist to which the left hand is cuffed. The right hand is cuffed both to the belt and to the gurney. The patient is then hooked up to a monitor for continuous monitoring of pulse, blood pressure and oxygen saturation levels. Head of bed is elevated at an approximate 30° angle.

* 7:48 am - Staff previously identified as a nurse establishes intravenous access on the right hand or wrist.

* 7:58 am - Staff member performs EKG.

* 8:07 am - Staff identified as staff #5 [resident physician] enters room, stands beside the head of the bed, speaks to patient and places stethoscope on 5-6 different areas of patient's chest and abdomen. ***No physician assessment is observed until this time***

* 8:09 am - Same staff identified as staff #5 moves to side of room and examines an item inside a clear, plastic bag.

* 8:18 am - Cuffs are removed from patient's left wrist and ankles. Patient scoots himself off foot of bed and a urinal is placed in his hands.

* 8:21 am - Patient hands the urinal containing yellow-colored liquid to one of the officers present in the room. Patient then crawls back onto the stretcher and the ankle and left wrist cuffs are reapplied.

* 8:30 am - Left hand cuff is removed from waist belt and cuffed to the gurney.

* 8:44 am - Patient begins calling out, moaning and thrashing about on the gurney.

* 8:52 am - Staff identified as attending physician (staff #4) enters room, stands at foot of bed, observes patient and leaves the room approximately 30 seconds later. ***No corroborating assessment by staff #4 was noted to have taken place during the patient's stay***

* 8:54 am - Staff enters the room and begins the process of replacing handcuffs on upper extremities with soft wrist restraints.

* 8:57 am - An injection is given in the left deltoid.

* 9:06 am - The patient begins exhibiting symptoms of apnea, including snoring, sternal retractions and the use of accessory muscles to breathe. Patient appears sedated with eyes closed, although he requires intermittent restraint by law enforcement.

* 9:17 am - An injection is given in the right upper extremity.

* 9:21 am - Patient exhibits increased difficulty breathing and now emits whistling and grunting sounds with inspiration.

* 9:31 am - Patient continues to exhibit sternal retractions and the use of accessory muscles to breathe. Whistling and grunting noises continue to be heard that coincide with the patient's sternal retractions and use of accessory muscles. A staff member cuts off the patient's clothing and drapes his genital area with a white sheet.

* 9:44 am - Staff re-enter room and "we need to tube him" is heard. 2 staff previously identified as staff #4 & staff #4 (resident physician and attending physician) enter room and leave room together a few seconds later, only to return together approximately 30 seconds later. During this time, some of the officers have been sent outside the room, as the patient's condition has now declined.

* 9:45 am - Bodycam is again directed into room, where male staff is seen performing compressions.

* 9:57 am - Resuscitation efforts continue.

**The bodycam intermittently recorded a panoramic view of the ED room where the patient was located. Although there were staff members in and out of the room, there was not a staff member continuously present in the room throughout the patient's stay in the ED.**


A review of Medical Staff bylaws, rules and regulations revealed the following regarding EMTALA:

Page 34, Article X Emergency Services states, in part:

"10.B. Medical Screening Examinations

(1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ("QMP") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:

(a) Emergency Department:

(i) members of the Medical Staff with clinical privileges in Emergency Medicine;

(ii) other Active Staff members; and

(iii) appropriately credentialed Allied Health Professionals."


Review of the credentialing file for [staff #4] revealed current licensure, DEA certification, insurance, privileges and appointment. Staff #4 also held current board certification in emergency medicine.


In an interview with staff #3 on 3-12-20, staff #3 stated that both an ER resident/fellow (staff #5) and the ER Physician on duty (staff #4) examined patient #1 when patient #1 was a patient in the ED. She stated that MCH was a teaching hospital and was associated with Texas Tech University Health Science Center. When asked if the hospital had a credentialing file on staff #5, staff #3 stated that all residents/fellows were credentialed through TTUHSC and that their care was supervised by their attending physician.


Since the patient declined and then had a more emergent condition, this change and deterioration was not addressed. Therefore causing a delay in completion medical screening exam. The decline without treatment or attempting to stabilize the patients abnormal vitals signs, including and elevated HR and BP, and declining mentation with respiratory decline, also demonstrates how that the medical screening exam was not complete. The patient was going to be admitted to the ICU for his condition but became more and more unstable and no medical intervention was performed to prevent this.

Based on observation, a review of the clinical record and an interview with staff, the hospital failed to provide the patient further medical treatment as needed to stabilize his condition, despite the fact that the staff present were qualified to do so.


Findings:


Review of the clinical record for patient #1, a 32-year-old male, revealed that the patient was brought into the emergency department of MCH on 8-23-19 at 7:38 am. Patient #1 was brought to the ED by ambulance, in the custody of the Odessa Police Department on an emergency detention order. The patient had called 911 from a church parking lot and stated that he felt homicidal. The patient arrived in the triage area via wheelchair and stated to staff #7 (triage nurse) that he had taken "at least 10 flexeril 10 mg at 0630". He stated that he had also been drinking beer the previous evening. Patient #1's GCS [glasgow coma score] was 15. He was classified as an ESI II and wheeled to an ED examination room.


Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI: "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."


During triage, patient #1's vital signs were as follows:
* Blood pressure 150/123 mmHg
* Pulse 149 bpm
* Temperature 98.2° Fahrenheit
* Respirations 24 breath/minute
* O2 Saturation 99% on room air

The patient's height was 5'10" tall and his weight was documented as 289 lbs with a BMI [body mass index] of 41.9. The patient stated that he used smokeless tobacco daily and denied having any allergies.


A review of the clinical record reveals staff #5's (resident physician) encounter with [patient #1] at 7:48 am. The encounter states the following:

"History of present illness: 32-year-old male presents to the emergency department with the police department. Brought in for resisting arrest. Was found in the parking lot of a church in his car saying he was homicidal. Subsequently resisted arrest. Multiple please(sic) officers present. Question of overdose on cyclobenzaprine [flexeril]. Patient states he took a handful but unable to quantify. Patient not answering questions. Denies injury anywhere. Denies pain.

General Appearance: Well developed, well-nourished, alert, agitated

HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light, extraocular muscles intact. Pharynx normal. No oral lesions. Moist mucous membranes.

Neck: Normal inspection, no thyromegaly, no lymphadenopathy. Neck supple.

Respiratory: chest nontender. No respiratory distress. Breath sounds clear and equal bilaterally.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Strong distal pulses with good perfusion.

Abdomen: Soft, nontender, nondistended. No organomegaly. No palpable masses. Normal bowel sounds.

Back: Normal inspection, no CVA tenderness.

Skin: Warm, dry, intact with normal color and no rash. No embolic lesions. No petechiae.

Extremities: Nontender, full range of motion, no calf tenderness. No pedal edema.

Neuro: Awake, alert, oriented x 4. Cranial nerves II through XII grossly intact. Motor and sensation grossly intact. Mood and affect normal."


Following this recorded encounter, the clinical record contained an "Attending Attestation" written by staff #4, which stated:
"The patient was independently seen, interviewed, and examined by me. I agree with the assessment and care plan as documented by [staff #5]. [Patient #1] initially arrived extremely agitated requiring multiple officers (nearly ten officers) to restrain patient for several minutes. Yelling at staff and kicking and punching. After failure of verbal instructions failed, physical restraints were applied to protect patient from self (he pulled out his initial IV) and to protect staff. Patient given Benadryl, Haldol, Ativan. Continued to be combative. Subsequently given another dose of Haldol. Nurse was present in room and entire time throughout ED course. Patient remained with a pulse ox[imetry] in the 90s on 2 L nasal cannula for several minutes. Nurse witnessed pulse ox suddenly decreased to 70s. I was notified immediately and entered the room and patient was being bagged. I witnessed bradycardia down to 50s and then to 0. ACLS started immediately. See nursing notes for details PED --> Asystole. I suspect patient had cardiac arrest due to cocaine, ethanol (cocaethylene), benzodiazepines (UDS was before ED Ativan). Extreme catecholamine surge from agitation coupled with drugs likely led to cardiac arres which led to apnea. Unsuccessful resuscitation. Pronounced [dead] 10:04AM. No family present."


A review of the Vital Sign Flowsheet indicated that the patient's vital signs were assessed at the following times:
*7:41 am
°Blood pressure 150/123 mmHg
°Pulse 123 bpm

*7:48 am
°Blood pressure 123/100 mmHg
°Pulse 164 bpm

*8:01 am
°Blood pressure 145/92 mmHg
°Pulse 145 bpm

*9:26 am
°Blood pressure 194/191 mmHg
°Pulse 195 bpm

*9:31 am
°Blood pressure 145/124 mmHg
°Pulse 192 bpm

*9:46 am
°Blood pressure 170/113 mmHg
°Pulse 155 bpm


The patient became apneic around 9:30 am and oxygenation was supplied with a bag-valve mask. The patient's oxygen saturation dropped significantly and the decision was made to intubate. The patient was found to be in asystole at 9:47 and ACLS protocol was initiated. The patient expired and was pronounced dead at 10:04 am.


In a review of footage from the arresting officer's bodycam[era], the following events were noted:

* 7:38 am - Patient #1 arrives in triage via wheelchair

* 7:44 am - Patient is wheeled to a treatment room in the ED and transfers himself from the wheelchair to the bed. Hospital staff (identified by staff #3 as a registered nurse) is present in the room.

* 7:45 am - Officers begin the process of cuffing the patient's hands and feet to the gurney. The patient has a leather belt around his waist to which the left hand is cuffed. The right hand is cuffed both to the belt and to the gurney. The patient is then hooked up to a monitor for continuous monitoring of pulse, blood pressure and oxygen saturation levels. Head of bed is elevated at an approximate 30° angle.

* 7:48 am - Staff previously identified as a nurse establishes intravenous access on the right hand or wrist.

* 7:58 am - Staff member performs EKG.

* 8:07 am - Staff identified as staff #5 [resident physician] enters room, stands beside the head of the bed, speaks to patient and places stethoscope on 5-6 different areas of patient's chest and abdomen. ***No physician assessment is observed until this time***

* 8:09 am - Same staff identified as staff #5 moves to side of room and examines an item inside a clear, plastic bag.

* 8:18 am - Cuffs are removed from patient's left wrist and ankles. Patient scoots himself off foot of bed and a urinal is placed in his hands.

* 8:21 am - Patient hands the urinal containing yellow-colored liquid to one of the officers present in the room. Patient then crawls back onto the stretcher and the ankle and left wrist cuffs are reapplied.

* 8:30 am - Left hand cuff is removed from waist belt and cuffed to the gurney.

* 8:44 am - Patient begins calling out, moaning and thrashing about on the gurney.

* 8:52 am - Staff identified as attending physician (staff #4) enters room, stands at foot of bed, observes patient and leaves the room approximately 30 seconds later. ***No corroborating assessment by staff #4 was noted to have taken place during the patient's stay***

* 8:54 am - Staff enters the room and begins the process of replacing handcuffs on upper extremities with soft wrist restraints.

* 8:57 am - An injection is given in the left deltoid.

* 9:06 am - The patient begins exhibiting symptoms of apnea, including snoring, sternal retractions and the use of accessory muscles to breathe. Patient appears sedated with eyes closed, although he requires intermittent restraint by law enforcement.

* 9:17 am - An injection is given in the right upper extremity.

* 9:21 am - Patient exhibits increased difficulty breathing and now emits whistling and grunting sounds with inspiration.

* 9:31 am - Patient continues to exhibit sternal retractions and the use of accessory muscles to breathe. Whistling and grunting noises continue to be heard that coincide with the patient's sternal retractions and use of accessory muscles. A staff member cuts off the patient's clothing and drapes his genital area with a white sheet.

* 9:44 am - Staff re-enter room and "we need to tube him" is heard. 2 staff previously identified as staff #4 & staff #4 (resident physician and attending physician) enter room and leave room together a few seconds later, only to return together approximately 30 seconds later. During this time, some of the officers have been sent outside the room, as the patient's condition has now declined.

* 9:45 am - Bodycam is again directed into room, where male staff is seen performing compressions.

* 9:57 am - Resuscitation efforts continue.

**The bodycam intermittently recorded a panoramic view of the ED room where the patient was located. Although there were staff members in and out of the room, there was not a staff member continuously present in the room throughout the patient's stay in the ED.**


According to professional reference site www.heart.org:

* Normal blood pressure - Systolic reading (top number) less than 120; Diastolic reading (bottom number) less than 80

* High Blood Pressure Stage II - Systolic reading 140 or higher; Diastolic reading 90 or higher

* Hypertensive Crisis - Systolic reading higher than 180; Diastolic reading higher than 120


According to professional reference site www.webmd.com:

* Normal blood pressure - Systolic reading less than 120 AND Diastolic reading less than 80

* Elevated blood pressure - Systolic reading 120-129 AND Diastolic reading less than 80

* High Blood Pressure Stage I - Systolic reading 130-139 OR Diastolic reading 80-89

* High Blood Pressure Stage II - Systolic reading 140 or higher OR Diastolic reading 90 or higher

* Hypertensive Crisis - Systolic reading higher than 180 AND/OR Diastolic reading higher than 120

**Both references state that a "hypertensive crisis" is a medical emergency and that care should be sought immediately.


According to professional reference site www.mayoclinic.org, "A normal resting heart rate for adults ranges from 60 to 100 beats per minute. Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness."


According to professional reference site www.webmd.com, "A normal resting heart rate is usually 60-100 beats per minute. Your number may vary. Children tend to have higher resting heart rates than adults."


A review of Medical Staff bylaws, rules and regulations revealed the following regarding EMTALA:

Page 34, Article X Emergency Services states, in part:

"10.B. Medical Screening Examinations

(1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ("QMP") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:

(a) Emergency Department:

(i) members of the Medical Staff with clinical privileges in Emergency Medicine;

(ii) other Active Staff members; and

(iii) appropriately credentialed Allied Health Professionals."


Review of the credentialing file for staff #4 (attending physician) revealed current licensure, DEA certification, insurance, privileges and appointment. Staff #4 also held current board certification in emergency medicine.


In an interview with staff #3 on 3-12-20, staff #3 stated that both an ER resident/fellow and the ER Physician on duty examined patient #1 when he was a patient in the ED. She stated that MCH was a teaching hospital and was associated with Texas Tech University Health Science Center. When asked if the hospital had a credentialing file on staff #5, staff #3 stated that all residents/fellows were credentialed through TTUHSC and that their care was supervised by their attending physician.


Despite patient #1's blood pressure and pulse documented well outside acceptable range (critically so, at times) according to professional standards, the clinical record contained no documentation of efforts to stabilize him and the patient expired approximately 2 1/2 hours after arrival in the emergency department.