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Based on medical record review, and interview the hospital failed to ensure all patients presenting to the Emergency Department (ED) received treatment and reassessment/follow-up of abnormal vital signs or medical administration for 1 of 21 (Patient #2) patients that presented to the hospital's ED when Patient #1, an acutely hypertensive patient, was discharged home without having his blood pressure reassessed.

The findings included:

Review of the hospital's Physical Assessment Within Normal Limit Definitions revealed, "...Neurological Assessment...Adult: Patient is alert and oriented to person, place, time and situations, Moves all extremities equally. Follows commands. Speech clear..."

Review of the Prehospital Patient Record report received from Emergency Medical Services (EMS) revealed EMS was dispatched emergently on 10/3/2022 at 7:25 AM to Patient #2's home who was complaining of "Chest Pain." The EMS unit arrived at the patient's home at 7:35 AM and found the patient lying in his bed, "alert and fully oriented... The patient explained to crew that he had been experiencing chest pain since the previous morning [10/20/2022]...pain localized to the left [L] side of his chest and reported that the pain radiated into his left arm and the left side of his neck...also reported shortness of breath upon exertion..." The Medical Assessment completed at 7:35 AM revealed Patient #2's "Speech Normal..." While on-scene, EMS performed electrocardiogram (EKG) which showed normal sinus rhythm. (An EKG is a procedure that measures the electrical signals of the heart. An EKG can show if the heart is beating at a normal rate and strength. An abnormal EKG can be a signs of heart disease or damage. The term "leads" or electrodes refers to small plastic patches that stick to the skin and are placed at certain spots on the chest, arms, and legs. The leads are connected to the EKG by lead wires. The electrical activity of the heart is then measured.) The patient was placed on a cardiac monitor. The patient's vital signs were monitored with an initial blood pressure reading of 180/110 taken at 7:42 AM. The "CVA Scale" [Cerebro-vascular accident scale] was "Normal (Negative)." (A CVA commonly called a "stroke" occurs when there is loss of blood flow to a part of the brain, which damages brain tissue. CVA symptoms include dizziness, numbness, weakness of one side of the body, and problems with talking, writing or understanding language.) The patient's blood glucose was assessed with a level of 96 noted. A second blood pressure was obtained at 7:51 AM and noted to be 186/117. An Intravenous (IV) catheter was inserted into the patient's left antecubital space. A final blood pressure was taken at 7:56 AM and was noted to be 211/111. The "CVC Scale" was "Normal (Negative)." Report was called to the hospital's ED and the patient was transported non-emergently to the hospital's ED.

Review of the "Prior to Arrival/EMTALA Form" dated 10/3/2022 at 7:55 AM revealed EMS was enroute with Patient #2 with complaints of "Chest pain since yesterday [10/2/2022] and cough with an estimated time of arrival of 10 minutes to Hospital #1."

Medical record review revealed Patient #2 arrived at the hospital's ED on 10/3/2022 at 8:20 AM. The ED Medical Director (EDMD) documented Patient #2 was complaining of chest pain that radiated down his left arm, neck, and back since 10/2/2022. The physician further documented the patient reported he had blurred vision bilaterally and had been non-compliant with his medications for Hypertension (high blood pressure). The "Review of Systems" revealed Patient #2 had "...no weakness...vision unchanged...no shortness of breath, no cough...mild chest pain, no palpitations...mild back pain...no headache, no dizziness..." The "Physical Exam" revealed Patient #2 was in no acute distress, but was diaphoretic, and "slurred speech at his baseline...Cardiovascular: regular rate and rhythm, normal peripheral perfusion...Musculoskeletal: no deformity, normal ROM [range of motion]. Neurological: alert and oriented x 4 [Alert and oriented times four means the patient was alert and oriented to person, place, time and event.], LOC [level of consciousness] appropriate for age, speech normal, no focal deficits..." A complete blood count (CBC) complete metabolic panel (CMP), serial Troponin-1, Pro B- type Natriuretic Peptide (BNP), Prothrombin time (PT), and Partial Thromboplastin Time (PTT), were ordered along with an EKG and Computerized Tomography-Angiogram (CTA) of the chest. The physician also ordered a one-time dose of chewable aspirin 325 milligrams (mg) be given.

The chewable aspirin was administered at 8:38 AM. (Aspirin is used when a patient presents with symptoms of an acute heart attack to keep blood flowing and help to prevent further damage to the heart.)

A triage assessment was completed at 8:29 AM, which revealed the patient had been experiencing chest pain that radiated "from the chest, down the L arm, and into the back." The patient also complained of bilateral blurred vision and had a history of being non-complaint with his antihypertensive medications. The patient's blood pressure was 185/116, and his pulse was 73. The patient was assigned a level of 2 emergency severity index. All initial blood work was collected while the patient was still being triaged.

At 8:37 AM the patient's blood pressure was reassessed and noted to be 229/120.

At 8:47 AM the "Nursing Assessment -System Review" revealed the patient's "Neurological Assessment-System Review" was "WDL [within desired limits]."

At 9:32 AM, a total of 55 minutes after the last blood pressure reading was obtained, the patient was given 20 mg of Labetalol IV push. (Labetalol is a medication used to treat high blood pressure which works by relaxing blood vessels and slowing the heart rate to improve blood flow.) There was documentation of blood pressure immediately prior to medication administration.

At 9:45 AM, the patient was taken to radiology for his CTA of his chest. The CTA revealed, "...Findings are essentially stable."

At 10:01 AM the patient's blood pressure was re-assessed and noted to be 226/120 and his pulse was 63.

At 10:33 AM the patient was given 10 mg of Hydralazine IV push. (Hydralazine is a medication used to treat high blood pressure that works by relaxing the blood vessels so that blood can flow more easily through the body.) There was no documentation of blood pressure immediately prior to medication administration.

At 11:04 AM the patient's blood pressure was reassessed and noted to be 220/104 and his pulse was 67.

At 11:31 AM the patient was given 0.2 mg of Clonidine by mouth. (Clonidine is a medication used to treat high blood pressure that works by decreasing the heart rate and relaxing the blood vessels so that blood can flow more easily through the body.) There was no documentation of blood pressure immediately prior to medication administration.

At 12:06 PM the patient was given 12.5 mg of Phenergan IV piggy- back. (Phenergan is a medication used to treat allergies and motion sickness. It is also used to treat nausea and vomiting. The term piggy-back means the medication was diluted in a small bag of solution (fluid) then administered slowly IV.)

At 12:58 PM, the patient's blood pressure was assessed and noted to be 191/107.

At 1:15 PM the "Decision to Discharge" order was written by the EDMD.

At 1:29 PM, the RN documented, "...pt [patient] is d/c [discharged] home; pt aox4 [alert and oriented] and can ambulate without assistance." Note: Patient #2 did not physically leave the ED at this time.

There was no documentation the patient's blood pressure was reassessed.

At 2:00 PM, the patient was given 100 mg of Losartan by mouth. (Losartan is a medication used to high blood pressure that works by keeping the blood vessels from narrowing, which lowers blood pressure and improves blood flow.) There was no documentation the patient's blood pressure was reassessed.

At 3:00 PM, Patient #2 was re-examined by the EDMD. The physician documented, "Patient with chest wall pain and hypertension negative work-up here patient has a history of being noncompliant with medications will recommend patient take his medications as prescribed and follow-up with his primary care provider. Patient had negative CTA of chest for arteries or blood clots 3 troponins which were normal blood pressure did come down here some in the emergency department and is ambulatory at the time of discharge...Disposition...Condition Stable..."

Patient #2 was discharged from the ED on 10/3/2022 at 3:15 PM in "stable" condition with diagnoses which included Hypertension and Chest Wall Pain. The patient was given instructions on when to follow-up with his primary care physician, signs and symptoms of a hypertensive emergency and chest pain emergency, and when to return to the ED. Prescriptions for Amlodipine 10 mg daily and Losartan 100 mg daily were sent electronically to the patient's pharmacy.

Patient #2, an acutely hypertensive patient that required multiple antihypertensive medications during his ED visit, was discharged in "stable condition," but there was no documentation the patient's blood pressure had been reassessed since 12:58 PM, a total of 2 hours and 17 minutes prior to his discharge from the ED. There were no discharge vital signs obtained; therefore, there was no way to determine if the patient's vital signs were stable at the time of his discharge.

In an interview on 10/20/2022 the ED Medical Director (MD) at Hospital #1 stated he did not specifically recall Patient #2, but he had reviewed the record. The EDMD stated the patient reported that he had been non-compliant with his medications and complained of Chest pain. The EDMD was asked what the parameters for blood pressures were in hypertensive patients before they were considered to be safe for discharge. The physician stated, there are "No discharge parameters for discharge blood pressures. He had a history of Hypertension and was non-compliant with his medications. I called in a prescription for him. The blurred vision would be more likely related to his Hypertension."

The hospital's Quality Improvement & Risk Manager was asked to provide a copy of the ED policy for vital signs via e-mail on 10/24/2022 at 11:36 AM.

In an electronic response received on 10/24/2022 at 5:16 PM, the Quality Improvement & Risk Manager responded with, "There is no vital sign policy. They base the needs on the acuity of the patient or if the condition changes during the ED visit. Generally, vital signs are assessed during triage and about 15-30 minutes prior to discharge; more often if the patient is acutely ill. There is no set time process."