HospitalInspections.org

Based on facility policy review, hospital document review, medical record review, video review and interview, the hospital failed to ensure all patients who were seeking emergency medical care received individualized treatment and examination to treat the emergency medical condition and to meet the medical needs of the patient. The failure of the hospital to provide the necessary assessment, examination and treatment resulted in the death of 1 of 1 (Patient #1) sampled patients who had presented to the hospital's emergency department (ED), was discharged without necessary treatment and who was found dead on the hospital's pavement outside the hospital's ED..

The hospital's failure to provide appropriate and necessary treatment for an emergency condition resulted in an SERIOUS AND IMMEDIATE THREAT to Patient #1 who died on the driveway and places all patients seeking emergency medical treatment at risk for IMMEDIATE JEOPARDY (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause injury, harm, impairment, or death to a patient).

The findings included:

1. The hospital failed to ensure the staff in the ED provided necessary care and services to a patient presenting to the ED with an emergency medical condition. The hospital failed to ensure after a patient had fallen outside the hospital's ED entrance and who was visible on hospital video camera view, received an assessment, examination and treatment following the fall.
Refer to A1103.

Based on hospital policy review, medical record review, video recording review and interview, the hospital failed to ensure the emergency department (ED) staff performed ongoing assessments of patients who were in the ED seeking treatment for an emergency medical condition in order to determine, diagnose and provide treatment for the emergency medical condition; and made available to the full extent all patient care resources to assess and render appropriate care for all emergency patients. The hospital failed to ensure all patients received access to services, and resources to diagnose and treat emergency medical conditions for 1 of 1 (Patient #1) patients who had presented to the hospital's ED seeking treatment for an emergency medical condition, and was discharged without receiving treatment for the emergency medical condition and who died on the hospital pavement outside the ED.

The failure of the hospital to provide an appropriate and ongoing assessments and treatment to patients presenting to the hospital's ED and the failure of the hospital to assess and provide services to patients who had fallen outside the ED places all patients presenting to the hospital's ED in a SERIOUS AND IMMEDIATE THREAT to the their health and safety resulting in an IMMEDIATE JEOPARDY for all patients presenting to the the hospital's ED.

The findings included:

1. Review of the hospital's policy titled Unified General Rules and Regulations revealed,
"...The ED call physician will be responsible for seeing all consults received by him/her during his time on ED call...In non-emergent circumstances, a physician should examine and evaluate the patient before an elective consult. An emergency consultation will involve physician to physician communication."

Review of the hospital's policy titled Falls Prevention Program revealed,"...A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface...Interventions...Immediate Post Fall: The nurse will assess the patient for injury...The patient's provider will be notified of the fall and appropriate medical assessment and treatment will be obtained as indicated...All ED...patients...are considered as high risk for fall, therefore no risk assessment is documented. Basic safety interventions are initiated for all ED...patients..."

Review of the hospital's policy titled Triage of Emergency Patients Policy revealed, "...Triage of patients arriving to the ED will be conducted by a RN [registered nurse]...and assign the final triage acuity based upon a five-level triage system known as the Emergency Severity Index (ESI)...The triage assessment will also include a pain assessment...Acuity is determined by the stability of vital signs and potential for life, limb or organ threat based on ESI five level triage system...The Acuity assignments include the following categories;
Level I: Emergent-requires immediate life-saving intervention
Level II: High risk situation, is confused/lethargic/disoriented, severe pain/distress, or vitals are in danger zone
Level III: Multiple resources (lab, x-ray, IV, etc.) are required to stabilize the patient , but vitals are not in the danger zone
Level IV: One resource needed to stabilize the patient
Level V: No resources required to stabilize patient".

Review of the hospital's policy titled Pain Assessment Policy revealed, "...All patients will be assessed for pain based upon their clinical presentation, services sought, and in accordance with the care, treatment, and services provided. When pain in identified, the patient is treated or referred for treatment...The identification and treatment of pain is an important part of the plan of care because unrelieved pain has adverse physical and psychological effects...Use most appropriate pain scale for patient...Numeric Rating Scale...0 (no pain) to 10 (worst pain)...8 to 10 Severe Pain..."

Review of the hospital's policy titled Discharge From Emergency Department revealed, "...Vital signs and reassessment are obtained 30 minutes prior to discharge except for Level 4 and 5 patients..."

Review of the hospital's policy titled Policy Security Management Plan revealed, "...[this hospital] maintains a security management program that is designed to provide a safe and secure physical environment free of hazards and risks for patients...The purpose of the Security Management Plan is to define the program to minimize the risk of injury...involving patients...Goals and Objectives...Appropriate and timely action is taken to prevent...injury..."

2. Review of the hospital's Security Officer Job Description revealed, "...Key Job Responsibilities...Patrols hospital, parking and/or assigned area to ensure safety and security for...patients..."

3. Medical Record Review for Patient #1 revealed the patient was an uninsured 30 year old morbidly obese male and arrived to the ED on 12/1/2020 at 8:12 PM in a private vehicle and wheelchair. The patient's chief complaint was chest pain. Patient #1 also complained of leg pain and unable to walk for 1 day.

The triage assessment performed by Registered Nurse (RN) #1 beginning at 8:12 PM revealed Patient #1 described his chest pain as an 8 out of 10 on a scale of 1 - 10 with 10 being the most severe, and the chest pain was constant and aching. The triage nurse assigned the patient's acuity level as level 2.
Patient #1's vital signs at 8:12 PM were:
Blood Pressure (BP) 144/88,
Heart rate 114,
and a Mean Arterial Pressure (MAP) 107-high (normal range is 70-100. A high MAP can lead to heart disease, blood clots, heart attack and stroke).
There was no documentation of other vital signs for Patient #1 until 3:11 AM.

Physician #1 ordered a Chest X-ray on 12/1/2020. The chest x-ray was completed at 8:17 PM. Review of the chest x-ray results revealed the patient had chronic infiltrate or atelectasis (a partial or complete collapse of the entire lung or area of the lung) which was noted within the region of the right middle lobe. The impression revealed chronic appearing opacity right middle lobe when compared to multiple prior exams. There was no evidence Physician #1 or other ED medical staff reviewed the chest x-ray results while Patient #1 was in the ED.

FNP #1 ordered an Electrocardiogram (ECG) on 12/1/2020 at 8:17 PM which revealed Patient #1 was in Sinus tachycardia (fast heart rate greater than 100) and had Left Ventricular Hypertrophy (enlargement and thickening of the heart's main pumping chamber and the heart often times caused by hypertension). The Radiologist noted the current ECG was different than Patient #1's previous ECG that was done on 6/24/2020. The previous ECG done on 6/24/2020 showed Patient #1 had a normal sinus rhythm and did not have Left ventricular hypertrophy.

Physician #1's note dated 12/1/2020 at 11:41 PM revealed Physician #1 reviewed the results of Patient #1's ECG while the patient was waiting in the ED. Physician #1 documented the patient was in Sinus tachycardia and that there was no indication Patient #1 was experiencing a heart attack. There were no further assessments performed of Patient #1's sinus tachycardia. There was no evidence of a cardiology consult in the medical record.

Review of Physician #1's note dated 12/1/2020 at 11:41 PM revealed "...When questioned, patient [Patient #1] weakly mutters "I can't speak" and does not answer any further questions. According to the ED tech [ED tech is a non-licensed person] patient was speaking to him just fine prior to exam. Pt was repeatedly in the ED around 6 months ago for chest pain...The course/duration of symptoms is constant..." There was no documentation FNP #1, Physician #1, Physician #2 or other ED medical staff further examined Patient #1's inability to speak or respond to questioning. FNP #1 documented Patient #1's behavior was cooperative, appropriate mood and affect with normal judgment.

Review of Patient #1's laboratory results collected on 12/1/2020 at 12:22 AM revealed the following abnormal results:
White Blood Count (WBC) of 12.1, normal being 4.2-10.2.
Protein 9.4, normal being 6.4-8.2.
There was no evidence the ED Physician or other ED medical staff reviewed Patient #1's abnormal results while the patient was in the ED.

On 12/2/2020 at 3:11 AM, Patient #1's vital signs were taken for the second time since arriving to the ED and were elevated as follows:
BP 165/101,
MAP 122,
Heart Rate 100
There was no documentation of any follow up, assessment, examination or treatment of Patient #1 after the elevated vital signs were taken.

Physician #1 transferred care to Physician #2 for the last 30-45 minutes of Patient #1's visit until Behavioral Health could complete a crisis assessment.

On 12/2/2020 beginning at 3:30 AM a behavioral assessment was performed on Patient #1. The Assessor documented Patient #1 had history of Bipolar and was in the ED for complaints of chest pain. The Assessor documented the patient reported hearing voices, has been off his medication, and was uncooperative during the assessment. The Assessor documented Patient #1's speech was rambling and mumbling and at times selectively mute. The Assessor documented the patient was not currently a danger to self or others and the patient denied suicidal and homicidal ideations. The Assessor documented the patient was dispositioned home with a safety plan and an outpatient referral.

There were no further assessments, examinations or treatments for Patient #1.
Patient #1 did not receive any medications during this ED visit.

On 12/2/2020 at 5:04 AM, Patient #1 was discharged from the ED on foot with his belongings and discharge papers. There was no documentation vital signs or reassessments were done 30 minutes prior to discharge.

Patient #1 was discharged through the ED ambulance doors. Patient #1 was on foot with no one picking him up from the hospital. Patient #1 stayed outside the ambulance doors and walked around. According to the local weather forecast the temperature outside on 12/2/2020 from midnight to 6:00 AM was 30 to 34 degrees Fahrenheit.

4. Review of the hospital's security video of the ED dated and timed 12/2/2020 at 5:35:04 revealed the following:
5:37:38 - Patient #1 was seen walking outside the ED entrance doors and walked in front of an ambulance that was parked on the hospital's property. Patient #1 was walking with a slow noticeable limp away from the ED door entrance. Patient was carrying a folder. Patient continued to walk around past the ambulance.
5:42:10 - Patient #1 walked toward the ED driveway away from the ED ambulance entrance.
5:44:24 - Security Guard #1 walked into camera view from the ED doorway and walked out toward the driveway beside the ambulance. The Security Guard appeared to be signaling to Patient #1 by raising his arm and pointing to the driveway.
5:44:34 - Patient #1 was observed looking at Security Guard #1 and then Patient #1 turned toward the ED driveway and was slowly walking away from the ED entrance. Security Guard #1 turned towards the ED entrance.
5:44:54 - Patient #1 remains outside the ED doors on the hospital property. The patient is seen losing his balance, stepping backwards, dropped the folder, and falling on his back and his buttocks and hitting the back of his head on the concrete.
5:44:57 - Security Guard #1 is seen watching as Patient #1 struggled to get up. The Security Guard did not assist Patient #1.
5:45:19 - Patient #1 got up off the pavement, picked up his packet and Security Guard #1 again pointed toward the driveway as Patient #1 turned away appearing to limp slightly toward the driveway.
5:45:36 - Security Guard #1 turned and walked toward the hospital ED entrance.
There was no observations of any ED staff checking on Patient #1 after he had fallen on the hospital property outside the hospital's ED doors.
There was no observations Security Guard #1 checked on Patient #1 after he had fallen.
5:45:46 - Patient #1 was observed falling a second time. The patient fell forward and landed on his side, rolled over and straightened his legs out. Patient #1 appeared unable to get up. Patient #1 continued to move and roll around on the ED entrance way property.
5:46:26 - Patient #1 was moving and raised his arm straight up in the air, and rolled back and forth. He appeared unable to get up. There is still no observation of anybody assisting Patient #1.
5:50:32 - Patient #1 remains on the pavement outside the hospital's ED. The patient put his arm up in the air a second time.
5:51:33 - Patient #1 remains lying on the pavement outside the hospital's ED. No assistance is offered to the patient. The patient put his arm up in the air a third time.
5:51:43 - Patient #1 remains on the pavement. The patient sat up and pulled a shirt off over his head.
5:52:15 - Patient #1 laid back down on the driveway.
5:54:20 - Security Guard #1 came into camera view as he walked away from the ED entrance, he visualized Patient #1 lying on the driveway and walked at a normal pace toward him. There was no assistance offered by the Security Guard.
5:54:43 - Patient #1 remained lying on the hospital's pavement outside the ED. The patient was still moving periodically.
5:55:02 - Security Guard #1 is seen turning away from Patient #1's direction and walking out of the camera view.
5:55:49 - EMT #1 was seen outside the ED entrance and seen walking around the ambulance towards the ED door entrance. The EMT did not offer assistance to Patient #1.
5:56:06 - Patient #1 remains on the pavement outside the ED entrance. The patient sat up momentarily.
5:56:22 - Patient #1 laid back down on the pavement.
5:56:55 - A Security van came into view with lights on going toward Patient #1 who remained lying on the pavement outside the hospital's ED. The van appeared to have had direct view of Patient #1 lying on the hospital's pavement.
5:56:58 - The Security van turns left and disappeared from the camera view. At this time, Patient #1 remained lying on the pavement outside the hospital's ED. There was no observation of further movement from Patient #1.
5:59:34 - Patient #1 remains on the pavement outside the hospital's ED entrance. The patient was not moving.
6:01:06 - Security Guard #1 walked back into the camera view then immediately walked back out of view. He had direct visualization of Patient #1.
6:01:22 - The Security van came back into camera view. Patient #1 remained lying on the pavement outside the hospital's ED. The van appeared to have direct sight of Patient #1. The van then drives out of camera view.
6:09:31 - Two (2) private company ambulances appear outside the hospital's ED entrance. The ambulances passed by Patient #1 who remained lying on the hospital's pavement. The ambulances did not offer assistance to Patient #1.
6:13:17 - A white vehicle drives toward the hospital ED entrance and stopped by Patient #1. A driver exited the vehicle and walked toward Patient #1 and walks around him.
6:14:10 to 6:14:43 - Observations during this time show the person from the white vehicle kicked Patient #1, stepped back and stood there, walked back and forth then kicked Patient #1 again. Patient #1 does not appear to move.
6:15:13 - Three emergency medical technicians (EMTs) are seen walking back into camera view with a stretcher and walked toward the ED entrance.
6:15:18 - The person from the white vehicle standing next to Patient #1 appears to be yelling for assistance. One EMT in camera view turns around toward Patient #1 and the person from the white vehicle walks quickly out of camera view.
6:16:10 - The person in the white vehicle is seen getting something out of the trunk of the white car.
6:16:25 - The person in the white vehicle appeared to be donning gloves.
6:16:26 - The Security van appeared in camera view and pulled and parked beside Patient #1.
6:16:46 to 6:19:30 - Observations during this time showed multiple hospital ED staff walking towards Patient #1 and bringing equipment, a stretcher, a chair.
6:20:09 and 6:21:16 - Two local Police vehicles with blue lights flashing parked by Patient #1. Police Officers exited the vehicles and walked toward Patient #1.
6:24:04 - Multiple ED staff were bringing Patient #1 on a stretcher towards the ED entrance. One (1) staff member was riding on the stretcher on their knees doing chest compressions. All staff and Patient #1 went out of camera view once inside the ED entrance door.

Patient #1 laid outside the hospital's ED on the pavement from approximately 5:45 AM until 6:20 AM in 30 -34 degree Fahrenheit temperatures until the hospital's Security Guard and ED staff went out to assist Patient #1. The ED staff put Patient #1 on a stretcher and brought the patient back into the ED. One ED staff person was on the stretcher with Patient #1. The chest compressions were unsuccessful and Patient #1 was pronounced dead 12/2/2020 at 6:38 AM per the ED death log. As of 1/7/2021, the autopsy report for Patient #1 is still pending.

5. Review of the facility's investigation of the death of Patient #1 revealed the staff interviews were typed by the interviewer. Times were not documented in some of the interview summaries. There were no dates, times or signatures verifying the statements by the interviewees. The typed statements also reflected the hospital staff's propensity to place blame on the patient for the reactions and/or inactions of the staff, as well as there was no accountability by the ED staff or security staff for the ultimate death of Patient #1. There was no process changes or new interventions implemented to ensure all patients presenting to the hospital's ED receive an appropriate and ongoing examination and assessment in order to provide quality of care to all patients presenting to the hospitals' ED seeking emergency treatment.

6. In a telephone interview on 1/7/2021 at 12:18 PM, Security Guard #1 stated the first time Patient #1 fell Security Guard #1 did not see the patient fall but did see Patient #1 getting up off the pavement. Security Guard #1 stated he asked Patient #1 what was he doing and the patient stated "I'm fixing to go". Security Guard #1 stated he pointed and said to Patient #1 "it's that way, that's the way you leave the property."
Security Guard #1 stated the second time Patient #1 "supposedly" fell Security Guard #1 had already walked inside the hospital. Security Guard #1 stated he did not see the second fall. Security Guard #1 was asked when he was walking toward the Patient #1 at 5:54 AM and then went out of view of the camera was Patient #1 visible at that time and Security Guard #1 responded stating that he was on a disturbance call regarding another psychiatric patient who he was trying to get off the hospital property because the psychiatric patient was "acting up" in the hospital. Security Guard #1 stated then a second disturbance call came in at that time. Security Guard #1 stated he called another Security Guard and told him about the situation and that Patient #1 was still on the hospital grounds.
Security Guard #1 stated the other Security Guard had already called the local police about Patient #1. Security Guard #1 stated when the security van arrived Security Guard #1 was inside of the hospital with the disruptive psychiatric patient.
Security Guard #1 was asked if it was normal protocol to call the local police when a patient had fallen outside on hospital property and the Security Guard #1 stated, "During the procedure we was in, you know by it being only two [2] on duty, we was short staffed and trying to keep the two [2] guys from cutting up and from tearing up the hospital, yeah that's protocol to get [named local police] up there."
Security Guard #1 was asked if the ED staff or the ED charge nurse would be notified to let anybody know Patient #1 was outside and Security Guard #1 stated, "Yes, at the time we wasn't dealing with that situation of course we would let them know, but everything was happening so fast. Our protocol is like we got these guys in here threatening the staff and tearing up the hospital we was on it and we have to get get these folks out of here. We got these workers in here scared. [Patient #1] was laying from where we was at all the way to the front of the hospital. So that's when [named police department] came and [Named Security Guard #2] went back over there on the other side. I never went back over there, I was on one side of the hospital handling the problem."
Security Guard #1 was asked if he was handling one (1) or two (2) psych patients and Security Guard #1 stated, " First it was one (1) then when I got inside it was two (2)."
Security Guard #1 confirmed he knew about Patient #1 on the laying on the hospital pavement at 5:54 AM.
Security Guard #1 confirmed he was notified over the radio at that police officers had arrived and were on the scene.
Security Guard #1 stated, "I was calling for help, I was by myself up front dealing with the troubles and [Named Security Guard #2] alerted me that he was over there with named local police] on the scene."
Security Guard #1 confirmed he never went back around to check on Patient #1.

In a telephone interview on 1/7/2021 at 12:37 PM Nurse #1 stated Patient #1 was a known patient to the facility. Nurse #1 stated Patient #1's sister dropped him off at the ED and the sister told the receptionist Patient #1 needed psychiatric meds refilled. When Patient #1 was taken to triage, Patient #1 complained of chest pain to the triage nurse. The chest pain then became the primary complaint. Nurse #1 stated Patient #1 is sometimes withdrawn and will only talk to certain people. Nurse #1 stated Patient #1 did not display any behaviors during this ED visit. Nurse #1 stated the hospital always has security walk Patient #1 out of the hospital because the patient doesn't always leave when asked to leave. Nurse #1 verified she saw Patient #1 walking back and forth outside in the ambulance bay on the camera. Nurse #1 stated about 5:30 AM Physician #2 was leaving the hospital and the ED staff were concerned about Physician #2 walking outside alone because Patient #1 was just standing there outside and walking around outside. Nurse #1 stated she was notified Patient #1 was outside on the laying on the ground and she sent a nurse and a technician to the ED entrance door to watch Patient #1. Nurse #1 stated Patient #1 has masturbated before in front of the ED staff.
Nurse #1 stated this was behavior they were used to with Patient #1. Nurse #1 confirmed she was never notified Patient #1 fell and did not know until the tapes were reviewed. Security knew he fell.

In a telephone interview on 1/8/2021 at 12:23 PM Security Guard #2 confirmed there were 3 issues going on in the ED at the same time referring to Patient #1 and two (2) other patients. Security Guard #2 stated he talked to Security Guard #1 about the other situations going on but thought Patient #1 situation had been resolved. Security Guard #2 confirmed Patient #1 would pull his pants down and play with himself for attention. Security Guard #2 stated Patient #1 would do this so the local police would come and give him a ride somewhere. Security Guard #2 stated Patient #1 is one of our frequent flyers. Security Guard #2 confirmed he called local police. Security Guard #2 was not able to confirm if he saw Patient #1 was moving around while laying on the ground. Security Guard #2 stated he hated that happened [death of Patient #1] but the patient who was up at the front desk took precedence because he was pretty violent toward staff members. Security Guard #2 verified it was cold outside that night. Security Guard #2 stated he drove the security van back around to block the street so no one would hit Patient #1 and was there to assist local police.

Telephone calls were made to Nurse #2, and Physician #2 with messages left to return the call. As of 1/8/2021 at 12:00 PM they have not returned the call.