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Based on record review and interview, the facility failed to ensure emergency services were provided in a timely manner for Patient #9.

Findings:

Review on 01/05/15 of the Emergency Department (ED) Physician Assistant history dated 12/31/14 at 12:00pm revealed Patient #9 presented from the Women's Clinic with high blood pressure. The patient has complaints of intermittent blurred vision and headache.

Review of vital signs revealed the following blood pressures were documented on 12/31/14 in the ED:
-178/108 at 11:07am
-193/114 at 12:00pm
-194/120 at 1:00pm
-180/120 at 2:07pm
-176/112 at 2:09pm

Review of ED PA note dated 12/31/14 at 1:07pm revealed a decision to admit the patient was made and while awaiting transfer the patient's blood pressure increased to 190/120. Hydralazine was ordered from the pharmacy. The patient then began to "shiver". Ativan 1mg IV and Magnesium was brought to the ED for administration and the patient was transferred to the Labor and Delivery unit as planned.

Review of Physician Progress Note dated 12/31/14 at 3:02pm revealed the physician was called to evaluate a pre-eclamptic patient. The patient had been evaluated in the ED with multiple severe blood pressure ranges with no antihypertensive treatment. Upon involvement, the patient began to seize. Magnesium Sulfate 6mg. was brought from Labor & Delivery as there was no immediate access to Magnesium or anti-hypertensive medication for intravenous push by the ED providers. The patient's last recorded blood pressure was 194/120 at 1:00pm. Magnesium push started and BP is now 217/135.

Review of Medication Administration Record dated 12/31/14 revealed the following antihypertensive medications were administered as follows:
-Labetalol 20mg IV push at 2:15pm
-Labetalol 40mg IV push at 2:48p
-Labetalol 80mg IV push at 3:44pm
-Hydralazine 10mg IV push at 4:32pm and 4:58pm.

Review of the Nursing Progress Note dated 12/31/14 at 2:25pm revealed the patient arrived to the Labor and Delivery unit currently having a seizure.

Interview on 01/06/15 at 11:20am with Staff #1 confirmed these findings.

Based on document review and interview, the facility failed to initiate and implement proposed actions to standardize the process for care and transition of care for adult patients with special medical needs and/or adult surgical patients.

Findings:

Review of the Adult Medical Management Quality Assurance Committee meeting minutes dated 07/23/14 revealed an internal review of the care provided to Patient # 1 revealed the patient transition process (child to adult) was in need of improvement. When young adult patients present to the ED, a designee needs to be available who can navigate and direct their care and make decisions in terms of triage fairly quickly based on the needs of the patient and not necessarily their age. Need to identify who can " captain the ship " and make nuanced triage decisions based on medical needs. A senior Physician needs to drive the patient ' s care. It was determined that Staff #12 would convene a group to standardize the process, develop a care plan that is easily accessible which every subspecialist will regularly complete and use for immediate access when a patient presents to any area in the hospital, and that a " captain of the ship " for each of these patients is clearly identified and treated as such in handling the patients care. No evidence was found to indicate all of these actions were initiated and implemented.

Review of algorithm " Management of Critically Ill Adult Patients at Women and Children's Hospital " , version 2.0 dated 11/07/14 revealed a step by step procedure for caring for an adult (>21 years of age) patient who becomes unstable while at the facility, who will be responsible for caring for a patient should the patient remain unstable and are unable to be transferred and the phone number for the adult medicine provider on call.

Interview on 01/06/15 at 1:45 pm with Staff # 12, MD CMO, revealed this algorithm was given to department heads who were responsible for staff education. No evidence was provided to indicate staff were educated on this algorithm.

Interview on 01/06/14 at 11:20am with Staff #1 confirmed that all of the actions proposed in the Adult Medical Management Quality Assurance Committee were not initiated and/or implemented.