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Based on document review, medical record review and interview, the facility failed to ensure compliance with the Condition of Participation of Emergency Services as evidenced by inadequate monitoring of an ED patient and a delay in provider notification when neurological assessment changes were noted. This finding places all patients at risk for harm.

Findings include:

-- Hospital staff failed to monitor a patient (Patient #1) who presented to the emergency department with a chief complaint of chest pain. See Tag A1104.

-- Nursing staff did not timely notify a provider when a patient (Patient #2) had changes in their neurological status. See Tag A1112.

Based on medical record review, document review and interview, in 1 of 21 (Patient #1) medical records reviewed, the hospital failed to monitor a patient who presented to the emergency department with a chief complaint of chest pain. The facility lacked a policy and procedure identifying staff who are responsible to monitor and reassess patients that have arrived via emergency medical services prior to room assignment and medical screening exam. This lack of a medical screening exam and reassessment could result in a poor patient outcomes.

Findings include:

-- Review of Patient #1's medical record revealed, a 63-year-old, presented to the emergency department via by emergency medical services on 10/25/2023 at 12:05 pm, after experiencing an episode of stabbing chest pain of 8 out of 10 (0 = no pain - 10 = severe pain), shortness of breath, diaphoresis, and dizziness. He/she/they believed this episode was related to anxiety. Patient #1 had a past medical history of aortic stenosis status post aortic valve replacement in 2019. During transport, the patient received Aspirin 324 milligrams and refused intravenous access.

At 12:27 pm, Patient #1 was triaged by nursing as an Emergency Severity Index level 2 (on scale of level 1- resuscitation - level 5 - non urgent). Patient #1 reported during triage that the chest pain had subsided to a level 2 out of 10 and did not radiate. An electrocardiogram was ordered and showed sinus bradycardia. Initial vital signs were blood pressure 106/67, pulse 46, respirations 16, oxygen saturation on room air 98%, and oral temperature of 96.8 Fahrenheit.

Following triage, the patient remained on the emergency medical services stretcher with emergency medical services staff in the hallway of the emergency department, until a room became available. Vital signs were reassessed by a care attendant at 2:53 pm, blood pressure 108/71, pulse 54, respirations 18, oxygen saturation 100% on room air, and oral temperature of 97.5 Fahrenheit. Pain level was zero.

Patient #1 was moved into a room in the emergency department at 3:04 pm (3 hours after arrival) and placed on the telemetry monitor at 3:09 pm. A provider was assigned at 3:25 pm.

There was no documentation in the medical record that the patient remained on the emergency medical services cardiac monitor or was reassessed by nursing staff prior to room assignment.

Physician orders were entered at 4:35 pm (4.5 hours after arrival), intravenous access was initiated at 5:17 pm. The patient had multiple laboratory studies performed along with a chest x-ray. Lab work included serial troponin, complete blood count, magnesium, D-dimer, and basic metabolic panel. The serial troponins, chest x-ray, and all other laboratory studies resulted in normal findings. The patient was placed in observation status and transferred to the Upstate Community Campus via emergency medical services.

On 10/26/23 at 10:40 am, Patient #1 was discharged home with instructions to follow up with his/her/their primary care physician.

-- Review of the facility's policy and procedure titled, "Arrival and Triage of Emergency Department Patients and Triage Training Process for Staff," revised 10/2022, indicated the triage nurse is responsible for all triaged patients, until they are assigned a room/nurse.

The policy and procedure does not address patients, on emergency medical services stretchers, awaiting a room.

-- Per interview of Staff A, Charge Nurse on 11/14/2023 at 9:35 am, patients are placed in rooms according to their acuity. There is a nurse assigned to emergency medical services triage. Once the patients are triaged, the nurse discusses the patient with Staff A to determine placement. Emergency medical services staff stays with the patient until a bed is available. The goal is to offload emergency medical services patients within 1 hour. There are 11 hall beds in the unit and if the patient is stable enough and a bed is available, they will be placed there. If they don't meet the criteria, they should stay on the emergency medical services stretcher and monitor until a room is available. Rarely have patients had to stay on an emergency medical services stretcher for 2 or more hours. It is expected that emergency medical services staff will monitor the patient and alert staff to any changes in condition. There is no documentation in the medical record that emergency medical services are monitoring the patient.

-- Per interview of Staff B, Registered Nurse on 11/14/2023 at 9:40 am, when emergency medical services arrives, the initial intake starts with the triage process to evaluate the patient's acuity level, vital signs, height, weight, and reason for visit. Some patients can be placed in the waiting room if they are stable. If they are not stable and there are no rooms available, the patient would stay on the emergency medical services stretcher in view of the nurse. Emergency medical services continues to monitor them and should let the nurse know if there are any changes in the patient's condition.

-- Per interview of Staff C, Nurse Manager on 11/14/2023 at 1:10 pm, he/she/they keeps track of the emergency medical services offload time frames. When there is 80+ patients in the emergency department the offload times increase. The emergency medical services triage nurse, charge nurse, and emergency medical services staff primarily monitor the patient. The triage nurse assesses the patient to determine their triage level, does vital signs and electrocardiogram when necessary. It is rare that a physician will start orders on a patient before the patient is placed in a room unless the patient is more unstable and requires the provider to see them sooner. The emergency department is stretched thin with the high acuity of patients that present.

-- Per interview of Staff D, Registered Nurse on 11/14/2023 at 3:10 pm, when a patient presents via emergency medical services, he/she/they receives report from emergency medical services and triages the patient. He/she/they keeps an eye on the patient until a bed is assigned. Staff D is not clear who is in charge of monitoring patients on the emergency medical services stretcher. The physicians wait to place orders until the patient is roomed. Staff D also assists with traumas and cardiac arrests and is not always able to visualize the patients waiting on the emergency medical services stretchers.

-- Per interview of Staff E, Emergency Department Director, on 11/27/2023 at 9:00 am, emergency medical services triage nurse takes report from emergency medical services, does the patient's vital signs and patient assessment. The triage nurse would notify the charge nurse of a patients' Emergency Severity Index level and ask where the patient should be placed. There are many patients that present with chest pain. If those patients are stable and have a normal electrocardiogram, they will be a priority but do not necessarily require a room immediately. The triage nurse and charge nurse are responsible for the patients on the emergency medical services stretchers. Emergency medical services is not responsible for the patients once they arrive in the emergency department. It has been a practice in the emergency department not to start care on a patient prior to rooming. Once roomed the patient would be seen by the resident.

The triage nurse will also assist with other emergent patients (e.g., trauma, stroke, or cardiac arrest) and will not always be able to see the patients on emergency medical services stretchers. Starting orders is difficult until the patient is placed in a room. The patients become the hospitals responsibility once they cross the threshold. The goal is to start care and orders as soon as possible to get the emergency medical services personnel back on the street.

-- Per interview of Staff F, Registered Nurse, on 11/27/2023 at 9:15 am, when a patient presents via emergency medical services, he/she/they will triage them as quickly as possible. Staff F would notify the charge nurse if a patient looked bad and needed a room immediately. Emergency medical services notifies staff if a patient looks like they need immediate attention. There is no nurse assigned to monitor when the patients are on the emergency medical services stretcher. Orders are not initiated until the patient is in a room or assigned a hallway stretcher. Staff F indicated there is a risk to patients when they have to wait to be roomed. Also there is no documentation in the medical record on their condition. If a trauma patient presents to the emergency department Staff F would leave the triage area to assist.

-- Per interview of Staff G, Physician, on 11/27/2023 at 9:35 am, patients are assigned rooms based on illness presentation. Staff G always looks at the Emergency Severity Index level of the patient and will see the higher acuity patients first. Patients that need providers assigned show up on the registration board in red. Once assigned to a provider the patient name on the registration board changes to pink. (The registration log is used to track patients' statuses and ensure all patients are seen by a provider timely and according to their ESI level.) Staff G can't perform a medical screening exam on a stretcher, but providers will walk around the emergency department including the emergency medical services bay to observe patient status. Staff G cannot write orders until a patient is roomed because there will not be a nurse assigned to those patients. When patients are on an emergency medical services stretcher, they are emergency medical services responsibility.

-- Per interview of Staff H, Physician, on 11/27/203 at 10:00 am, medical screening exam cannot be delayed. The hospital is responsible for the patients as soon as they come into the emergency department. Staff H indicated providers should complete an medical screening exam on the emergency medical services stretcher and have an nurse monitor patients waiting in the emergency medical services hallway. The systemic problem is the number of boarders in the emergency department which is constantly being addressed.

-- Per interview of Staff I, Emergency Department Medical Director, on 11/27/2023 at 1:40 pm, emergency medical services is not responsible to watch the patients once they arrive to the emergency department. Emergency medical services patients should be treated as the waiting room patients who arrive by car. An emergency medical services stretcher is not the appropriate place to perform a medical screening exam. Staff I indicated that having a second nurse assigned to assist with the emergency medical services patient reassessment and performing vital signs would be useful.

-- Per interview of Staff J, Division Chief of Emergency Services,on 11/27/2023 at 2:35 pm, when patients come to the emergency department via emergency medical services, they are no longer emergency medical services responsibility. There is no nurse assigned to these patients to complete the orders before a patient is roomed. It is not appropriate for patients to remain on an emergency medical services stretchers for extended periods of time. Staff J wants to offload patients quickly to get emergency medical services back out in the community.

-- During interview of Staff K, Director of Risk Management, on 11/27/2023 at 3:00 pm, he/she/they acknowledged the above findings.

Based on document review, medical record review and interview, in 1 (Patient #2) of 10 medical records, staff assessed and documented changes in the patient's neurological status. Staff failed to timely report these changes to a provider. This lack of timely provider notification could lead to untoward patient outcomes.

Findings include:

-- Review of the facility's policy and procedure titled "Care of the Stroke Patient (ischemic or hemorrhagic)," revised 11/2022, indicated patients presenting to the Comprehensive Stroke Center at University Hospital State University of New York Health Science Center "with actual or potential stroke will receive timely recognition and treatment based on the most current evidence-based practice guidelines."

-- Review of the facility's policy and procedure titled "Nursing Assessment and Documentation," revised 10/2023, indicated "documentation of nursing care shall be pertinent, concise and shall reflect the patient's status and response to interventions. Nursing care documentation should be recorded promptly at the time of observation or completion of any tasks to ensure that accurate and timely information is reflected in the medical record. The needs of the patient (including interpreter needs) shall be initially assessed upon admission/presentation for services and reassessed when there is a change in the patient's general status or after any diagnostic, operative, or invasive procedure. Assessment will be documented in the patient's medical record."

-- Review of Patient #2's medical record revealed he arrived to the Emergency Department (a designated Comprehensive Stroke Center) on 5/26/2023 at 1:21 am with stroke symptoms. Chief complaints were left facial droop, left upper extremity weakness, and aphasia (trouble with speaking, writing, and understanding speech) after falling from a chair at home at approximately 11:00 pm on 5/25/2023. Past medical history included diabetes mellitus and deep vein thrombosis which was being treated with Eliquis (medication used to treat and prevent blood clots as well as strokes). A Stroke Code (a multidisciplinary clinical team experienced and dedicated to the management of patients with stroke) was activated prior to Patient #2's arrival to the emergency department on 5/26/2023. Computerized tomography angiogram of head and neck was done and revealed: 1. Region of hypoattenuation in the right frontal lobe which could represent age-indeterminate infarct. No acute intracranial hematoma. 2. Major intracranial arteries and arteries of the neck are patent. 3. Patent main arteries of the circle of Willis. Addendum by attending: Additional old infarcts are present in the left cerebellar hemisphere, occipital poles bilaterally as well as right posterior parietal lobe.

At 1:30 am - Emergency Department provider documented left facial droop, left upper extremity weakness, and aphasia. National Institutes of Health stroke scale total score 3 (National Institutes of Health stroke scale is a standardized tool that measures and records the level of impairment caused by a stroke. Higher the number equals greater severity of stroke symptoms). He is on Eliquis. After computerized tomography angiogram of head and neck, patient does not appear to have any intracranial bleed at this time. Of note, patient was not a candidate for thrombolysis because of Eliquis use at this time. Impression: Acute cerebral vascular accident.

At 1:43 am - Registered Nurse documented neurological assessment; right lower extremity decreased sensation and left upper extremity weakness.

At 1:46 am - Registered Nurse documented patient complained of left upper extremity weakness, mild left facial droop which has since resolved, expressive aphasia, intermittent right lower extremity loss of sensation.

At 3:31 am - Neurology resident examined Patient #2 with family member present. Documented right upper extremity had mild pronation with no drift, muscle strength of 5 out of 5 throughout, and expressive aphasia improved significantly with patient's family member agreeing speech was very close to baseline. National Institutes of Health stroke scale total score 2. Patient #2 was admitted to stroke (neurology) inpatient service. Patient #2 remained in the Emergency Department as a "boarder patient" pending bed availability in the inpatient unit.

At 3:44 am - Neurology resident documented a history and physical (in part) that on initial encounter, patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. National Institutes of Health stroke scale = 3. Diagnosis: Acute ischemic stroke; small vessel, Left Middle Cerebral artery. Etiology: most likely small vessel disease. Plan: admit, start on home medication, monitor blood pressures until sure cerebrovasculature is patent, full stroke work up including Magnetic Resonance Imaging. Swallow evaluation to be performed, if patient passes will start on regular diet, physical therapy and occupational therapy, and speech evaluations. Order for neurological checks every 4 hours.

At 4:00 am - (oncoming) Registered Nurse documented neurological assessment; expressive aphasia with strong grip in both hands.

At 4:01 am - Registered Nurse documented stroke dysphagia screen completed, patient "passed" the water trial instructions.

At 4:41 am - Magnetic Resonance Imaging of brain findings were acute embolic type infarct in the left frontal lobe and the left parietal lobe, severe ischemic microvascular white matter disease, asymmetrical to the right. Addendum by attending: Acute cortical-based infarcts are present in the posterior left insular cortex and left postcentral gyrus while acute infarct is also seen in the left anterior centrum semiovale. All infarcts are in the left Left Middle Cerebral territory.

At 8:00 am - (different oncoming) Registered Nurse documented neurological assessment; expressive aphasia and right upper extremity drift. (changes in neurological assessment)

At 8:33 am - Registered Nurse documented vital signs.

At 8:45 am - Registered Nurse noted physical therapy/occupational therapy were at Patient #2's bedside.

At 8:53 am - Registered Nurse administered Patient #2's prescribed medications.

At 9:10 am - Registered Nurse documented neurological assessment; right facial droop, expressive aphasia, drift and weakness in right upper extremity, and decreased sensation in right lower extremity. (changes in neurological assessment)

At 9:10 am - occupational therapy documented (in part) response to evaluation (after assessment), the session was tolerated well. Demonstrates significant deficits in speech/language, coordination, balance, etc. On initial encounter patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. General observation: patient met semi-reclined on stretcher surface, awake and alert in no acute distress. Plan: restorative occupational therapy recommended for 7 times/week for 6 weeks. Physical therapy documented (in part) response to evaluation (after assessment), the session was tolerated fair as evidenced by patient reported fatigue. On initial encounter patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. General observation: supine in bed with head of bed slightly elevated in no apparent distress. Strength: left and right upper extremity and lower extremity at least 3/5 grossly, decreased grip strength to right, decreased dorsiflexion strength on right. Pain unchanged, patient's heels offloaded at end of session. Plan: restorative physical therapy is recommended for 7 times/week for 5 weeks. (changes in neurological assessment)

At 10:56 am - Speech Language Pathology saw the patient for clinical swallow evaluation. History of present illness (in part) initial National Institutes of Health stroke scale score = 3 for facial palsy, sensory loss, and aphasia (although National Institutes of Health stroke scale score documented 7 minutes later also 3 but for facial palsy, sensory loss, and partial neglect (can the patient pay attention to stimuli on both sides at the same time). Overnight Registered Nurse swallow screen documented as "pass" and regular diet ordered. Registered Nurse reports attempting oral meds with sips and a few bites of breakfast tray earlier this morning and had immediate anterior loss and sputtering cough with liquids, significant difficulty manipulating solids so further oral held until Speech Language Pathology exam. Seen and examined at bedside. Awake and alert. Breathing comfortably on room air. Functionally nonverbal due to aphasia and apraxia (the loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them), able to indicate yes/no with approximate verbalization and head nod/shake. Response to evaluation (after assessment), the session was tolerated well. Plan: restorative Speech Language Pathology services recommended 4-5 times a week.

At 11:09 am - Case Management screen and assessment; met with patient at the bedside; patient had difficulty communicating due to aphasia. Tried calling family member twice to discuss baseline assessment but no answer. Chart reviewed to complete screen. Physical therapy and occupational therapy recommendation is for short term rehabilitation, this was discussed with the patient.

At 11:13 am - Registered Nurse paged physician due to Patient #2's family identifying a change in patient's ability to express speech. Requesting physician to come evaluate patient.

At 11:30 am - Registered Nurse paged physician to evaluate Patient #2.

At 11:45 am - Registered Nurse called stroke team to evaluate Patient #2.

At 11:57 am - Physician was at bedside and called an acute stroke page at 11:58 am.

At 12:00 pm - Registered Nurse documented neurological assessment; expressive aphasia, drift in right upper extremity and decreased sensation in right lower extremity.

At 12:30 am - Neurology resident examined and documented patient was admitted to stroke service for left Middle Cerebral Artery embolic strokes. National Institutes of Health stroke scale total score increased to 10 (from previously documented score of 2). Family observed worsening aphasia and right sided hemiparesis (weakness). Magnetic Resonance Imaging brain without contrast. Impression: Acute embolic type infarct in the left frontal lobe and left parietal lobe. Severe ischemic microvascular white matter disease, asymmetrical to the right.

At 4:00 pm - Registered Nurse documented neurological assessment; expressive aphasia, right upper extremity with drift, and right lower extremity with decreased sensation.

At 5:51 pm - Vascular Neurology Attending documented diagnosis: Recurrent left Middle Cerebral Artery (most common artery involved in acute stroke) territory strokes. Etiology: Embolic, suspected cardio-embolic due to atrial fibrillation (a type of arrhythmia, or abnormal heartbeat). Daily updates: Patient's exam worsened in the Emergency Department with worsening aphasia and right sided weakness, repeat Magnetic Resonance Imaging of brain showed new stroke in the left Middle Cerebral Artery territory. Echocardiogram did not show a clot. Patient was in atrial fibrillation during echocardiogram (confirmed with Cardiology attending).

At 6:38 pm - Patient #2 was physically admitted inpatient and transferred to neuroscience critical care unit.

-- During interview of Staff K, Director of Risk Management on 11/27/2023 at 3:00 pm (Exit Conference), he/she/they acknowledged the above findings.