HospitalInspections.org

Based on review of medical record and interview, the facility failed to ensure the safety of a patient undergoing treatment in the Emergency Department (ED). Specifically, ED staff did not ensure a medical handoff was done when a patient was transported from the Emergency Department to another clinical area for further evaluation. This finding was noted in one (1) of one (1) medical record reviewed (Patient #1).

Findings:

Review of the medical record for Patient #1 identified: on 12/12/16 at 2:46 PM, this patient presented to the ED with facial pain, blurred vision and hypertension. The patient had a past medical history for asthma, temporal arteritis and hypertension. The patient's vital signs recorded at the 2:51 PM Triage were Blood Pressure (BP) 192/94 (normal range less than 120/80), Temperature 98.1F (average body temperature 98.6), Pulse 72 (normal range 60-100), Respirations 16 (normal 12-16), Pain Scale was 4 (four) on a scale of 1-10.

On 12/13/16 at 12:01 PM, the nurse notes, "Patient taken to SBH Opth, Clinic via wheelchair. No signs of distress noted."

On 12/13/16 at 12:50 PM, Ophthalmology consultation was documented which diagnosed retinal vein occlusion. Recommendations (were) to continue with the same treatment plan for steroids with follow up in retina clinic the next day.

On 12/13/16 at 1:58 PM, while the patient was at the Ophthalmology clinic, Physician (Resident) documented the History and Physical (H&P), noting that the patient was admitted, and patient was seen in the eye clinic and was waiting for transfer back to the ED. The H&P noted the patient was admitted under the impression of possible temporal arteritis versus central retinal vein occlusion versus hypertensive emergency. The plan for treatment of hypertensive emergency included: restart home medication, titrate BP down at timely fashion with extra doses of clonidine, and monitor BP.

On 12/13/16 at 3:56 PM, the ED Physician (Resident) noted, "At 3:55 PM, patient was called in the ED without an answer and was not found and has not returned from the eye clinic. Called the eye clinic and patient was not found in the eye clinic. Called patient on number provided and left voicemail to return. Patient has apparently absconded from the ED. The patient was well aware that neither the diagnosis nor treatment was complete and has apparently walked out nevertheless. Attending notified. "

There was no documentation that when the patient was escorted to the eye clinic, there was handoff between the ED Staff and Ophthalmology Staff regarding the need for the patient to be returned to the ED for further treatment.

On 12/13/16 at 4:31 PM, approximately four hours and thirty minutes after the patient's departure from the ED, the patient returned to ED via EMS, from a location outside the hospital, with an elevated blood pressure of 218/126 at triage.


During interview on 2/2/17 at 12:50 PM, Staff B, ED Director stated, "There was no written policy at that time to delineate the handoff process when ED patients go from the ED to the dental and eye clinic(s)." It was reported that patients are sent from the ED to the ophthalmology clinic for complete focused ophthalmologic evaluation on an emergency basis because the specialized equipment there is not mobile.

Based on medical record review and interview, there was no documented evidence that the facility formulated and implemented an integrated plan of emergency care for a patient who presented with elevated blood pressure and was not responsive to emergency department medical interventions. This finding was evident in one (1) of one (1) medical record reviewed (Patient #1).

Findings:
Review of the medical record for Patient #1 identified: 65-year-old female who presented to the Emergency Department (ED) on 12/12/16 at 2:46 PM with complaint of left facial pain for four (4) days. The patient had a past medical history for asthma, temporal arteritis and hypertension. The patient's vital signs recorded at the 2:51 PM Triage were Blood Pressure (BP) 192/94 (normal range less than 120/80), Temperature 98.1F (average body temperature 98.6), Pulse 72 (normal range 60-100), Respirations 16 (normal 12-16), Pain Scale was 4 on a scale of 1 to 10.

The medical physical assessment on 12/12/16 at 4:29 PM, noted; the patient with a past medical history of asthma, hypertension temporal arteritis, complained of left facial pain with pins and needles associated with left sided blurring of vision, denied weakness on the right side. The Impression: Temporal arteritis and the medical plan documented, "Headache, facial pain, blurry vision- CT Scan brain, Steroids, Pain meds and likely need eye consult.
There was no documented plan by the physician to address the patient's abnormal blood pressure.

The CT Scan brain was completed at approximately 12/12/16 at 5:35 PM and on 12/13/16, approximately at 12:50 PM, Ophthalmology Consult was documented. The CT brain revealed no acute intracranial pathology and no hemorrhage.


On 12/12/16 at 8:00 PM, Nurses Note documented, "received patient resting on stretcher. Alert and Oriented. Reports continued left face and ear pain. No shortness of breath. Continue to monitor."
There is no documented evidence of monitoring, including BP.

On 12/12/16 at 11:18 PM, approximately eight hours after initial presentation to the ED, the patient was noted to have blood pressure of 210/123 and at 11:30 PM the nurse noted, "Patient with elevated blood pressure, MD aware and will continue to monitor."
There was no documented evidence that the physician was aware and implemented a medical plan to address the increasing blood pressure.

On 12/13/16 at 2:40 AM, Nurses Note documented, "medicated for continued elevated blood pressure. Patient resting on stretcher, in no apparent distress. Continue to monitor."
There is no documented evidence of monitoring, including blood pressure.

On 12/13/16 at 4:08 AM, Nurses Transfer Note documented, "B/P 210/123."

On 12/13/16 at 5:00 AM, Nurses Note documented, "vital signs, Blood Pressure 211/120, Heart Rate 74, Respiration 18, Temperature 97.4 F, medicated for continued elevated BP. Patient is cleared for admission, however patient is refusing admission until she speaks with consulting Ophthalmology. Medical Doctor made aware."

On 2/13/16 at 7:36 AM, the patient's blood pressure was 226/121.

On 2/13/16 at 9:30 AM, blood pressure was 220/142 with a repeat blood pressure at 9:31 AM of 190/142.

There was no documentation that the medical care plan was revised to address the patient's increased blood pressure

On 12/13/16 at 12:01 PM, the nurse notes, "Patient taken to SBH Opth, Clinic via wheelchair. No signs of distress noted."


On 12/13/16 at 1:58 PM, Physician (Resident) documented the History and Physical (H&P), noting that the patient was admitted. The documented noted that the patient was seen in the eye clinic while waiting for transfer back to the ED. At the time of the assessment, the patient complained of severe headache, and pain on the right temple with no improvement of vision after steroids, patient states this episode has been worse than others have. The patient was admitted under the impression of possible temporal arteritis versus central retinal vein occlusion versus hypertensive emergency. The plan included treatment for hypertensive emergency: restart home medication, titrate BP down at timely fashion with extra doses of clonidine, will monitor BP.

On 12/13/16 approximately 3:55 PM, it was determined that the patient had apparently walked out of the clinic.
At approximately 4:31 PM on 2/13/16, the patient returned to ED via EMS, from a location outside the hospital, with increasing head pain and blood pressure of 218/126 at triage. The patient was placed on monitor and Neurology Consult called. Patient was successfully intubated, sedated and her condition was monitored and reassessed. The repeat CT scan showed acute intraventricular hemorrhage.

There was no documented evidence of the monitoring and reassessment of the patient's blood pressure provided during the hours the patient was initially in the ED on 12/12/16 from 2:46 PM, to 12/13/16 approximately 2:00 PM.

These findings were confirmed with Staff A, Medical Director of Emergency Services on 2/1/17 at 1:30 PM. Staff A stated, "The physician could have had better follow-up to the initial spike in blood pressure. The documentation was terrible and there was nothing documented by the physician before allowing the patient to leave for the clinic."