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Tag No.: A0395
19907
Based on a review of clinical records, interviews with hospital personnel and review of hospital policies, the hospital failed to ensure that four patients (Patient #215, 217, 218, and 225) were accurately triaged, assessed and/or monitored in accordance with hospital policy. The findings include the following:
a. Patient #215 presented to the Emergency Department on 10/21/10 at 9:41 PM by ambulance. Review of the ambulance run record reflected that the patient had undergone cataract surgery the day before and subsequent to starting a new eye drop medication, developed a body rash and felt that his/her tongue was swelling. In the ambulance, the patient's blood pressure (B/P) was 250/110, heart rate 110, respirations 18, and had an oxygen saturation of 100% on 4 liters/min of oxygen. Upon arrival to the ED, Patient #215's blood pressure at 9:45 PM was 206/108, heart rate 80, and respirations were 16. Review of the triage record and interview with RN #109 on 4/19/11 at 12:50 PM failed to reflect evidence that a past medical history was obtained other than the recent cataract removal, current medications, reassessment of abnormal vital signs and pain assessment. RN #109 stated that she did not approach the patient to complete a physical assessment during triage as EMS personnel provided information as documented in the ED record. Based on this information the patient was triaged as a level 4 (stable, minor problem according to ESI Standards per hospital policy).
Review of hospital policies for ED triage and documentation directed that the triage nurse should assess the patient, in part, to include a past medical history, history of present illness, allergies and pain level. The triage RN should acknowledge vital signs outside the accepted parameters and consider upgrading the triage level based on vital sign abnormalities.
Patient #215 was transported by EMS personnel via stretcher to a room following triage with hand off to RN #110. Although the patient's B/P was dangerously elevated upon triage at 9:45 PM, RN #110 failed to assess the patient's B/P until 10:41 PM (56 minutes later). At this time the patient's B/P was 179/87. According to the clinical record at 10:47 PM, the patient was very anxious and complained of chest pain. RN #110 failed to perform a comprehensive assessment of the chest pain and failed to notify a medical practitioner of the patient's new onset of chest pain. A B/P of 165/92 was obtained at 11:00 PM. This was the last documented B/P in the record prior to the patient leaving the ED at 2:00 AM. During interview on 4/18/11, RN#110 stated that she could not recall why the patient was not assessed for pain according to hospital policy and/or why she failed to notify the medical practitioner of the patient's new onset of chest pain.
Review of hospital policy directing documentation in the ED identified that all patient handoffs required a focused assessment by the assigned nurse with appropriate reassessment at least every two hours.
Review of the record indicated that at 10:55 PM, RN #110 received a verbal order to complete an EKG. The EKG was completed and given to PA#2 for review at 12:14 AM on 10/22/10. The computerized EKG interpretation reflected "borderline EKG" with a sinus arrhythmia and possible left atrial enlargement. This was a computerized interpretation of the results and not that of PA#2. During interview on 4/19/11, PA#2 stated that he could not recall the patient and that while the EKG pattern in the clinical record did not alarm him, he would have expected the nurse to notify him that the patient had a new complaint of chest pain. PA#2 had reviewed the EKG, however, failed to evaluate the patient clinically.
The patient notified RN #110 at 1:59 AM on 10/22/10 that he/she was leaving the ED. Patient #215 left the hospital at 2:00 AM and was admitted to another hospital with an elevated troponin level, ischemia, and hypertension.
During the period of 9:45 PM (on 10/21/10) through 2:00 AM, the hospital failed to ensure that the patient was evaluated by a medical practitioner. RN #110 failed to intervene by requesting the patient be evaluated and/or inquire as to what the plan of care was for this patient.
b. Patient #217 presented to the ED on 4/15/11 at 2:01 PM with complaints of chest pain. The patient rated the chest pain as a 6 on a scale of 0-10 (10 being the worst possible pain). The pain assessment failed to include characteristics of the chest pain and/or interventions to address the pain.
The patient was triaged as an ESI Level-3. Review of the triage system protocol reflected that a patient presenting with active chest pain should be designated as a Level-2. The hospital failed to ensure the patient was triaged in accordance with protocol.
Review of Patient #217's record identified that an EKG was completed and given to PA #3 at 2:20 PM. The computerized EKG interpretation reflected a "borderline EKG" with left atrial enlargement, normal sinus rhythm with short PR, and when compared to the 11/24/10 EKG, nonspecific T wave abnormality was evident in the lateral leads. PA#3 failed to document his interpretation of the EKG results and conduct an assessment of the patient.
The patient was sent back out to the waiting room at 2:20 PM. Review of the triage protocol directed that at the completion of triage, the triage RN would arrange for the patient to go directly to a treatment room/hall bed. In the event there are no rooms available, the patient will be placed in the reception area for no longer than 15 minutes while the triage RN collaborates with the Clinical leader to have the patient go to a treatment area. The hospital failed to ensure the patient was transferred back to a bed in accordance with policy. The patient was not monitored by nursing and/or evaluated by medical professional while waiting to be seen from 2:21 PM through 8:45 PM when the patient was noted to be absent from the waiting room with a discharge designation as "left without being seen".
c. Patient #218 presented to the ED with a chief complaint of "rapid heart rate" on 4/15/11 at 2:42 PM. The triage assessment at 3:05 PM indicated the patient's pulse rate was 87 beats per minute. The patient was triaged as a Level-3 and sent back out to the waiting room. The hospital failed to ensure that a comprehensive cardiac assessment was completed (e.g. heart sounds, apical rate vs. radial pulse). At 7:29 PM, the patient notified staff that he/she was leaving the ED with a discharge designation of "left without being seen". The hospital failed to ensure that the patient was monitored and/or evaluated from 3:06 PM through 7:29 PM. The hospital failed to ensure the patient was moved back to a bed in accordance with policy.
d. Patient #225 presented to the hospital on 1/24/11 at 8:09 AM with a chief complaint of lower leg pain for one week. Review of the record failed to identify that a comprehensive pain assessment was completed upon triage (e.g. number scale, pain quality, duration, and interventions that addressed the pain).
In addition, physician's orders dated 1/24/11 at 8:58 AM directed administration of Dilaudid 2 mg IM and Valium 5 mg PO now. Documentation reflected that the medication was administered at 9:15 AM. The hospital failed to document the efficacy of the administered medications.