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The current policy for communication of critical values was not followed by the nursing staff. The nurses did not document or act once they were notified of critical values. The current policy for reassessment was not followed and no documentation of the patient's condition was recorded in the patient's chart while in the waiting.


Based on the review of records and interviews, the facility failed to ensure patient #1 was provided the required; documentation, reassessments and communication of critical values by Registered Nurses (RNs) to providers. The following was not found on the record;


a) Date and Time of the RN communicating a critical value to the provider
b) Reassessment of the patient's condition after receiving a critical value


Findings included;
Patient #1's chart was reviewed on 6/3/2021. The document indicates that patient #1 arrived to the Emergency Department (ED) at this facility on 5/24/2021 at 2:50 pm and the patient expired on 5/24/2021 at 10:08 pm.
Reviewed of the nursing triage and provider notes, upon the medical screening of patient #1, indicate that;
On 5/24/2021 at 2:50 pm, the patient was triaged for abdominal pain and swelling. Patient #1 was given an emergency severity index (ESI) of 3 (urgent) by the triage nurse. The Medical Screening provider documented that the chief complaint was "abdominal tightness and swelling and sob (shortness of breath) x2 weeks". The patient told the provider that he had been recently been admitted for a plural effusion and had a chest tube history. The provider documented that the patient had a history of atrial fibrillation, Congested Heart Failure, Coronary artery disease, hypertension, hyperlipidemia, and pacemaker.
The review of symptoms was unremarkable other than the abdominal pain reported.
V/S demonstrated that the patient was hypotensive with a 96/69. Pulse of 100, Temp of 98.1. Pulse ox; 98%.

On 5/24/2021 at 3:00 pm, the provider, based on the patient's presentation and history ordered; an EKG, Blood work that included a set of cardiac panels which denote cardiac issues if elevated.
The EKG was completed at 3:03 pm and signed after reviewed by a provider at 3:05 pm. Results: "ventricular-paced rhythm with occasional sinus complexes".

On 5/24/2021 at 4:47 pm, the patient remained in the waiting room.

On 5/24/2021 at 8:10 pm, the patient remained in the waiting room.

On 5/24/2021 at 9:05 pm, the patient was taken from the lobby to room 30 after the patient's internal defibrillator fired while the patient waited in the ED lobby, as documented in the ED nursing notes, entered as a late entry on 5/25/21 at 7:20 am by nursing staff.

On 5/24/2021 9:24 pm the records show that the patient was pulseless, and a code blue was called due to cardiac arrest.

On 5/24/2021 at 10:08 pm. The patient was pronounced dead by the provider team after several attempts to revive the patient.

The Chemistries cumulative summary report for patient #1 on 5/24/2021 indicates that the patients' preliminary diagnostic blood work was completed at 3:02 pm.
This document includes an interpretative guidance for the cardiac markers including Cardiac Troponin;
"<0.033; Troponin appears normal or minor myocardial damage or other cause
>0.033; Consistent with myocardial Infarction
>0.290; Critical value
Cardiac Troponin-I (cTN-I) levels may be elevated in conditions known to result in Myocardial injury, such as angina, unstable angina, congested heart failure, myocarditis, cardiac surgery, or invasive testing and non-cardiac related causes such as pulmonary embolism , renal failure and sepsis"

The Chemistries cumulative summary report for patient #1 on 5/24/2021 from the patient's medical record indicates that the patients' preliminary diagnostic blood work had one critical value. The record states that patient #1 had a Troponin-I results of 0.797, which was labeled as a critical result for this cardiac marker. The lab technician documented that the results were notified and "read-back successfully" to specific Registered ED Nurse on 5/24/2021 at 4:47 pm. This record also shows that the second Troponin-I test which was completed at 8:10 pm and was documented by the lab staff as "read-back successfully" notification to a different ED RN at 9:00 pm was not relayed to a provider.

The ED nursing record does not demonstrate that this interaction was documented by the nursing staff.
The ED nursing record does not indicate that the nurse documented relaying this information to a provider.
The ED nursing record does not indicate that a RN reassessed the patient after diagnostic results were obtained.

The interview with administration and Quality department validated this finding on 5/24/2021. The administrators stated that the failure to communicate and relay the critical values occurred. It was explained that the nursing staff involved was questioned regarding this failure and it was not clear to whom the staff member communicated the results. The lack of documentation and reassessment by the nursing staff was also confirmed during this interview. The administrative took immediate action to improve reassessment and the provider team introduced guidelines to improve the management of patients after medical screening in the waiting area pending treatment area placement.

The Policy review;
Policy Title: Communication of Critical Results of Tests and Diagnostic Procedures - PROCEDURE
Date Issued: 03/07, Date(s) Reviewed: 08/08, 07/10, 07/11, 11/11, 12/13, 03/14, 1/18
Section: Patient Care, Number: H-143-P

This policy states;
Purpose: To outline the organization's responsibility to facilitate timely and reliable communication of critical results of tests and diagnostic procedures. Critical results of tests and diagnostic procedures that can immediately impact the health of the patient shall be communicated quickly to the ordering or on call physician (or other Licensed Independent Practitioner) so action can be taken.

Procedure: "When diagnostic test results (laboratory or radiology) have been identifies as critical, the result should be reported immediately to the physician or the patient's nurse, who will notify the ordering physician or licensed independent practitioner, or the covering physician. Notifications of all critical results are to occur within one hour of result availability."
Exceptions: 1. In the Emergency Department the nurse will document the date and time critical result received and reported to physician. The physicians' name that the critical result reported to is also to be documented"


Policy title: Title: CHRISTUS Health Clinical Guideline; Vital Signs Reassessment in the Emergency Department per ESI Level
Number: 5.061 Created: 02/2021

OBJECTIVE: To provide guidance related to the frequency of vital sign monitoring in the emergency
department.

POLICY STATEMENT:
A. Vital signs assessment serves as an early warning of a change in patient condition. While there
are no published standards regarding the frequency of vital sign monitoring in the emergency
department, ESI triage level can provide a guideline for vital sign reassessment.
B. The Emergency Severity Index (ESI) is a 5-level triage algorithm that categorizes emergency
department patients by evaluating both patient acuity and resource needs.
1. If the patient does not meet a high acuity level (levels 1 or 2) the triage nurse then
evaluates the expected resource needs to determine a triage level of 3, 4 or 5.
2. Acuity is determined by the stability of vital functions and the potential threat to life,
limb or organ.
3. Resource needs are defined as the number of resources a patient is expected to
consume in order for a disposition decision (discharge, admission, or transfer) to be
determined.

NOTE: This guideline reflects evidence-based practices derived from contemporary literature review.
Individual patient assessment and other clinical situations may influence specific courses of action.

PROCESS OR PROCEDURES:
A. ESI Level 1
1. Reassess vital signs every 5 to 15 minutes X 1 hour as needed based on clinical
presentation THEN
2. Every hour for the next 4 hours, then every 2 hours if clinically stable
B. ESI level 2:
1. No less frequently than every hour X 4 hours, THEN
2. Every 2 hours if clinically stable
C. ESI level 3:
1. Patients with normal vital signs should be reassessed at the discretion of the nurse BUT
2. No less frequently than every 4 hours
3. Patients with abnormal vital signs should be reassessed no less frequently than every 2
hours X 4 hours, then every 4 hours if clinically stable
D. ESI level 4:
1. Vital signs should be reassessed per acuity and clinical assessment BUT
2. No less frequently than every 4 hours
E. ESI level 5:
1. Vital sign assessment should be current within 30 minutes of discharge

Based on the review of records and interviews, the facility failed to provide an appropriate medical screening exam and treatment as required to stabilize the presenting medical condition of patient #1. The medical team failed to review and communicate a critical value result while the patient waited in the lobby of the ED. There is no documentation of reassessment while the patient waited in the lobby of the ED.

Findings:
Patient #1's chart was reviewed on 6/3/2021. The document indicates that patient #1 arrived to the Emergency Department (ED) at this facility on 5/24/2021 at 2:50 pm and the patient expired on 5/24/2021 at 10:08 pm.


Review of the nursing triage and provider notes indicate that;
On 5/24/2021 at 2:50 pm, the patient was triaged for abdominal pain and swelling. Patient #1 was given an emergency severity index (ESI) of 3 (urgent) by the triage nurse. The Medical Screening provider documented that the chief complaint was "abdominal tightness and swelling and sob (shortness of breath) x2 weeks". The patient told the provider that he had been recently been admitted for a plural effusion and had a chest tube history. The provider documented that the patient had a history of atrial fibrillation, Congested Heart Failure, Coronary artery disease, hypertension, hyperlipidemia, and pacemaker.
The review of symptoms was unremarkable other than the abdominal pain reported.
V/S demonstrated that the patient was hypotensive with a 96/69. Pulse of 100, Temp of 98.1. Pulse ox; 98%.


On 5/24/2021 at 3:00 pm, the provider, based on the patient's presentation and history ordered; an EKG, Blood work that included a set of cardiac panels which denote cardiac issues if elevated.


On 5/24/2021 at 3:03 pm, the EKG was completed and reviewed by a provider at 3:05 pm. Results: "ventricular-paced rhythm with occasional sinus complexes".


On 5/24/2021 at 4:47 pm, the lab staff documented in the medical records that they communicated with a RN to relay a critical value. No documentation found in the record by the nursing staff. The patient remained in the waiting room. No Vital signs nor assessment in the medical record.


On 5/24/2021 at 8:10 pm, The lab staff documented that a blood sample for troponin had been completed. No documentation that this procedure took place. No documentation of reassessment nor vital signs. The patient remained in the waiting room as no documentation of his location was found in the medical record.


On 5/24/2021 at 9:05 pm, the patient was taken from the lobby to room 30 after the patient's internal defibrillator fired while the patient waited in the ED lobby, as documented in the ED nursing notes, entered as a late entry on 5/25/21 at 7:20 am by nursing staff.


On 5/24/2021 9:24 pm the records show that the patient was pulseless, and a code blue was called due to cardiac arrest. Clinical team performing multiple rounds of ACLS on patient #1.



On 5/24/2021 at 10:08 pm. The patient was pronounced dead by the provider team after several attempts to resuscitate the patient.