HospitalInspections.org

Based on medical record review, interviews and review of policy and procedures, Hospital # 1 failed to reassess Patient Identifier (PI) # 1, a Category 3 patient with a pain score of ten out of ten, every two hours as stated in the Triage Policy and Procedure. As a result, PI # 1 left Hospital # 1 without notifying staff of the decision to leave and without obtaining a medical screening examination to determine the existence of an emergency medical condition.

This affected PI # 1, one of ten sampled patients.

Findings Include:

Hospital # 1:
A review of the Emergency Department's (ED) medical record reveals PI # 1 arrived via a private vehicle at Hospital # 1's Emergency Department on 8/21/2011 at 1350 with a chief complaint of "HA" (Headache).

PI # 1's Vital Signs, documented on 8/21/2011 at 1:50 PM were: BP: 144/83, Pulse: 47, Respirations: 20, Temperature: 98.2. PI # 1's pain score was 10 of 10.

History/Assessment as documented on 8/21/2011 at 1350 on Hospital # 1's Emergency Department Medical Screening /Nursing Assessment (Patient Data Profile): "C/O (complains of) HA (headache) that started this AM. On left side of head. Took 2 Ibuprofen without relief a couple of hours ago.
+ (Positive) nausea. No emesis. + (Positive) mild light sensitivity. Speech clear. = Equal facial symmetry. PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) @ 3 mm (millimeters) bilaterally and brisk. NADN (No Apparent Distress Noted). Pt. (patient)
amb. (ambulates) with steady gait.
Category: III
Waiting due to no bed available." (Documented by Employee Identifier (EI) # 1.

ED Focus Notes 8/21/2011:
"1525: Pt. amb. outside. Gait steady." (Documented by EI # 2).

"1545: Family approached window stating pt. (patient) is vomiting - pt. asked to come inside - VS (vital signs) re-evaluated - remains neurologically intact, grips =, PERRLA @ 3 mm, no facial droop - ambulating with steady gait - pt. educated on wait/triage system-encouraged to wait inside in closed waiting room - pt. refused, ambulating outside." (Documented by EI # 3).

"1545: BP: 143/83, Pulse: 47, Respirations: 22, Temperature: 97.9 Pain score:10.

At 1912, "No Answer" and "LWBS (Left without being seen)" is documented on the Physician Order Sheet. There is no further documentation about PI # 1.

Interviews with Hospital # 1 Employees:

During an interview on 9/28/2011 at 11:07 AM, Employee Number (EI) # 1/ RN/ 7 AM- 3 PM Triage Nurse, stated she performed PI # 1's initial triage on 8/21/2011 at 1350. PI # 1 presented with a headache, was classified as a Category III, and reported his pain level was 10 of 10. According to EI # 1, the Category III classification is based on the need for medical evaluation, evaluation of vital signs, and services likely to be needed by the patient. The Triage Nurse (EI # 1) described PI # 1 as "very calm." EI # 1 asked PI # 1 to sit in the waiting room closest to the triage area to wait because there were no beds available in the ED.

After PI # 1's initial triage, EI # 1(Triage RN) said she was in a triage room with another patient when she heard yelling. EI # 1 opened the door of the triage room and reported that she saw PI # 1 on the floor in the waiting room. EI # 1 also said she was unsure if PI # 1 "screamed or yelled" that his head hurt. According to EI # 1, she observed the other triage RN and the ED Charge Nurse talking to PI # 1. EI # 1 reports the Charge Nurse told PI # 1 that he would be seen by the physician as soon as possible and PI # 1 returned to his chair. The RN (EI # 1) was asked if she placed all Category III patients in the small waiting room and she replied, "No."

During an interview on 9/28/2011 at 1:26 PM, Employee Number (EI) # 4/ RN Triage/ED Charge Nurse, said he worked triage from 7 AM to 3 PM on 8/21/2011. EI # 4 said he thought the patient (PI # 1) laid on the floor because his head was hurting. According to EI # 4, he explained to PI # 1 that no beds were available in the ED. EI # 4 asked the patient (PI # 1) to sit in a chair and
PI # 1 complied with the request. EI # 4 said PI # 1's speech was clear and his neurological status was okay.
EI # 4 said PI # 1 was "Obviously hurting and upset about having to wait." Because "He (PI # 1) was visibly upset about having to wait." EI # 4 asked the ED Day Shift Charge Nurse to talk with PI # 1. According to EI # 4, some ED patients lie on the floor.

EI # 4 stated it is ED policy to re-evaluate Category III patients every two hours. The staff called PI # 1's name for reassessment around 7 PM, but PI # 1 was not in the ED.

During an interview on 9/28/2011 at 2:45 PM, the RN/Triage Nurse /Employee Number (EI) # 2 stated her shift began at 3:00 PM on 8/21/2011, and she saw PI # 1 sitting in the small waiting area where Category II patients usually wait. EI # 2 stated PI # 1 then walked outside. When staff called PI # 1 for reassessment at 1912 on 8/21/2011, PI # 1 did not answer. EI # 2 documented that PI # 1 left without being seen (in PI # 1's medical record).

During an interview on 9/29/2011 at 10:30 AM, the RN/Triage Nurse /Employee Number (EI) # 3, who documented PI # 1's reassessment on 8/21/2011 at 1545, said PI # 1's family came to the window in the ED waiting room and reported that PI # 1 had vomited in the car. EI # 3 said she instructed PI # 1's family to ask PI # 1 to return to the waiting room for reassessment. During this reassessment at 1545, PI # 1's pain level remained a 10 and his vital signs were almost the same as they were at 1350. According to the RN (EI # 3), PI # 1's presentation, "Sounded like a migraine." When the surveyor asked how often a Category III patient (like PI # 1) should be reassessed, EI # 3 replied, "Every two hours." EI # 3 stated PI # 1 was not reassessed at 1745. PI # 1 did not answer when staff called his name at 1912 and it was documented that PI # 1 left without being seen. PI # 1 did not inform staff that he was leaving. According to EI # 3, many ED patients report their pain as a 10. The RN/ EI # 3 said, "Not to downplay his (PI # 1's) pain. He wasn't doing anything that concerned me...no special worries" about this patient.

During an interview on 9/29/2011 at 1:00 PM, the ED Charge Nurse 7 AM - 3 PM/Employee Number (EI) # 5, said she was called to the "first" waiting room on 8/21/2011 and saw a man (PI # 1) lying on the floor. A triage RN told PI # 1 he could not lie on the floor. PI # 1 returned to his chair and "calmed down." The Charge Nurse (EI # 5) reports she apologized to PI # 1 for the wait and explained it was a busy day in the ED (Emergency Department). According to EI # 5, there were three intubated patients in the ED on 8/21/2011. EI # 5 stated she did not hear anything else about PI # 1 on 8/21/2011.

EMS Report 8/21/2011 at 1836:
"A: AOS (arrived on scene) to find...male lying left lateral on hallway floor in front of bathroom..."

C: Unconscious

H: PHM (primary medical history) unknown at time. Family states no history. Present due to pt. being found unconscious.

A: Family states pt. was complaining of headaches throughout the day and was seen at...(name of Hospital # 1). Pt. left Hospital # 1 approximately 30 min. (minutes) prior to being found unconscious at residence by family. Pt. unconscious, breathing approximately 18-20 bpm (breaths per minute). Strong radial pulse. Pt. has some blood coming from mouth. Unable to find cause of bleeding due to pt's teeth being clinched.

Rx: Blood wiped away from pt's mouth. NPA (naso-pharngeal airway) inserted into right nostril...ventilations assisted with BVM (bag-mask ventilation) and 15 LPM (liters per minute) O2 (Oxygen)...mouth suctioned as needed. Teeth remained clenched throughout transport...BP 151/116...cardiac monitor = sinus tach (tachycardia) at 150 - 160...Aseptic 16 G (gauge) IV initiated in pt's left AC...Pt. then given 2 mg. (milligrams) Narcan...Left pupil = 3 - 4 mm, Right = 2 mm. Care during transport keyed in on keeping airway open, patent and clear as well as making sure pt. had adequate ventilation.

Tx: Pt. transported to Hospital # 2 per family request and care transferred to ED staff."

Hospital # 2:
A review of the ED Physician and ED Nursing Notes dated 8/21/2011 reveal PI # 1 arrived unconscious and posturing via EMS to Hospital # 2's ED at 1848. A code was called at 1850. PI # 1 required intubation and a ventriculostomy drain prior to admission to the Neurological Intensive Care Unit. According to the History of Present Illness, the "unwitnessed incident" occurred 12 to 24 hours ago.

A review of the History and Physical dated 8/21/2011, documents PI # 1 presented to the ED in respiratory arrest. "According to the patient's (PI # 1's) girlfriend, the patient began to experience a frontal lobe headache along with nausea and excessive vomiting that began at approximately 10:30 AM this morning. The patient(PI # 1) went to the Emergency Room at (Hospital # 1) to be evaluated. The patient (PI # 1) reportedly left before being seen by a physician due to the long wait. The patient's girlfriend reports a couple of hours later the patient's mother found the patient unresponsive, face down in a pool of blood..."

According to the Discharge Summary, PI #1 was unresponsive upon arrival via ambulance at Hospital # 2's Emergency Department on 8/21/2011 at 1848. PI # 1 was intubated. A CT (Computed Tomography) scan of the brain showed extensive acute subarachnoid hemorrhage, likely due to a ruptured intracranial aneurysm. PI # 1 expired at Hospital # 2 on 8/31/2011.


Triage Policy and Procedure (Hospital # 1), Revised 11/09:
"...III. General Information
A. The Triage Nurse assesses the patient's condition and prioritizes the need for treatment based on th Emergency Severity Index (ESI) Triage Acuity System. Patients will be categorized as follows:
...ESI Level 3: If the patient doesn't meet criteria for ESI Level 1 or 2 the triage nurse must determine the patient's resource needs based on the patient's chief complaint and presentation, subjective and objective assessment, past medical history, current medications, age and gender. An ESI Level 3 patient requires two or more resources..."