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Based on a medical record review, a review of policies and procedures, a review of an online article, a review of an investigation report from the facility, and interviews conducted with staff, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the emergency departments capability, including ancillary services routinely provided to its patients for one patient (P#1) out of 20 sampled patients. Specifically, the facility failed to begin cardiac catheterization for P#1 in a timely manner.

Refer to A2406 as it relates to the facility's failure to provide an appropriate MSE for P#1.

Based on a medical record review, a review of policies and procedures, a review of an online article, a review of an investigation report from the facility, and interviews conducted with staff, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) and stabilization within the emergency departments capability, including ancillary services routinely provided to its patients for one patient (P#1) out of 20 sampled patients. Specifically, the facility failed to begin cardiac catheterization for P#1 in a timely manner.

Findings:

A medical record review revealed that P#1 was a 73-year-old male who presented to the emergency department (ED) via private vehicle on 7/22/21 at 11:52 p.m. with a chief complaint of chest pain. P#1 had a past medical history of hypertension (high blood pressure), Congestive Obstructive Pulmonary Disease (COPD) (progressive lung disease that causes airflow limitations), and asthma (a lung condition that causes airways to narrow, swell, and produce mucus that can make breathing difficult). In addition, P#1 was a current smoker. Continued review revealed that P#1 was on the following medications at home: Amlodipine 5 milligram (mg) (medication for high blood pressure), Atenolol 50 mg (medication to treat blood pressure), Advair (medication used to prevent symptoms of asthma or COPD) inhaler as needed, and Lisinopril (medication to treat high blood pressure and congestive heart failure).
P#1 had an electrocardiogram (EKG) (a recording of the electrical signal from the heart to check for different heart conditions) performed at 11:53 p.m. The medical record review failed to reveal documentation of the results of the EKG.
P#1 was triaged on 7/23/21 at 12:02 a.m. P#1 stated he became diaphoretic (sweating heavily) at home and had a sudden onset of chest tightness. P#1 described the pain as eight out of 10 when the episode first occurred eight hours prior. On arrival, P#1 described his pain as a three out of 10. P #1 denied shortness of breath, nausea, vomiting, palpitation (feeling of heart fluttering or racing), or syncope (a temporary loss of consciousness associated with a drop in blood pressure). P#1's initial blood pressure was 138/79 (normal range 120/80) with 100 percent oxygen saturation.
At 12:06 a.m., an order for "STEMI Documentation Times" (STEMI: ST-Elevation Myocardial Infarction) (type of heart attack) and "STEMI Transfer Documentation" was initiated.
A continued review of the medical record showed an order was initiated at 2:23 a.m. for a main cardiac panel (blood work performed in laboratory to evaluate heart functioning) and cardiac monitoring. In addition, continuous pulse oximetry was ordered and was to be started immediately, as well as an order to initiate chest pain guidelines.
A second EKG was performed on P#1 at 2:23 a.m. P#1's EKG was to be given to the ED physician STAT for review. The 'ED Note" revealed that the EKG showed "T wave inversions in leads I and avL and st elevation lead v2" (abnormal findings related to heart complication). A continued medical record review revealed that the ED physician made notation that there was no documentation of an old EKG for P#1 to indicate if the bundle branch block (abnormal heart condition) was new or old.

P#1 was seen by a physician at 2:27 a.m. On physical examination, P #1 had normal lung and heart sounds. There were no signs of distress reported. P#1 was alert and oriented.
At 2:28 a.m., P #1 had a chest X-ray completed. In addition, the ED provider ordered vital signs with pulse oximetry every 15 minutes.
A Troponin (a blood test that measures signs of heart muscle damage) level of 21 (normal level: less than 0.030) was reported at 3:27 a.m. At 6:14 a.m., a second Troponin level was ordered, resulting in over 80.
At 6:17 a.m., Aspirin 324 mg was ordered once orally STAT (urgent) for P#1. In addition, Heparin Sodium 5,000 units was ordered intravenously (IV) to be given once, STAT.
Further review of 'ED Note' revealed that the ED provider had spoken to the on-call cardiologist and was awaiting a call back as to when P#1 would go to the Catheterization Laboratory (examination or imaging of the heart to visualize the arteries and the heart chambers and treat any abnormalities).
At 6:22 a.m., the decision was made to admit P #1 to the Cardiac Care Unit with the following clinical impressions: Acute Non-ST Elevation Myocardial Infarction (NSTEMI), Chest Pain, Left Bundle Branch Block, and Acute Renal Failure.
P#1 was transferred to the Catheterization Laboratory at 7:58 a.m. P#1 was admitted to the Cardiac Unit.
Continued review of the 'ED Note' revealed that the ED provider documented 30 minutes of critical care time for serial bed exams, treatment of life-threatening cardiac arrhythmia, interpretation of laboratory data, and discussion with family, consultant, and admission team.

A review of an online article from American College of Cardiology titled "LBB in Suspected Patients with MI: An Evolving Paradigm", dated 2/28/17, revealed that patients with a suspected myocardial infarction (MI) (heart attack) in the setting of a left bundle branch block (LBBB) presented a unique diagnostic and therapeutic challenge to the clinician. LBBB was more often a pre-existing marker of underlying structural heart disease. Patients with LBBB had an increased risk for cardiovascular mortality, coronary artery disease, heart failure, and sudden cardiac death. The diagnosis of MI in the setting of LBBB was especially challenging by ECG. Because left ventricular activation was delayed in LBBB and the initial septal activation was from right to left (opposite of the normal situation), septal Q waves indicative of an MI were absent. Additionally, secondary ST-T wave abnormalities that occurred in LBBB obscured the recognition of injury currents in ischemia (restricted blood flow) and infarction (obstruction of blood flow). Overall, studies demonstrated that less than half of all patients with suspected MI and LBBB ultimately would be diagnosed with an MI. Moreover, a significant proportion of those patients with MI would not have an occluded culprit artery at catheterization and thus were classified more appropriately as having a non-ST-segment elevation MI (NSTEMI), unstable angina (UA), or non-acute coronary syndrome (ACS) presentation. This had important implications for the treatment of patients with presumed new LBBB who did not have immediate access to coronary angiography.

A review of the facility's policy titled "EMTALA, "policy # 10440009, effective 3/2020, revealed that the purpose was to ensure that the facility fully complied with the Emergency Medical Treatment and Active Labor Act (EMTALA). Therefore, the facility must provide to any individual, who came to the ED, an appropriate MSE within the capability of the hospital's ED, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition (EMC) existed. Screening was to be conducted to the extent necessary, by physicians and/or other Qualified Medical Person or Personnel (QMP) to determine whether an EMC existed. Continued review of the policy revealed that if an EMC was determined to exist, the facility must provide necessary stabilizing treatment. Additionally, the policy stated that the MSE and other emergency services need not to be provided in a location specifically identified as the dedicated ED (DED). The facility may use areas to deliver emergency services that were also for other inpatient or outpatient services. MSEs or necessary treatment could require ancillary services available only in areas or facilities of the hospital outside of the DED.

Definitions:

Capabilities: Physical space, equipment, supplies, and services, including ancillary services available at the facility. The facility was responsible for treating the individual within the capabilities of the facility as a whole, not necessarily in terms of the particular department at which the individual presented.

An interview was conducted with Triage Nurse, Registered Nurse (RN) GG on 5/4/22 at 10:25 a.m. in the facility conference room. RN GG explained that the ED had a protocol for any patient who presented to the ED with a complaint of chest pain. RN GG stated chest pain was a priority. As soon as the patient registered, an EKG was performed. ED nurses did not need a provider's order for the EKG. RN GG explained that ED nurses had a 10-minute window to have the EKG performed. The EKG reading was given to the ED physician STAT. Triage and further necessary assessment began after. RN GG said after the ED physician read the EKG, he/she would proceed with the necessary steps based on the results of the EKG.

An interview was conducted with ED Director, RN EE, on 5/4/22 at 10:39 a.m. in the facility conference room. RN EE explained the process in the ED for a patient with a complaint of chest pain. RN EE stated that when a patient complained of chest pain, there were questions the triage nurse asked the patient, such as medical history and other risk factors. Then, ED staff performed an EKG immediately on the patient, and the reading was directly taken to the ED physician. RN EE stated the next step was determining if the EKG had abnormalities. RN EE said if the physician decided to admit a patient with chest pain to the facility, it would take more time because the cardiac unit was specialized. It had thirty-six beds in the unit compared to the regular medical-surgical units with more beds. However, RN EE said once staff got the admission order, they started treatment immediately and did not wait for a bed to be available to get treatment underway. Director EE stated location in the facility had nothing to do with treatment or patient care. RN EE said the patient could remain in the ED for a bed, but there was never a delay in treatment because the ED was equipped to provide the same level of care for the patients.

A phone interview was conducted with medical doctor (MD) DD on 5/4/22 at 11:30 a.m. MD DD stated he did not have any contact with patient #1. MD DD said the only service he provided for P#1 was the EKG reading. MD DD reviewed P #1's medical record and said P#1 did not meet the criteria for acute heart attack on the first EKG taken in the ED. MD DD said he read the EKG after the ED physician about nine hours later.

A review of the facility's 'Investigation Report, Complaint Event #21-179' revealed that a complaint involving P#1 was filed to the facility on 7/26/21 at 3:34 p.m. Continued review revealed complainant stated she brought her husband to the Emergency Center (EC) on 7/23/21 and was in the waiting area for five hours and 45 minutes while her husband was having a heart attack. The complainant continued to explain that her husband was triaged and while in the back with the nurse, she was told her husband would need to go to the Catheterization Laboratory but was informed that no one would be there until 8:00 a.m. The complainant said a physician told her that her husband had a heart attack, but another person told her he did not. The complainant stated she would go to another facility but was advised by the staff that she should not leave with her husband.

Based on a medical record review, a review of policies and procedures, a review of a published medical journal, a review of an investigation report from the facility, and interviews conducted with staff, it was determined the allegation be substantiated. The facility failed to begin cardiac catheterization for P#1 in a timely manner when a second EKG was performed on 7/23/21 at 2:23 a.m. and P#1 was not transferred to the Catheterization Laboratory until 7:58 a.m..