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Based on interviews and document review, the hospital failed to implement a sustainable and/or measurable corrective action plan, for one (Pt #30) of thirty-one patients sampled, that would address the identification of patients seeking medical care in the Emergency Department (ED).

See tag A0286.

Based on interviews and document review, the hospital failed to implement a sustainable and/or measurable corrective action plan, for one (Pt #30) of thirty-one patients sampled, that would address the identification of patients seeking medical care in the Emergency Department (ED).

Findings include:

The surveyor was conducting document review on 12/14/2021 and identified a poor outcome for a patient, Patient #30 in the ED, that occurred on the night of 11/15/2021 into 11/16/2021.

Document review of Pt #30 indicated that on 11/15/2021 at 6:55 P.M., Pt #30 arrived via EMS, was registered into the ED hospital system, and triaged out to the ED waiting room.

Medical record review of Pt #30 indicated that hospital ED staff attempted to call out for Pt #30 for a total of three times, firstly at 7:59 P.M., secondly at 8:15 P.M., and lastly at 8:40 P.M. After the third attempt, record review indicated that Pt #30 was documented as Leave Without Being Seen (LWBS).

The Event Investigation Summary of Pt #30, undated, indicated that at 11/15/2021 at 11:50 P.M., another patient in the waiting room notified triage of a patient of concern. The triage nurse went to Pt #30 and determined Pt #30 to be unresponsive and pulseless.

A physician emergency medicine note of Pt #30, dated 11/16/2021, indicated that Pt #30 was found to be pulseless and unresponsive with vomitus in his mask and jacket. Pt #30 was placed on a stretcher and cardiopulmonary resuscitation (CPR) was initiated, first by compressions by staff and then a Lucas device was applied (Lucas is a mechanical chest compression device that delivers chest compressions to cardiac arrest patients). After 30 minutes of CPR along with finding a MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) once the patient was fully registered in the system indicating DNR/DNI (Do Not Resuscitate/Do Not Intubate), time of death was called at 11/16/21 at 12:21 A.M.

An attending physician addendum to the emergency medicine note of Pt #30, dated 11/16/2021, indicated that Pt #30 presented in cardiac arrest, unknown downtime suspect Pt #30 may have been hyperkalemic (high potassium) and periarrest (the moments just prior to and after cardiac arrest) for hours since being dropped off by EMS prior to Pt #30 being found. The addedum note further details Pt #30 was unresponsive once taken back to an ED bed, no pulses, apneic (cessation of breathing), and copious vomit. Followed ACLS (Advanced Cardiac Life Support) guidelines for about 30 minutes. The addendum note further indicated that towards the end of resuscitation, the team was able to access the system and see that Pt #30 was DNR/DNI and that shortly after that, the team ceased resuscitative efforts and notified family.

The surveyor interviewed the Senior Director of Patient Safety on 12/14/2021 at 2:30 P.M. An action plan had not been complete as of 12/14/2021.

The surveyor interviewed the Chief Medical Officer (CMO) on 12/20/2021 at 10:30 A.M. The CMO could not provide evidence that the hospital completed an action plan that would prevent a similar event suffered by Patient #30.

On 12/21/2021, the surveyor requested the hospital's internal investigation of Pt #30. No documents were brought to the surveyor regarding an investigation nor a corrective action plan in relation to Pt #30's ED event, that occurred on 11/15/2021 into 11/16/2021.

Based on interviews and document review, the hospital failed to meet the emergency needs for one of thirty-one patients, Pt #30. Pt #30 presented to the hospital ED seeking care, and after failing to be triaged appropriately, was discovered approximately five hours later in the ED waiting room by hospital staff, only after another patient in the ED waiting room notified triage staff of a very ill patient, Pt #30. Pt #30 was discovered by hospital staff unresponsive in the ED waiting room, and despite resuscitative efforts, Pt #30 passed.

See tag 1112.

Based on interviews and document review, the hospital failed to meet the emergency needs for one of the thirty-one patients, Pt #30. Pt #30 presented to the hospital ED seeking care, and after failing to be triaged appropriately, was discovered approximately five hours later in the ED waiting room by hospital staff, only after another patient in the ED waiting room notified triage staff of a very ill patient, Pt #30. Pt #30 was discovered by hospital staff unresponsive in the ED waiting room, and despite resuscitative efforts, Pt #30 passed.

Findings include:

The surveyor was conducting document review on 12/14/2021 and identified a poor outcome for a patient, Patient #30 in the ED, that occurred on the night of 11/15/2021 into 11/16/2021.

Document review of Pt #30 indicated that on 11/15/2021 at 6:55 P.M., Pt #30 arrived via EMS, was registered into the ED hospital system, and triaged out to the ED waiting room.

Medical record review of Pt #30 indicated that hospital ED staff attempted to call out for Pt #30 for a total of three times, firstly at 7:59 P.M., secondly at 8:15 P.M., and lastly at 8:40 P.M. After the third attempt, record review indicated that Pt #30 was documented as Leave Without Being Seen (LWBS).

The Event Investigation Summary of Pt #30, undated, indicated that at 11/15/2021 at 11:50 P.M., another patient in the waiting room notified triage of a patient of concern. The triage nurse went to Pt #30 and determined Pt #30 to be unresponsive and pulseless.

A physician emergency medicine note of Pt #30, dated 11/16/2021, indicated that Pt #30 was found to be pulseless and unresponsive with vomitus in his mask and jacket. Pt #30 was placed on a stretcher and cardiopulmonary resuscitation (CPR) was initiated, first by compressions by staff and then a Lucas device was applied (Lucas is a mechanical chest compression device that delivers chest compressions to cardiac arrest patients). After 30 minutes of CPR along with finding a MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) once the patient was fully registered in the system indicating DNR/DNI (Do Not Resuscitate/Do Not Intubate), time of death was called at 11/16/21 at 12:21 A.M.

An attending physician addendum to the emergency medicine note of Pt #30, dated 11/16/2021, indicated that Pt #30 presented in cardiac arrest, unknown downtime suspect Pt #30 may have been hyperkalemic (high potassium) and periarrest (the moments just prior to and after cardiac arrest) for hours since being dropped off by EMS prior to Pt #30 being found. The addedum note further details Pt #30 was unresponsive once taken back to an ED bed, no pulses, apneic (cessation of breathing), and copious vomit. Followed ACLS (Advanced Cardiac Life Support) guidelines for about 30 minutes. The addendum note further indicated that towards the end of resuscitation, the team was able to access the system and see that Pt #30 was DNR/DNI and that shortly after that, the team ceased resuscitative efforts and notified family.