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Based on observation, interview, record review, and policy review, the hospital failed to provide complete, thorough, and timely assessments for 13 current Emergency Department (ED) patients (#14, #16, #17, #33, #34, #37, #38, #39, #40, #41, #43, #44, and #45) of 42 current patients, and one discharged ED patient (#10) of three discharged patients whose records were reviewed. (A-0395)

These failures resulted in the death of Patient #10 and placed all ED patients at risk for their health and safety.

These deficient practices resulted in the hospital's non-compliance with specific requirements found under 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 347.

The severity and cumulative effect of these practices had the likelihood to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 08/19/20, after the survey team informed the hospital of the IJ, the staff put interventions into place that ensured patient safety.

As of 08/20/20, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Effective immediately, vital signs would be obtained prior to the assessment of an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) level by the Triage Registered Nurse (RN).
- A technician would be assigned to each occupied sub-section of the waiting areas and they would maintain visual contact of patients.
- A RN would complete a focused reassessment, in addition to vital signs, on patients that had a waiting room time of greater than two hours, but not to exceed three hours.
- Electronic Health Records (EHRs) would include vital signs, pain level assessments, and patient rounding tasks. If there was a change in patient condition, it would be documented with a patient observation note and a triage nurse would be notified to assess for further intervention.
- A Triage RN or Advanced Practice Provider would initiate a focused assessment based on the patient's chief complaint within 30 minutes of arrival.
- Patients/family would be educated at triage on how assistance could be obtained or reassessment requested during their time in the waiting room.
- Effective immediately, education on the action plan would be provided to all RNs, advanced practice professionals, physicians, and technicians.

Based on observation, interview, record review, and policy review, the hospital failed to provide complete, thorough, and timely assessments for 13 Emergency Department (ED) patients (#14, #16, #17, #33, #34, #37, #38, #39, #40, #41, #43, #44, and #45) of 42 current patients whose records were reviewed and one discharged ED patient (#10) of three discharged patients whose records were reviewed.

These failures had the potential to place all ED patients at risk for their health and safety.

The lack of adequate assessment and reassessments of patients had the potential to affect all ED patients and placed them at risk for deterioration and possible death. The hospital census was 347. The ED had an average of 5783 patient visits per month.

Findings included:

1. Review of the hospital's document titled, "Patient Triage in the Emergency Trauma Center (ETC)," revised 11/05/18, showed the following directives for staff:
- An initial set of vital signs were to be obtained while the patient registered.
- When there were extended wait times, triage recheck technicians were to provide a consistent manner in which patients' vital signs were rechecked.
- Recheck technicians obtained vital signs and performed pain checks on patients (including temperature checks if appropriate) while in the waiting room every two hours, and should not exceed three hours.
- Recheck technicians were to report changes in vital signs, or worsening of condition to the primary triage Registered Nurse (RN), then document in the electronic health record (EHR) the contact made with the patient and the contact with the RN.
- If the primary triage RN was notified of any change in patient condition, a triage nurse would provide a focused reassessment and document it in the EHR.

Review of the hospital's document titled, "Assessment and Reassessment of Patients in the Emergency Trauma Center," revised 06/01/18, showed that all patients were to be assessed upon admission to the Emergency Trauma Center. In addition, all patients who had a change in condition should be reassessed and the reassessment documented in the EHR.

Review of the hospital's document titled, "Emergency Department Triage Orientation Packet," revised 05/08/18, showed the following directives for staff:
- Reassessment of vital signs for all patients in the waiting room were to be done every two hours.
- If there was a change or worsening in condition prior to two hours, a reassessment should be completed, documented, and the primary triage RN would be notified.
- An Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) of two, was assigned to high risk situations, and included patients in severe pain and distress.
- ESI level two patients were escorted to a room by a RN or Technician. Once in the room whoever transported them was responsible to place the patient on the monitor, assist with the gown and vital signs. They were to stay with the patient until the RN arrived in the room.
- A heart rate of greater than 120 or less than 50 was considered out of normal range.
- An oxygen saturation (amount of oxygen in the blood) should be above 92 percent.

2. During an interview on 09/10/20 at 8:45 AM, Staff PPP, Nurse Practitioner (NP) at the Urgent Care Clinic, stated the following:
- She saw Patient #10 at the clinic the morning of 08/07/20.
- Patient #10 looked slightly jaundiced (a medical condition typically related to issues with the liver organ, causing yellowing of the skin or whites of the eyes) and very unwell.
- She wanted Patient #10 to be admitted to the hospital and felt she would qualify for the Intensive Care Unit (ICU).
- She called the hospital, but was told that the ICU was on diversion (unable to accept patients because of capacity or capability of the unit or hospital) because there were no available beds, however the ED was not on diversion.
- She did call a report to the ED regarding Patient #10, and was told that the ED would watch for the patient to arrive.

Review of Patient #10's ED record showed the following:
- She presented to the ED on 08/07/20 at 4:36 PM with complaints of nausea, vomiting and a cough.
- Her vital signs were not taken until 5:12 PM (36 minutes after the patient arrived).
- Her pulse was elevated at 131 beats per minute (60 - 100 is normal) and her blood pressure was 149/61 (normal is 140 or less over 60 or greater).
- There was no documentation that the elevated blood pressure and pulse was reported to a nurse.
- At 6:34 PM, one hour and 58 minutes later, Staff NNN, RN, documented that Patient #10 got out of her wheelchair, laid on the floor, and began moaning and crying loudly. The husband reported (when the patient went to the bathroom), that there was blood in the stool (there was no documentation that the patient's vital signs were rechecked, or that the patient received a focused [to assess the part of the body specific to a person's complaint] assessment).
- At 6:45 PM, (11 minutes later) Patient #10 was found pulseless, attempts made to resuscitate were unsuccessful, and the patient died.

Review of recorded video, dated 08/07/20, provided by the hospital showed:
- At 4:33 PM, the patient arrived to the ED registration desk, by wheelchair, pushed by her spouse, and appeared to speak to staff sitting at the desk. At 4:37 PM, the spouse pushed the patient to the side of the ED waiting room area, where she remained sitting in the wheelchair.
- At 4:38 PM, the patient's spouse began to fan the patient intermittently (as if the patient was hot or sweaty) with paperwork that he held in his hand.
- At 4:43 PM, the spouse pushed the patient to the bathroom area. The patient required assistance by the spouse to get out of the wheelchair and the patient walked out of view. At 4:46 PM, the patient returned into view, got in the wheelchair, and appeared to pant (short, shallow breaths) as she was pushed back to the waiting room.
- At 5:07 PM, the patient's vital signs were taken by a staff member, and the staff member appeared to speak with the patient until 5:09 PM. The spouse fanned the patient.
- At 5:09 PM, the spouse continued to fan the patient, and at 5:10 PM, the spouse pushed the patient in the wheelchair back to the bathroom area, the patient got out of the wheelchair, and disappeared out of sight. At 5:15 PM, the patient reappeared, sat in the wheelchair, and the spouse again fanned the patient while they remained in the hall of the bathroom area. Staff were observed walking by the patient without providing assistance, and the patient left the bathroom area moaning. At 5:16 PM, the spouse pushed the patient back into the ED waiting room area, and began to fan the patient.
- At 5:25 PM, the spouse provided a blanket (indicating the patient was now cold) for the patient, and at 5:40 PM, the spouse began to rub on/massage (appeared to comfort) the patient.
- At 5:52 PM, the spouse pushed the patient back to the bathroom area, the spouse assisted the patient out of the wheelchair, and the patient disappeared out of sight. At 5:58 PM, the patient reappeared and returns to wheelchair, and the patient was pushed back to the waiting room.
- At 5:59 PM, the spouse left the patient and exited through the ED doors.
- At 6:06 PM, the patient unwrapped herself from the blanket, and at 6:11 PM, the patient got out of the wheelchair, and sat down next to the wheelchair (what she sat on is not visible). At 6:15 PM, the patient, walked to the bathroom area unassisted (spouse was still not in the area), disappeared, and at 6:18 PM, reappeared and walked back to the waiting room, while she braced herself on the wall as she walked.
- At 6:24 PM, the patient laid down on the waiting room floor, and at 6:25 PM, the spouse approached the ED registration desk, appeared to speak to staff, and returned to the patient. A second patient, waiting in the area in a wheelchair, got up out of his wheelchair and approached the patient and her spouse. The second patient leaned down to the patient (as if concerned about her) and appeared to converse with the spouse.
- At 6:27 PM, the second patient stopped a staff member, and appeared to speak to her, when a second staff member approached the second patient. The second patient appears to anxiously point to the patient on the floor, and to himself, and back to the patient on the floor. At 6:28 PM, a third staff member approached the patient on the floor, and along with the patient's spouse, assisted the patient back into the wheelchair. It took one minute and 24 seconds to get the patient from the floor into the wheelchair with maximum assistance. The staff member remained with the patient until 6:30 PM, and appeared to converse with the patient, then left the patient.
- At 6:34 PM, the spouse pushed the patient to the bathroom area and assisted the patient out of the wheelchair, while the patient moaned and cried out. The patient disappeared from sight. At 6:41 PM, there was an overhead speaker call for staff to assist in the bathroom. At 6:42 PM, a staff member was observed pushing the patient from the bathroom area to the right side (from video view) of the ED registration desk, while the spouse followed. The patient's head laid back without support, over the back of the wheel-chair, and the patient's eyes appeared closed. The patient, staff and spouse remained in view, but activity with the patient is unobservable.
- At 6:44 PM, the patient was urgently wheeled from the right to the left side of the ED waiting area (from video view) by staff, a second staff member hurriedly followed behind. The patient's head was laid back, unsupported above the wheelchair, and her eyes were closed. The patient and staff are no longer visible on the screen.

During an interview on 09/09/20 at 2:59 PM, Patient #10's spouse, reported the following:
- Staff never assessed his wife's chest or stomach with a stethoscope.
- Patient #10 did not have blood in the stool prior to their arrival in the ED.
- He reported to several staff members that his wife had blood in the toilet (while waiting) and that she needed help.
- Another patient in the waiting room was so concerned about his wife that the other patient went and asked staff to help her.
- When his wife laid in the floor, a nurse came and told her she could not lay on the floor, and both he and the staff member had to help his wife back into the wheelchair because she could not stand.
- He called for help while he and his wife were in the restroom because she could not stand up.

During an interview on 08/19/20 at 9:40 AM, Staff WW, ED Nurse Manager, stated that patients were to be reassessed every two to three hours while they were in the waiting room. A change in condition meant that the patient didn't feel the same way they did when they came into the ED.

During an interview on 08/20/20 at 11:50 AM, Staff MMM, RN (patient #10's triage nurse), stated the following:
- She was the primary triage RN on 08/07/20 when patient #10 presented to the ED.
- She was not aware of Patient #10 having abdominal pain.
- If patients had new complaints, or any type of change in condition, they should be reassessed.
- If she had been notified of Patient #10's elevated blood pressure and heart rate, she would have changed her ESI level from a three (lower risk) to a two (very ill and high risk).

During an interview on 08/20/20 at 12:10 AM, Staff NNN, RN, stated the following:
- She often performed primary and secondary triage in the ED.
- Her first encounter with Patient #10 was when she found her lying in the floor in the waiting room, moaning and crying in pain.
- She verified with the primary triage RN that Patient #10 presented to the ED with a chief complaint of abdominal pain (she confirmed during review of the medical record that abdominal pain was not one of the patient's chief complaints upon presentation).
- She denied knowing that the patient had blood in the stool, and stated that it wasn't until after the patient died, that she became aware of the patient's blood in the stool (after this statement, Staff NNN confirmed that she documented at 6:34 PM, in the medical record, that the patient had blood in the stool, indicating that she was aware of the blood in the stool 11 minutes prior to the patient being found pulseless).
- She failed to obtain repeat vital signs or perform more than a visual assessment on the patient at that time (when she documented that patient had blood in the stool), because she felt a visual assessment was adequate.

During an interview on 08/19/20 at 9:25 AM, Staff YY, RN, stated the following:
- The ED goal for initial vital signs was within 15 minutes of arrival.
- Technicians rounded and obtained repeat vital signs, ideally within two hours.
- A change in condition would constitute a new assessment, but was dependent on the issue.
- If a patient reported new blood loss. it would trigger a new assessment.

During an interview on 08/19/20 at 8:55 AM, Staff XX, RN, stated the following:
- Obtaining initial vital signs depended on the number of patients in the ED at the time.
- If a patient complained of a change in condition there should be a focused re-assessment.
- A change in condition called for a new set of vitals and assessment to determine if they should be "bumped" in line to either a secondary triage, or to be roomed immediately.

During an interview on 08/17/20 at 4:45 PM, Staff S, ED Technician, stated the following:
- Staff were supposed to obtain patient's vital signs every three hours while they were in the waiting room.
- If a patient had an ESI of two, they would need to have their vital signs obtained every two hours while in the waiting room.
- If vital signs were out of the normal range, technicians were to report that to the primary triage RN, document the vital signs, and the name of the nurse they were reported to.

Review of the hospital's document titled, "Root Cause Analysis (RCA) Action Plan," dated 08/11/20 showed the following:
- Patient #10 presented to her primary care physician's office on 08/07/2020 at 9:57 AM with a fever of 103 degrees, headache, nausea, vomiting, diarrhea and a prior urinary tract infection.
- The NP documented that she was jaundice and possibly dehydrated.
- The NP ordered blood work which revealed a critically high blood sugar (418 [normal is 80-130]), elevated liver enzymes (indication of poor liver function), and a white blood cell count of 22,000 (indicates severe infection, normal is 5,000 to 10,000).
- The NP contacted Mercy to have Patient #10 admitted to the hospital, but was told that the ICU had no available beds.
- The NP contacted the ED and gave a report to an unknown staff member on Patient #10.
- Patient #10 arrived to the ED by private vehicle with her husband on 08/07/20 at 4:36 PM.
- Patient #10's husband reported (to ED staff) that she had been to urgent care that morning.
- ED triage assigned Patient #10 an ESI of three and placed her in the waiting room.
- Vital signs were taken at 5:12 PM, Patient #10's heart rate and blood pressure were above normal limits.
- Patient #10's husband reported that she had some vaginal bleeding. The RN added the bleeding to Patient #10's complaint list.
- Vital signs were not rechecked because Patient #10 was pink, warm and dry on the initial assessment.
- Root causes identified included that there were no inpatient beds available, causing the ED to board patients, which resulted in longer wait times in the ED.

There was no root cause identified related to the hospital's failure to assess or reassess the patient or her vital signs, or to adequately monitor the patient for changes in condition.

Review of the hospital's document titled, "Mercy Safety Event Review/Approval Form," dated 08/08/20, showed the following:
- The ED was unsafe.
- Triage set up and the waiting room were dangerous.
- There was no way for staff to see patients because of the current layout.

3. Observation on 08/17/20 at 3:15 PM showed a waiting room that went around several corners and into three separate rooms, not visible from the nurse triage area, and there were no staff in those areas.

Review of Patient #14's ED records showed the following:
- She presented to the ED on 08/17/20 at 12:17 PM.
- She was not assigned an ESI level until 1:30 PM (one hour and thirteen minutes later), and was assigned an ESI level two (very ill and high risk).
- She remained in the waiting room until 3:38 PM (two hours and eight minutes after being given an ESI of two) with no reassessment or monitoring.

Review of Patient #16's ED record showed the following:
- She presented to the ED on 08/17/20 at 2:11 PM with shortness of breath.
- Her vital signs were obtained at 2:20 PM, and she had an elevated blood pressure of 141/85 (normal is 140 or less over 60 or greater), and there was no documentation that this was reported to a nurse.
- She was assigned an ESI level of three at 3:55 PM (one hour and 44 minutes after her presentation to the ED).
- As of 4:42 PM (two hours and 22 minutes after the original vital signs were taken), the patient's vital signs had not been repeated.

As per the ED triage orientation, vital signs for patients were to be repeated every two hours.

Review of Patient #17's ED record showed he presented to the ED on 08/17/20 at 3:26 PM with shortness of breath. At 3:55 PM, (29 minutes later) his vital signs were obtained and his respiratory rate was elevated at 32 breaths per minute (normal is 12-20 breaths per minute). There was no documentation that the elevated respiratory rate was reported to a nurse.

Observation on 08/19/20 at 9:08 AM, showed multiple staff searching for patient #33, who could not be located.

Review of Patient #33's ED record showed the following:
- He presented to the ED on 08/18/20 at 10:10 PM with dizziness and chills.
- Vital signs were obtained and his heart rate was 133 beats per minute (normal is 60-100 beats per minute). There was no documentation that the elevated heart rate was reported to a nurse.
- There was no additional documentation of an assessment or reassessment for 11 hours and four minutes, while the patient remained registered as an ED patient.

Review of Patient #34's ED record showed the following:
- She presented to the ED on 08/18/20 at 9:26 PM with a positive Covid-19 test and shortness of breath.
- Vital signs were obtained at 9:55 PM, and her blood pressure was 147/90 (normal is 140 or less over 60 or greater) There was no documentation that the elevated blood pressure was reported to a nurse.
- The patient was in the ED waiting room with no additional assessment or reassessments until 08/09/20 at 6:12 AM (eight hours and 16 minutes later).

Review of Patient #37's ED record showed the following:
- He presented to the ED on 08/19/20 at 8:55 AM with a chief complaint of shaking.
- At 9:08 AM his vital signs were obtained. His oxygen saturation was 91% (normal is 92-100%) and his blood pressure was unable to be obtained.
- He remained in the waiting room until 1:02 PM (four hours and seven minutes), with no repeat vital signs and no reassessment.

Review of Patient #38's ED record showed he presented to the ED on 08/18/20 at 9:32 AM with a rectal bleed. He remained in the waiting room until 1:42 PM (four hours and 10 minutes), with no repeat vital signs and no reassessment.

Review of Patient #39's ED record showed that she presented to the ED on 08/18/20 at 9:39 AM with a decreased appetite and nausea. She remained in the waiting room until 1:38 PM (three hours and 59 minutes) with no repeat vital signs and no reassessment.

Review of Patient #40's ED record showed the following:
- She presented to the ED on 08/18/20 at 9:41 AM with diarrhea and nausea.
- Vital signs were obtained at 10:08 AM, and her blood pressure was elevated at 147/66 (normal is 140 or less over 60 or greater). There was no documentation that the elevated blood pressure was reported to a nurse.
- The patient remained in the waiting room until 2:34 PM (four hours and 26 minutes) with no repeat vital signs or reassessment.

Review of Patient #41's ED record showed that she presented to the ED on 08/18/20 at 9:51 AM for Covid-19 symptoms following an exposure. After her initial vital signs, she did not have vital signs checked again until 2:58 PM, (four hours and 34 minutes).

Review of Patient #43's ED record showed that she presented to the ED on 08/18/20 at 10:06 AM with abdominal pain and vomiting. Her blood pressure was elevated at 142/90 (normal is 140 or less over 60 or greater). There was no documentation that her elevated blood pressure was reported to a nurse.

Review of Patient # 44's ED record showed that he presented to the ED on 08/18/20 at 10:13 AM with abdominal pain. Vital signs showed his blood pressure was elevated at 149/84. There was no documentation that his elevated blood pressure was reported to a nurse.

Review of Patient #45's ED record showed that she presented to the ED on 08/18/20 at 10:16 AM with chest pain. Vital signs were obtained and her blood pressure was elevated at 158/90. There was no documentation that her elevated blood pressure was reported to a nurse.

During an interview on 09/09/20 at 9:12 AM, Staff QQQ, RN, stated that patients in the ED should have their initial vital signs and assessment completed within 30 minutes of their arrival and then every two hours after that while in the waiting room.

During an interview on 08/19/20 at 9:25 AM, Staff YY, RN, stated that the ED goal for initial vital signs was within 15 minutes of arrival and that technicians rounded and obtained repeat vital signs, ideally within two hours.

During an interview on 08/19/20 at 3:30 PM, Staff B, Chief Nursing Officer (CNO), stated that the flow of the triage was very "botched up" due to construction, and that she did not feel that patients should sit in the ED waiting room with no assessment or supervision.

During an interview on 08/17/20 at 4:00 PM, Staff Q, RN, stated that patients didn't get the care they deserved and that there were many days when patients were in the ED for 24-30 hours.

During an interview on 08/17/20 at 4:20 PM, Staff R, ED Physician, stated the following:
- It was not uncommon for 12 to 14 hour patient wait times in the ED.
- He would expect a patient to have an assessment every two hours while in the ED waiting room.
- It was not uncommon for a patient to have only one set of vital signs and one assessment while they were in the waiting room, even if they had been there for several hours.

During an interview on 09/09/20 at 10:00 AM, Staff RRR, ED Physician, stated the following:
- He expected patients to have an initial assessment including vital signs within 20-30 minutes of their arrival to the ED.
- He would have expected vital signs to be rechecked every hour for critical patients in the waiting room and every two hours for non-critical patients.
- He often saw patients who had been in the waiting room for several hours with only one assessment and one set of vital signs.