HospitalInspections.org

Based on medical record (MR) review and interview, the hospital did not investigate an unexpected patient death in the Emergency Department (ED). This lack of review could lead to other similar adverse events.

Findings include:

-- Review of Patient #1's MR (Urgent Care documentation) revealed, on 2/20/17 at 7:27 pm, Patient #1 presented to Urgent Care for treatment, staff reported vomiting, diarrhea and seizure activity. After the patient vomited in the waiting area there was a strong smell of feces. Patient appeared to be in pain (note was entered by the receptionist). Documentation by the Physician's Assistant at 7:56 pm stated "to ED (emergency department) for further evaluation."

Patient #1 presented to the ED with chief complaint of vomiting brown emesis and not being himself. Past medical history included encephalitis, seizures, profound mental retardation, gastroesophageal reflux disease (GERD), erosive esophagitis with gastrointestinal (GI) bleed. His triage assessment did not include a blood pressure (B/P). Patient #1 was placed in a treatment room (2 hours later) and no vital signs were done. When evaluated by an ED physician, Patient #1 was pale, in obvious discomfort, with fecal smelling coffee-ground emesis on the pillow. He was tachycardic (heart rate greater than 100 beats per minute [normal heart rate 60-100]) with regular rhythm. Abdomen was distended and tender. Within a short time staff were called into his room, Patient #1 profusely vomited dark foul-smelling emesis all over room and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed for 10 - 12 minutes without success. Patient #1 died.

-- During interview of Staff A (Physician) on 12/7/17 at 10:00 am, he/she indicated this case should have been reviewed and there were a numbers of events that should have been investigated (e.g., lack of B/P and reassessments and the length of the resuscitation).

-- During interview of Staff B (Nurse Manager, ED) on 12/6/17 at 2:15 pm, he/she does review patient deaths in the ED. If he/she is not scheduled to work, some of the deaths from the days he/she was not present may not be reviewed.

Based on document review, medical record (MR) review and interview, emergency department (ED) staff did not ensure that a description of resuscitative measures undertaken for 1 of 1 patients (Patient #1) who required cardiopulmonary resuscitation (CPR) was adequately documented in the MR. This could lead to inability to determine the sequence of events in a code.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Code Blue/ Code Blue Broselow Team," last reviewed 7/2016 indicated that a Code Blue (medical emergency) is called with the purpose to summon help in a life threatening situation. Nursing staff should document all interventions on the Code Blue sheet (resuscitation record) with time and results. The recorder and attending provider should sign the completed sheet and the sheet placed in the patient's MR.

-- Review of Patient #1's MR indicated on 2/20/17 at 10:20 pm, he became unresponsive and CPR was initiated. Provider documentation at 10:39 pm referred to CPR (Code Blue) flow sheet for further information, however, there was no Code Blue sheet contained in the MR.

-- During interview of Staff B (Nurse Manager, ED) on 12/6/17 at 2:15 pm, he/she acknowledged that a Code Blue sheet should be completed for all CPR performed in the ED.

Based on medical record (MR) review and interview, the hospital did not adequately integrate urgent care services with other hospital services. This could lead to a delay in care.

Findings include:

-- Review of Patient #1's MR from Urgent Care revealed, on 2/20/17 at 7:27 pm, Patient #1 presented to Urgent Care for treatment, staff reported vomiting, diarrhea and seizure activity. After the patient vomited in the waiting area there was a strong smell of feces. Patient appeared to be in pain (note was entered by the receptionist). Documentation by the Physician's Assistant at 7:56 pm stated "to ED (emergency department) for further evaluation." There was no documentation that a physical exam was performed or that the ED was contacted regarding the patient's condition and referral for evaluation.

-- During interview of Staff C, (Triage Nurse) on 12/6/17 at 3:30 pm, he/she indicated when patients are sent from Urgent Care, the provider will call and talk to the ED provider. The triage nursing staff are not always made aware of those cases. Staff C indicated ED staff are not able to access the MRs from urgent care.

-- During interview of Staff D, (ED Physician) on 12/6/17 at 4:45 pm, he/she could not recall being notified that Patient #1 was coming from Urgent Care. He/she would normally be called from a provider at Urgent Care when a patient is being sent to the hospital for evaluation.

Based on medical record (MR) review, document review and interview, in 1 of 14 MRs, nursing staff failed to obtain Patient #1's blood pressure (B/P) during triage and in 5 of 14 MRs nursing staff failed to reassess Patients (#1 - #5) while in the waiting room or treatment room. This may lead to untoward patient outcomes.

Findings include:

-- Review of Patient #1's MR (Urgent Care documentation) revealed, on 2/20/17 at 7:27 pm, Patient #1 presented to Urgent Care for treatment, staff reported vomiting, diarrhea and seizure activity. After the patient vomited in the waiting area there was a strong smell of feces. Patient appeared to be in pain (note was entered by the receptionist). Documentation by the Physician's Assistant at 7:56 pm stated "to ED for further evaluation."

-- Review of Patient #1's MR revealed, on 2/20/17 at 7:31 pm, Patient #1 presented to the ED with chief complaint of vomiting brown emesis and not being himself. Past medical history included encephalitis, seizures, profound mental retardation, gastroesophageal reflux disease (GERD), erosive esophagitis with gastrointestinal (GI) bleed.

Patient #1 was triaged at 7:42 pm as a Level 3. (Acuity level of 1 - 5 with 1 - resuscitation, 2 - emergent, 3 - urgent, 4 - semi-urgent, 5 - non-urgent). No B/P was documented during triage.

-- Review of the hospital's policy and procedure (P&P) titled "Triage Patient Flow," last reviewed 4/2017, indicated the triage nurse will document the focused triage assessment, vital signs, chief complaint and assign an acuity level of 1 - 5.

Patient #1 was returned to the waiting room until 9:45 pm. (No vital signs or reassessment of Patient #1 was completed while he was in the waiting room.)

-- Review of the hospital's P&P titled "Vital Signs Protocol for Emergency Patients," last reviewed 4/2017 indicated that nursing staff should obtain vital signs hourly on patients receiving active treatment and patients in the waiting room not yet evaluated by a provider with an Emergency Severity Index (ESI) triage level of less than or equal to 3 (urgent).

Patient #1 was placed in a treatment room at 9:45 pm, 2 hours after triage. He appeared uncomfortable and distressed. He was alert, respirations unlabored, abdomen distended soft and non-tender. Vomit is brown and smells of feces. (No vital signs obtained at this time.)

Patient #1 was evaluated by Staff D (ED physician) at 10:11 pm. Physical exam indicated patient was pale, in obvious discomfort,with fecal smelling coffee-ground emesis on the pillow. He was tachycardic (heart rate greater than 100 beats per minute [normal heart rate 60-100]) with regular rhythm. Abdomen was distended and tender.

Documentation by Staff D at 10:36 pm indicated the nurse and Staff D were called into Patient #1's room. Patient #1 profusely vomited dark foul-smelling emesis all over room and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed for over 10 - 12 minutes. Patient expired.

-- During interview of Staff D on 12/6/17 at 4:45 pm, he/she indicated Patient #1 was placed in a treatment room and nursing staff did not alert him/her to see the patient right away. Staff D was seeing other patients and indicated the ED was very busy. When he/she went to evaluate Patient #1, he appeared very ill, extremely pale and was moaning and groaning. He/she immediately went out of the exam room to enter orders for laboratory studies and intravenous fluids. Within a few minutes the patient went into cardiopulmonary arrest. CPR was initiated, however, Patient #1 expired.

-- During interview of Staff A (Physician) on 12/7/17 at 10:00 am, he/she confirmed the above findings and indicated Patient #1 was triaged as a level 3 without documentation of a B/P. He/she indicated that a triage level can not be determined without obtaining a blood pressure on a patient.

-- The same lack of documentation of hourly vital signs of patients in waiting room or treament room was noted for Patients #2, #3, #4, and #5.