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Based on interview and record review, the facility failed to ensure nursing services were provided in accordance with acceptable standards of practice and the facility's policy and procedure when treatment and interventions were not provided timely, for one of 30 sample patients (Patient 15), who was suspected to have an acute coronary syndrome (ACS, a range of conditions caused by a sudden reduction in blood flow to the heart muscle), when treatment and interventions were not provided timely and EKG was not done timely. In addition, activity restriction, such as bed rest, was not implemented for the patient (Refer to A 0398).

The cumulative effect of these failures resulted in Patient 15's condition to worsen and may have contributed to the patient's demise.

Based on interview and record review the facility failed to ensure the medical record was accurate, for one of 30 sample patients (Patient 18), when:

1. The anesthesia (medication for pain management and sedation) administered to Patient 18 was inaccurately documented on the patient's record; and

2. The x-ray result of Patient 18 was inaccurately documented.

These failures had the potential to affect Patient 18's care and treatment.

Findings:

1. On May 20, 2025, at 9:20 a.m., an interview and review of Patient 18's record were conducted with the Director of Maternal Child (DMC). A facility document titled, "History & Physical," dated November 8, 2024, was reviewed and indicated Patient 18 was admitted to the facility on November 8, 2024, for a "scheduled induction [a medical procedure where labor is artificially started to cause childbirth] of term pregnancy [a pregnancy that lasts between 39 weeks, 0 days and 40 weeks, six days]."

A facility document titled, "Anesthesia Record," dated November 10, 2024, was reviewed. The document indicated, "...5:48 [a.m.] Endotracheal Intubation [a medical procedure where a tube is inserted into the airway to help someone breathe]...6:12 [a.m.] ...Anesthesia Method: General [a deep sleep-like state induced by medications to allow surgical procedures to be performed without pain or awareness]..."

A facility document titled, "Operative Reports," dated November 9, 2024, at 8:11 a.m., was reviewed. The document indicated, " ...Procedure: Emergent Cesarean Section [a surgical procedure where a baby is delivered through incisions made in the mother's abdomen and uterus]...Anesthesia: General...She [Patient 18] was taken to the operating room, where spinal anesthesia [a type of anesthesia where medication is injected into the surrounding the spinal cord, causing temporary loss of feeling and movement in the lower body]..."

The DMC stated the anesthesia record indicated Patient 18 received general anesthesia and was intubated, but the Obstetrician (a physician who specialized in the care of the pregnant woman and delivery of the infant) (MD 1) documented that the patient was given spinal anesthesia. The DMC stated Patient 18 did not receive spinal anesthesia. The DMC stated the MD 1 documented spinal anesthesia in error and the anesthesiologist [medical doctors who specialize in the management of pain and the provision of anesthesia during surgical procedures and other medical interventions] documented the general anesthesia correctly. The DMC stated the anesthesiologist's documentation is correct and Patient A received general anesthesia and was intubated.

2. On May 20, 2025, at 9:20 a.m., a concurrent interview and review of Patient 18's record were conducted with the Director of Maternal Child (DMC). A facility document titled, "XR [x-ray, an imaging procedure] Abdomen...," dated November 9, 2024, at 2:49 p.m., authored by Radiologist (a medical doctor specializing in interpreting images to diagnose and treat diseases and injuries) Medical Doctor (RMD) 1, was reviewed. The document indicated, "...Findings...A rectal tube [a long, slender tube inserted into the rectum for various medical purposes] is present...Impression...Rectal probe in place..."

A facility document titled, "XR [X-Ray] Abdomen...," dated November 9, 2024, at 4:59 p.m., was reviewed. The document indicated, "...Addendum # [number] 1...A catheter [a flexible tube inserted into the bladder to remove urine] is projected over the midline lower pelvis, which looked like a rectal temperature probe. However, this is a foley catheter..."

The DMC stated Patient 18 never had a rectal tube nor probe inserted during the patient's hospitalization. The DMC stated it is not in labor and delivery's process to ever use a rectal probe or tube on a laboring patient. The DMC stated they looked into the results and determined there is no documentation and no indication for Patient 18 to have any kind of rectal tube or probe. The DMC stated Patient 18 did have a foley catheter (a thin, flexible tube inserted into the bladder to drain urine when normal urination is not possible or practical) in place that was seen and was not mentioned on the original x-ray result authored by RMD 1. The DMC stated RMD 1 documented a rectal tube or probe was present instead of the foley catheter. The DMC stated it comes down to how the radiologist interpreted the images.

On May 20, 2025, at 3 p.m., an interview was conducted with RMD 1. RMD 1 stated when she interpreted the images, it did not look like a regular foley she is used to seeing, so she documented it as a rectal temperature tube. RMD 1 stated after reviewing the radiology images with the medial director, it was determined that it was a foley catheter. RMD 1 stated on Patient 18's x-ray, the bladder and rectum were seen over each other, and at first it looked to be a rectal tube. RMD 1 stated a rectal tube, or probe is how she initially interpreted the images, but she made an addendum to the record to correct the error.

On May 21, 2025, at 9:30 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated in the case of Patient 18's abdominal x-ray, RMD 1 interpreted and documented the findings as a rectal probe instead of a foley catheter and balloon (a portion of the foley catheter that is inflated to keep the catheter in place). The CNO stated Patient 18 had no record of having had a rectal probe or tube placed. The CNO further stated RMD 1 planned to make an addendum to correct the x-ray results.


A facility document titled, "Medical Staff Bylaws," dated October 2021, was reviewed. The document indicated, "...Applicants and members of the medical staff shall be governed by such rules and regulations and medical staff policies as are properly initiated and adopted..."

A facility document titled, " [Name of facility] Medical Staff General Rules and Regulations," dated October 2021, was reviewed. The document indicated, "...1.3 A member of the medical staff will be responsible for the care and treatment of each patient in the hospital, for the prompt completion and accuracy of the electronic health record, and for necessary special instructions..."

Based on interview and record review, the facility failed to ensure treatment and interventions were provided timely, for one of 30 sample patients (Patient 15), who was suspected to have an acute coronary syndrome (ACS, a range of conditions caused by a sudden reduction in blood flow to the heart muscle), in accordance with acceptable standards of practice and the facility's policy and procedure, when EKG was not done timely. In addition, activity restriction, such as bed rest, was not implemented for the patient.

These facility failures resulted in Patient 15's condition to worsen and may have contributed to the patient's demise.

Findings:

On May 19, 2025, at 1:40 p.m., a concurrent interview and review of Patient 15's record was conducted with the Interim Director ICU (Intensive Care Unit, a unit for critically ill patients)/Education Director (IDICU/ED). A facility document titled, "ED Physician Record," dated September 16, 2024, was reviewed. The document indicated, "...BIBA [brought in by ambulance] from home for evaluation of chest pain, sudden onset, localized to the substernal [below the bone on the mid chest area] region, radiating to the left shoulder and the left side of her neck, onset 10 minutes after she ate dinner...Patient having nausea and vomiting on arrival...POC BG [Point of Care Blood Glucose, blood sugar, normal is 70-100 mg/dL (milligrams per deciliter, a unit of measurement) before meals and below 140 mg/dL two hours after eating] 506...Impression and Plan: STEMI [ST (a wave found on the tracing of heart activity) elevation myocardial infarction, a serious type of heart attack wherein prompt treatment is crucial to minimize the damage to the heart and improve survival chances], cardiac arrest [when the heart stops beating]...Respiratory arrest [when breathing stops]...Condition: Expired...Disposition: Expired..."

An emergency medical service (EMS, ambulance) document titled, "1) PATIENT CARE REPORT," was reviewed. The document indicated, " ...Arrived at patient [Patient 15]: 09/16/2024 [September 16, 2024] 21:33:26 [9:33 p.m.]...Transporting: 09/16/2024 21:45:18 [9:45 p.m.]... Arrived at Dest. [destination, facility]: 09/16/2024 22:00:40 [10 p.m.]...Primary Impression: Chest Pain- Suspected Cardiac [pain related to heart causes] ...Pain ...09/16/2024 21:42:35 [9:42 p.m.] 10 [pain scale of 1-10, 10 being the worst pain] ...21:50:03 [9:50 p.m.] 10 ...21:52 p.m. [9:52 p.m.] 10 ...2159 [9:59 p.m.] 10 ..."

On May 21, 2025, at 1:43 p.m., further review of Patient 15's record was conducted with the Chief Nursing Officer/Chief Operating Officer (CNO/COO), Emergency Department Manager (EDM), and the Chest Pain Program Coordinator (CPPC). A facility voice recording, labeled "091620242119," was reviewed twice for content. The voice recording contained the exchanges made during the arrival of Patient 15 to the facility on September 16, 2024. The voice recording indicated, "...35 years old...ETA [estimated time of arrival] 10 minutes...CP [chest pain]...not reading STEMI..."

An email document titled, "Timeline," authored by the ED Director and sent to the CNO and EDM, dated September 30, 2024, was reviewed. The document indicated, "...[name of Patient 15]...c/o [complaining of] Chest Pain: 22:04 [10:04 p.m.] Arrived ED via [name of EMS]; 22:17 [10:17 p.m.] Triage [name of Triage Registered Nurse, TRN]; 22:19 [10:19 p.m.] ED [room number] given, [name of EMS] took patient to BR [bathroom, as verified with EDM] not to room; 22:22 [10:22 p.m.] EKG [a non-invasive medical test that records the electrical activity of the heart, 18 minutes after arrival] done; 22:30 [10:30 p.m., 26 minutes after arrival] Cardiac Workup started by RN 1, New Grad with RN 2 Preceptor; 22:35 [10:35 p.m., 31 minutes after arrival] [Name of ED physician] to room, patient starts having seizure like activity [sudden, abnormal electrical discharges in the brain that can cause temporary changes in behavior, movement, or awareness], Ativan [medication used to treat seizures], Code Blue [a medical emergency, typically a cardiac or respiratory arrest, requiring immediate attention and intervention by the resuscitation team and a universal signal for staff to respond quickly to a patient's critical condition] called, CPR [cardio-pulmonary resuscitation, chest compressions to try to revive a patient] started; 22:37 [10:37 p.m.] 22:37 [name of respiratory therapist] at bedside; 23:01 [11:01 p.m.] Moved to room [room number]; 23:06 [11:06 p.m.] Code stopped by [name of physician]; 00:47 [12:47 a.m.] Coroner at bedside..."

The CPPC, the EDM, and the CNO were unable to provide documentation an EKG was completed 10 minutes from Patient 15's arrival to the facility on September 16, 2024, nor at 10:22 p.m., as recorded on their "Timeline," aside from the EKG completed at 10:30 p.m. (26 minutes after arrival), after Patient 15 was walked to the bathroom.

During a concurrent interview with the CPPC and the EDM, on May 21, 2025, at 1:43 p.m., the EDM stated, "Patient [Patient 15] is expected to arrive [to the facility]." The EDM stated the "Timeline" data started from registration when Patient 15 arrived by ambulance at the facility at 10:04 p.m., and was triaged by the Triage Registered Nurse (TRN) at 10:17 p.m. The CPPC stated an EKG should have been completed 10 minutes after Patient 15's arrival to the hospital.

On May 21, 2025, at 1:55 p.m., the CPPC and the EDM were interviewed regarding patients coming in for ACS and the activity restriction recommendation for these patients. The CPPC stated an ACS patient should have been placed in a bed right away and the activity should be restricted in accordance with the ACS Algorithm (a systematic approach designed to assist clinicians in rapidly identifying and treating patients experiencing ACS). The CPPC stated, "When patient arrive via EMS, they hand the patient record to the unit clerk to be registered." The CPPC stated, "depending on availability," the ED staff would have already pre-assigned a room and a nurse for the patient when the charge nurse receives the EMS call. The CPPC stated the unit clerk, when warranted, will overhead call for "Cardiac Alert [an alert signal for a heart patient]," the EKG will be done in 10 minutes, and laboratory tests will be drawn in 25 minutes. The CPPC stated, within 10 minutes, a physician had to see the patient and review the EKG, and the unit clerk will contact the cardiologist (a physician who specializes in the diagnosis and treatment of heart diseases) and overhead call for "STEMI" if warranted. The EDM stated the facility was responsible for any patient coming in as soon as they come to "our door."

A review of a web article titled, "CLINICAL PRACTICE GUIDELINES 2025 ACC [American College of Cardiology, a nationally recognized organization]/AHA [American Heart Association, a nationally recognized organization]/ACEP [American College of Emergency Physicians, a nationally recognized organization]/NAEMSP [National Association of EMS Physicians, a nationally recognized organization]/SCAI Society for Cardiovascular Angiography and Intervention, a nationally recognized organization] Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines," was conducted. The article indicated, " ...In patients with suspected ACS, acquisition and interpretation of an ECG [EKG] within 10 minutes is recommended to help guide patient management ...In patients with suspected ACS in whom the initial ECG is nondiagnostic [when the ECG does not provide enough information for the provider to arrive at a diagnosis]. Serial 12-lead ECG [a type of ECG] should be performed to detect potential ischemic [a condition where there's not enough blood flow to a specific part of the body, leading to a lack of oxygen and nutrients] changes, especially when clinical suspicion [a healthcare provider's awareness and concern about a patient's potential serious illness or injury, based on their symptoms and medical history] is high, symptoms persistent, or clinical condition [symptoms observed] deteriorates ..."

An undated ACS algorithm was reviewed and indicated, " ...Assess patient for symptoms of acute coronary syndrome (ACS) ...Crushing chest pain ...Pain radiates to jaw, arm, back ...Nausea/vomiting...Sweating ...Shortness of breath ...Rapid sequence of interventions and additional assessments ...If no aspirin allergies, administer aspirin [a blood thinner] (patient should chew)...If no contraindications, administer nitroglycerin ...Administer morphine [a pain medication], if needed...Obtain 12-lead ECG...Apply oxygen [O2] via nasal cannula [a plastic tube used to deliver oxygen through the nostrils] if O2 <94% [normal oxygen level in the blood is 95 to 100 percent and drops to 90% and below during a heart attack], normal is ...Trained professional should assess ECG; ST-segment elevation myocardial infarction (STEMI) ..."

A review of facility policy and procedure (P&P) titled, "Cardiac Care Program," dated November 2024, was conducted. The P&P indicated, " ...Purpose ...Establishment and maintenance of a Cardiac Care Program through the use of evidence based practices and multidisciplinary involvement to provide a full range of activities and services associated with cardiac prevention, care, treatment and rehabilitation to improve outcomes for patients with cardiac care needs...The Cardiac Care Program is organized by a multidisciplinary team to provide evidence based care through formally defined protocols, order sets, flow processes, continual medical and staff education, interface with EMS and Administrative Support...The Cardiac Care Program provides assessment and treatment in the event of cardiac disease and treatment of acute STEMI diagnosis by the ED provider results in Code STEMI call for rapid treatment using policies and protocols in place...The Cardiac Program provides a plan for the triage and treatment of patients...Procedure...Patient's arriving to the ED via EMS...cardiac related symptoms...The patient is pre-registered according to current practice by the Unit Coordinator (or designee)...Stat [immediate] EKG is performed for the patient within 10 minutes of arrival and taken to the provider for immediate interpretation. If the first EKG shows no STEMI, subsequent EKGs are done every Q15 [every 15 minutes] for 1 [one] hour. All EKGs are taken directly to the ED Provider for interpretation..."