HospitalInspections.org

Based on interview and document review it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure a medical screening examination was performed in a timely manner to an individual seeking care in the Emergency Department for 1 of 20 patients (#1), see A 2406.

Based on interview and document review the facility failed to initiate the triage process in a timely manner; failed to follow their acuity triage protocol; failed to perform a timely medical screening examination and failed to consistently monitor vital signs for 1 (#1) out of 20 patients reviewed for treatment and medical screening resulting in the potential to delay care and less than optimal patient outcomes. Findings include:

On 6/24/19 at 1400 a review of patient #1's medical record revealed the following:
Patient #1 was a 79-year-old-male who presented to the ED (emergency department) on 6/12/19. The patient was initially seen status post (s/p) fall at an Urgent Care (UC) that was affiliated with the hospital on 6/12/19 for a head injury. The patient was directed to go to the ED by the UC due to a laceration that was above his left eyebrow that required repair. The patient was reportedly more agitated than his baseline according to his caregiver who had accompanied him to the UC and ED via private vehicle. The patient also had an abrasion to his knee.

A review of the facility's internal patient placement center "One Call" electronic notes the ED had been contacted in advance by the UC. The patient had been accepted by the ED. The patient was expected to arrive in the ED on 6/12/19 at 1804 according to the documentation.

Further ED record review for patient #1 revealed the following:

On 6/12/19 documented "late entry" at 1935: Patient visitor came up to triage desk and was asking for update stating, "When we got here, we checked in, got a wrist band and sat down and never checked in at this desk." Triage RN Staff V notified to triage the patient next.

On 6/12/19 at 19:35:17, "Arrival complaint: 'One call', Head injury 2 hours ago, lives in group home. Fell on sidewalk, nonverbal at baseline, hx congenital disorder. Hit upper left area of eyebrow, laceration will need repair. Patient more agitated than baseline head is painful. Abrasion to knee. No neck pain."

On 6/12/19 at 19:35:17, patient arrived in ED
On 6/12/19 at 19:36:07, Chief Complaints: positive fall (head injury. Sent by Urgent Care).
On 6/12/19 at 19:36:18, allergies reviewed
On 6/12/19 at 19:36:20, history reviewed-medical
On 6/12/19 at 19:36:22, history reviewed-surgical
On 6/12/19 at 19:36:25, history reviewed-alcohol, tobacco, drug use

On 6/12/19 at 19:40:44, ED Triage notes, Patient fell at about 1500 today. Laceration on head. Denies LOC (loss of consciousness)
On 6/12/19 at 19:41, Vital signs: Temperature 97.3. Pulse/Heart Rate 114 (high). Blood pressure (B/P) 89/57 (low). Respiration 16. Oxygen saturation 98 percent (%). Restless
On 6/12/19 at 19:46, triage completed.
On 6/12/19 at 19:47, Patient alert oriented to person, place, time and pain. Clear speech.
Triage Plan: Patient acuity 3. ED destination Core.
On 6/12/19 at 19:47:11, ED Triage notes: Patient has about a 4 centimeter (cm) deep laceration above his right eyebrow.
On 6/12/19 at 21:23:50 patient roomed to D 076. (1 hour 48 minutes after triage).

Provider notes reviewed and revealed the following:
On 6/12/19 at 21:27, Provider examination started.

On 6/12/19 at 21:45, orders were initiated for laboratory studies, an electrocardiogram (EKG) and intravenous (IV) access. The EKG was performed and reflected significant changes (abnormal) when compared to a previous study (EKG) of 17 years prior according to the provider notes.

Imaging diagnostics were ordered for a CT scan of the patient's brain/ head and spine without contrast on 6/12/19 at 21:47. The tests were not performed due to the patient's deterioration.

Further review of provider notes revealed the provider was called back into the room as the patient #1 was unresponsive for staff on 6/12/19 and at 22:09. A "CODE" was called, an alert (term) used for cardiopulmonary arrest that requires immediate attention.

During the code there were 2 attempts documented for intubation. The second attempt was successful. The patient underwent chest compressions and defibrillation. The patient was administered Amiodarone (used for an irregular heart rhythm), Epinephrine (used to treat cardiac arrest), Amidate (an anesthetic used for general sedation), Zemuron (muscle relaxant used for to facilitate intubation), Zofran (used for nausea/vomiting), Calcium Chloride (used to improve heart contractions during cardiac arrest) and Sodium Chloride (used to replenish fluid and electrolytes) via intravenous injection during the Code.

The patient was pronounced (expired) at 22:30 on 6/12/19.

There was no evidence in the medical record that documented the patient was consistently monitored after triage. The patient's blood pressure was not retaken until 21:40 on 6/12/19 and read 80/50. (2 hours after triage).
Intravenous access was not placed until 21:46 on 6/12/19.

On 6/24/19 at 1530 an interview was conducted with the President/Chief Nursing Officer Staff F. He explained that a meeting had been scheduled for today to review the root call analysis regarding the handling of patient #1's ED event. Staff F said the nurse Staff V had been immediately suspended pending investigation. He said Staff V had since returned to work however, she was restricted from working the triage area. Staff V said they recognized that 2 errors had occurred within the ED registration and triage processes.

Error #1. He said the Unit Clerk failed to enter the patient's arrival into the ED. He explained that process would have alerted the nurse of the patient's arrival.

Error #2. He said the patient #1 should have been triaged at a level 2 instead of a level 3. He explained the patient's blood pressure was low and his pulse was high. He said the patient had a head laceration. He said the patient was restless according to the triage notes.

On 6/25/19 at 1523 and 1525 voice mail messages were left for ED Staff Nurse's V and W. There were no responses to the messages by end of survey. On 6/12/19 at 1530, Unit Manager Staff C explained neither Staff V nor Staff W were working this week.

On 6/26/19 at 0845 an interview was conducted with Staff F. Staff F was asked to explain if the Unit Clerk Staff U had been re-educated or counseled regarding her failure to enter the patient's arrival into the electronic data base or verbally notify nursing staff of the patient's arrival. Staff F responded no. He said, we've scheduled a meeting for this evening for all of our ED Unit Clerks.

On 6/26/19 at 0930 an interview and record of patient #1's chart was conducted with the Medical Director of the ED, Staff A. She explained she had reviewed the chart and she was aware of the surrounding circumstances. Staff A explained the patient should have been triaged at a level 2 instead of a level 3, based on his low B/P, elevated heart rate, restlessness, and his head laceration. Staff A was asked if she was aware of the time of the patient's arrival into the ED. She said based upon the documentation it was a late entry and the time was unknown. She explained that it was possible that the patient had waited for an hour or more to be triaged. She said based upon the notes from "One Call" the patients estimated arrival time was for 1804.

On 6/26/19 at 1030 Staff F was queried regarding a communication policy for the "One Call" unit and the ED. Staff F stated, "We don't have one."

A review of the facility's "PCS Emergency Department Triage" policy dated last revision date June 2019 p.1 documented:
3.0 Definitions:
Triage: An information-collecting and decision-making process that is performed in order to sort injured/ill patients into categories of acuity and prioritization based on the urgency of their medical or psychological needs.
4.0 Responsibilities:
Acuity: The ED RN (registered nurse) utilizes the Emergency Severity Index (ESI) to designate triage acuity for each patient.

A review of the facility's "ESI Triage algorithm, v4", p.1 dated 2004 documented:
-Requires immediate life-saving intervention? yes equals Code #1.
-High risk situation? or confused/lethargic/disoriented? or severe pain/distress? yes equals Code #2.
-How many resources are needed? many, one or none Code #3.
-Danger zone vitals? age greater than 8 years of age HR greater than 100 RR greater than 20 Oxygen saturation less than 92 percent (%) Consider Code #2.

Review of the facility's "Triage Assessment in the Emergency Department" policy dated 10/31/14, p.8 documented:
Implementation:
B. Documentation ongoing care will include:
1. time to treatment time.
2. serial vital signs and/or assessments.

i. Patient contact and documentation will occur minimally every hour. An update of the plan of care and any delays will be given to the patients and/or their representatives.
ii. Vital signs will be repeated and documented as follows:
Level 2. Every hour at a minimal or more frequently if clinically indicated.
Level 3, 4 and 5 every 2 hours at a minimal or more frequently if clinically indicated.

Review of the facility's "Vital Sign Reassessment in the Emergency Department" policy dated 6/13/19, p.1 documented:

Vital signs will be reassessed for all patients in the Emergency Department area based on clinical necessity.
...ESI Level 2 and 3 every hour to every 4 hours or more frequently as clinically indicated.