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Based on observations, interviews and review of 6 of 11 randomly selected Emergency Department (ED) records, the Hospital failed to ensure that Patient (Pt) #1, Pt #4, Pt #5, Pt #6, Pt #8 and Pt #11, who presented with complaints of chest pain and/or shortness of breath, triaged as a Level 2 [Level Emergency Severity Index (ESI) ranging from 1 to 5 to determine the level of emergency care needed. Severity levels categorized as: 1, indicative of a life threatening condition with the need for immediate intervention; 2, indicative of a serious condition with need for significant intervention; 3, indicative of a condition that was not serious but needed additional work-up, and 4 and 5 indicative of a minor condition with the need for little or no additional work-up] and placed in the "waiting area" of the ED, were appropriately reassessed and clinically monitored every hour as required by Hospital policies/procedures.

Patient #1, #4, #5, #6, #8 and #11 were in the waiting area for periods of approximately three to four hours during which there was no ED Physician evaluation, no further assessments of their presenting chief complaint and no additional vital signs obtained while waiting for a ED bed.

Findings included:

1) Please refer to Tag 1100 for details.

Based on observations, staff interviews, review of hospital policies and procedures and review of 6 of 11 ( #1, #4, #5, #6, #8 and #11) sampled Emergency Department (ED) records, the Hospital Nursing staff failed to conduct hourly assessments of patients triaged as a Level 2 [Level Emergency Severity Index (ESI) ranging from 1 to 5 to determine the level of emergency care needed. Severity 2 is indicative of a serious condition with need for significant intervention] presenting with chief complaints of chest pain, chest discomfort and/or shortness of breath and placed in the "waiting area" for an ED bed.

Findings include:

Review of the policy/procedure titled Waiting Area, Management of Patients indicated that the purpose of the policy was to provide guidelines for the management and reassessment of patients waiting in the ED Waiting Area after an assessment was performed by the Triage Nurse, utilizing the ESI rating system. The policy indicated that Patients will be reassessed for chief complaint/condition, vital signs and pain in time increments according to triaged ESI level. Patients with an ESI Level 2 will be assessed every one hour.

A) The Complainant was interviewed on 5/15/12 at 12:20 P.M. The Complainant said that Patient (Pt) #1 was triaged, had an Electrocardiogram [ECG] performed by a technician and was then sent back to the Waiting Area. The Complainant said that Patient (Pt) #1 went to the ED for severe pain in his/her upper torso and reported that he/she had a history of high blood pressure, but his/her blood pressure was very low. The Complainant said that Pt #1 was in such agonizing pain while waiting in the ED Waiting Area, the patient could not sit or stand and he/she asked a technician if there was a place where he/she could lie down.

Review of Pt's #1's ED record indicated that Pt #1 arrived at the ED on 4/16/12 and triage occurred at 11:30 A.M. Vital signs recorded at 12:34 P.M. indicated that Pt #1's heart rate was 50 (normal range = 60-90) and blood pressure (BP) was 124/67 (normal range 100-130/60-85). Pt #1 reported having shortness of breath with some back and chest discomfort. Pt #1 rated his/her pain as 2 out of a 0-10 paint scale (0=no pain, 10 the worst pain ever experienced). Nursing Assistant #1 drew blood for diagnostic testing and performed an (ECG.

Nurse #1, the triage nurse, was interviewed on 5/15/12 at 12:50 P.M. Nurse #1 said that he entered a triage time of 11:30 A. M. in error, into Pt #1's electronic record, and said that the actual time of triage for Pt #1 was 12:30 P.M. Nurse #1 said that Pt #1 complained of chest discomfort and was triaged as a Level 2. Nurse #1 said that patients with an ESI Level of 2 should be seen by the ED Physician within 1 hour after presenting with their chief complaint. Nurse #1 said that 4/16/12 was a very busy day in the ED and that it was his practice to tell patients, at triage, who were waiting for a ED bed in the Waiting Area, to report increased pain or any other changes to him. Nurse #1 said he was unaware of measures to obtain additional staffing/backup help, in situations of increased census and large numbers of waiting patients.


Nursing Assistant #1's documentation indicated that Pt #1's ECG was obtained at 12:31 P.M., during Pt #1's triage, was shown to an ED Physician. However, the ED Physician who reviewed the ECG was not identified and there was no documentation on the ECG report that it was reviewed/evaluated by the ED Physician at that time.

Review of Pt #1's ED record indicated that from 12:30 P.M. to 3:50 PM [3 hours and 20 minutes after triage], there were no re-assessments of the patient's chief complaint, no vital signs recorded and no assessment of pain, while Pt. #1 was in the ED Waiting Area. There was no documentation in the medical record indicating that Pt. #1 was placed on a telemetry monitor during the waiting period.

Nurse #2 was interviewed on 5/16/12 at 10:30 A.M. Nurse #2 could not recall any details regarding the transfer of Pt #1 from the waiting area to the main ED. Nurse #2 said that ED Nurses work as a team and whoever was not busy, would go to the Waiting Area and bring the patient to an open bed. Nurse #2 said that patients who are placed in the Telemetry [Continuous cardiac monitoring system that utilizes transmitters and a receiver] area within the ED, are not assigned to a particular nurse. The nurses working in the Telemetry area work together as a team and are assigned to rooms, not a particular patient. Nurse #2 said that it was her practice to report a patient's pain to an attending physician, however, there was no documentation to indicate Pt #1's agonizing pain was reported to the physician at that time.

Review of Nurse #2's documentation at 3:50 P.M., in her nursing note, indicated that Pt #1 was placed on a cardiac monitor (Telemetry) and the patient's heart rate was 43 beats per minute and BP was 113/43. Pt #1 rated his/her chest pain a #3 and rated his/her back pain at #9.

Review of Nurse #3's documentation at 4:15 P.M. indicated that Pt #1 was administered oral pain medication, Vicodin, at 4:43 P.M.

Nurse #3 was interviewed on 5/15/12 at 1:20 P.M. and said that she did not remember Pt #1. Nurse #3 said more than one nurse is assigned to the Telemetry area. Nurse #3 said the nurses work together as a team caring for the patients in that area.

Nurse #2 and Nurse #3 both said that the nurses working in the Telemetry area work together as a team, to care for patients, there is not one nurse assigned to a particular patient in the Telemetry area.


Review of the ED Attending Physician's physical examination of Pt #1 indicated that he evaluated Pt #1 at 4:03 P.M. The physical examination indicated that Pt #1 had an ECG with a report of sinus bradycardia (slow heart rate below 60 beats per minute). Review of the ED record indicated that an ECG strip dated 4/16/12 at 12:31 P.M. was marked as "abnormal ECG" - Sinus bradycardia, confirmed by a physician on 4/17/12 at 4:03 P.M.

The ED Attending also noted the computed tomography (CT) scan report revealing an acute dissection of the aorta (a tear in the inner wall of the aorta, the largest blood vessel in the body, which causes the blood to flow between the layers of the wall of the aorta and force the layers apart. This condition results in hemorrhage and may result in sudden death).

The ED Attending Physician was interviewed on 5/15/12 at 1:45 P.M. and said that 4/16/12 was a very busy day in the ED. The ED Attending Physician said that he did not know how often patients waiting in the Waiting Area were re-assessed before they were transferred from the Waiting Area to an bed in the main ED. The ED Attending Physician said he reviewed Pt #1's CT scan and the dissection was obvious. He said that he contacted the Cardio-thorascic surgeon and the surgeon came to the ED.

A nursing note, at 6:18 P.M. indicated the Thoracic Surgeon evaluated Pt #1 in the ED, however, there was no consult documented.

A nursing note, at 6:59 P. M. indicated that, Pt #1 was emergently taken to the Operating Room in stable, but critical condition to repair the thorcoabdominal aortic dissection.

An operative report, dated 4/17/12 at 1:37 A.M. indicated the details of the surgical repair for the dissection.


B) Review of the ED record indicated that Pt #4 arrived to the ED on 1/2/12 at 1:06 P.M. with a chief complaint of chest pain and triaged as a Level 2. Blood samples were obtained for diagnostic testing and an ECG was performed at 1:19 P.M. Pt #4 was sent to the Waiting Area after triage. There were no re-assessments of the patient's chief complaint documented, no vital signs recorded and no assessment of pain documented, from 1:06 P.M. to 4:21 P.M. [3 hours and 15 minutes], while Pt #4 was in the ED Waiting Area.

A physician progress note, dated 1/2/12 at 7:11 P.M. indicated that Pt #4's ECG was unchanged when compared with a prior ECG.

C) Review of the ED record indicated that Pt #5 arrived to the ED on 1/2/12 at 1:35 P.M. with a chief complaint of chest pain and triaged a Level 2. Blood samples were obtained for diagnostic testing and an ECG was performed at 1:54 P.M. Pt #5 was sent to the Waiting Area after triage. There were no re-assessments of the patient's chief complaint documented, no vital signs recorded and no assessment of pain documented, from 1:35 P.M. to 4:23 P.M. [2 hours and 48 minutes, approximately 3 hours], while Pt #5 was waiting in the Waiting Area.

Nursing documentation indicated that Pt #5 left the ED without being seen by a physician due to the long wait time.

D) Review of the ED record indicated that Pt #6 arrived to the ED on 1/2/12 at 6:15 P.M. with a chief complaint of chest discomfort and triaged as a Level 2. Blood samples were obtained for diagnostic testing and an ECG was performed at 6:34 P.M. Pt #6 was sent to the Waiting Area after triage. There were no re-assessments of the patient's chief complaint documented, no vital signs recorded and no assessment of pain documented, from 6:15 P.M. to 9:02 P.M. [2 hours and 47 minutes, approximately 3 hours], while Pt #6 was waiting in the Waiting Area.

Physician documentation in a progress note at 9:56 P.M. indicated that Pt #6's ECG identified specific changes when compared to prior ECG.


E) Review of the ED record indicated that Pt #8 arrived to the ED on 2/21/12 at 1:19 P.M. with a chief complaint of shortness of breath and chest tightness. Blood samples were obtained for diagnostic testing and an ECG was performed at 1:27 P.M. Pt #8 was triaged as a level 2. There were no re-assessments of the patient's chief complaint documented, no vital signs recorded and no assessment of pain documented from 1:10 P.M. to 4:40 P.M. [3 hours 21 minutes], while Pt #8 was waiting in the Waiting Area.

The ED physician, who evaluated Pt #8, did not document what time the medical exam was performed. The ED Physician's note, dated 2/24/12 at 7:46 P.M. indicated that Pt #8's ECG was documented as normal sinus rhythm with poor R wave progression.

F) Review of the ED record indicated that Pt #11 arrived to the ED on 4/16/12 at 1:10 P.M. with a chief complaint of chest pain. Pt #11 rated his/her pain as 4. Blood samples and an ECG were obtained at 1:34 P.M. Pt #11 was triaged as a level 2. There were no re-assessments of the patient's chief complaint documented, no vital signs recorded and no assessment of pain documented from 1:10 P.M. to 5:17 P.M. [Four hours and seven minutes], while Pt #11 was waiting in the Waiting Area.

Nursing Assistant #1's documentation indicated that Pt #11's ECG was shown to an ED Physician. However, the ED Physician who reviewed the ECG was not identified and there was no documentation on the ECG report that it was evaluated during triage.

The ED Physician, who evaluated Pt #11, did not document the time the medical exam was performed. The ED Physician's note dated 4/16/12 at 10:42 P.M., indicated that Pt #11's ECG identified Left Ventricular Hypertrophy [left ventricle is enlarged and associated with increased risk of death due to cardiovascular disease, stroke and other causes].

G) The Nurse Manager was interviewed on 5/15/12. The ED records for Pt #1, #4, #5, #6, #8 and #11's were reviewed with the Nurse Manager. The Nurse Manager acknowledged that the nursing staff failed to follow Hospital policy and procedures regarding reassessment of patients in the waiting area, specifically patients triaged as Level 2 who complained of chest pain and/or shortness of breath. The Nurse Manager said it was very busy that day, 4/16/12 [Patriot's day/Marathon Monday] and a Full Capacity Protocol, also known as a Code Help, was called at 2:30 P.M., which indicates that the ED is significantly overcrowded or at full census and additional resources are required. The full capacity protocol centers on having a multidisciplinary team participate in a structured conference call to develop an action plan to manage the event, with the goal of initiating decompression of the ED within 30 minutes of activation.

Despite the Full Capacity Protocol being called, patients continued to wait without proper assessments and clinical care.

Based on observations, staff interviews, review of hospital policies and procedures and review of 6 of 11 ( #1, #4, #5, #6, #8 and #11) sampled ED records, the Hospital Nursing staff failed to re-assess patients hourly that were triaged as a Level 2 [Level Emergency Severity Index (ESI) ranging from 1 to 5 to determine the level of emergency care needed. Severity 2 is indicative of a serious condition with need for significant intervention] according to policies and procedures.


Findings include:

1) Please refer to Tag 1100 for details.