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Based on observation, interview, and record review, the hospital failed to ensure the provision of services from other hospital departments was coordinated to provide the appropriate care to three of three sampled patients (Patients 1, 2, and 3) in the ED as evidenced by:

1. For Patient 1, the hospital failed to ensure the required initial assessment and ongoing focused assessments were conducted for Patient 1 after admitted to the ICU (while boarded in the ED). In addition, the hospital failed to ensure norepinephrine (a medication used to increase and maintain blood pressure in patients with severe, acute hypotension) was administered for the patient according to the prescribed order.

2. For Patient 2, the hospital failed to ensure the required initial assessments were completed for the patient after the patient's level of care was changed to telemetry while boarded in the ED.

3. For Patient 3, the hospital failed to ensure the required initial assessments were completed for the patient after the patient's level of care was changed to telemetry, while boarded in the ED.

These failures had the potential to result in substandard care for the patients.

Findings:

Review of the hospital's P&P titled Full Capacity Procedure (Surge Plan) dated 12/5/24, showed boarded patients are defined as patients that have an accepting admitting attending physician and are waiting in the ED for an inpatient bed, greater than 61 minutes.

Review of the hospital's P&P titled Assessment/Reassessment of Patients dated 3/2/23, showed the purpose of the policy is to ensure comprehensive assessment and documentation of both the initial assessment and ongoing reassessments of patients admitted to the hospital. The initial assessment includes evaluation of the patient's physical, psychological, and social condition; nutrition and hydration status; functional status; and spiritual and cultural considerations for end-of-life care, if indicated. In the Critical Care Unit, the initial assessment is to be completed immediately upon arrival. In the Telemetry Unit, it must be completed within one hour. In the Intensive Care Unit (ICU), a focused assessment or reassessment is performed at least every two hours for any systems that are unstable or deteriorating.

1. On 4/11/25 at 0921 hours, a closed medical record review for Patient 1 was initiated with the Stroke Coordinator, Director of Performance Improvement, Director of ED and ICU, Pharmacist 1, and the CNO.

Patient 1's closed medical record showed the patient was admitted to the hospital ED on 2/20/25.

a. Review of the ED Provider Notes dated 2/20/25 at 1848 hours, showed Patient 1 was brought to the ED by ambulance due to altered mental status and vomiting blood. Upon arrival, the patient was noted to be cyanotic and bradycardic with a faint pulse. The provider's note further showed Patient 1 was intubated upon arrival and shortly thereafter experienced pulseless electrical activity (PEA) cardiac arrest.

Review of Patient 1's Admit to Inpatient order dated 2/20/25, showed the level of care was designated as ICU and started at 2213 hours.

Patient 1's medical record also showed the patient was boarded in the ED while waiting for an available ICU bed.

Review of Patient 1's medical record did not show documented evidence the initial assessment was conducted after the patient's level of care was changed to ICU, nor the focused assessments/reassessments performed every two hours on systems that were unstable or deteriorating.

During the interview and concurrent closed record review, the Director of ED and ICU, along with the CNO, verified the findings and stated the nurses should have completed the comprehensive initial assessment when Patient 1 was boarded in the ED while waiting for an ICU bed, following the admission to the inpatient order. The Director of ED and ICU also verified the focused assessment of Patient 1's gastrointestinal, respiratory, cardiac, and neurological systems should have been conducted every two hours, but was not.

b. Review of the physician's order dated 2/20/25 at 2130 hours, showed an order to initiate norepinephrine infusion at a rate of 0.1 mcg/kg/minute. The order also specified the dose should be titrated by 0.03 mcg/kg/min every five minutes to maintain a mean arterial pressure (MAP) above 65 mmHg, with a maximum dose of 1 mcg/kg/minute.

However, review of Patient 1's All Administrations of norepinephrine (LEVOPHED) 8 mg in Dextrose 5% 250 ml Infusion showed the norepinephrine was not initiated at the ordered rate of 0.1 mcg/kg/minute, but was initiated at the maximum dose on 2/20/25 at 2208 hours, with no documented justification.

Review of Patient 1's medical record showed a MAP reading was obtained at 2155 hours prior to the initiation of the norepinephrine infusion, but no further MAP readings were obtained to titrate the medication as ordered.

During the interview and concurrent record review, the Director of ED and ICU, the CNO, and Pharmacist 1 verified the findings and stated that the medication was not initiated at the ordered dose, and there was no documented evidence that MAP readings were obtained as required.

2. On 4/10/25 at 0905 hours, during the tour of the ED conducted with RN 1, Patient 2 was observed in ED Bed 11. RN 1 stated Patient 2 was boarded in the ED, awaiting a bed in the Telemetry Unit.

On 4/10/25 at 1345 hours, a review of Patient 2's medical record was initiated with the Stroke Coordinator and Director of Performance Improvement.

Patient 2's medical record showed the patient was admitted to the hospital ED on 4/9/25.

Review of Patient 2's Admit to Inpatient order dated 4/9/25, showed the level of care was designated as telemetry and started at 2152 hours.

Review of Patient 2's medical record did not show evidence that an initial assessment was conducted after the patient's level of care was changed to telemetry.

During the interview and concurrent record review, the Stroke Coordinator and Director of Performance Improvement verified the findings.

3. On 4/10/25 at 0905 hours, during the tour of the ED conducted with RN 1, Patient 3 was observed in ED Bed 9. RN 1 stated Patient 3 was boarded in the ED, awaiting a bed in the Telemetry Unit.

On 4/10/25 at 1414 hours, a review of Patient 3's medical record was initiated with the Stroke Coordinator and Director of Performance Improvement.

Patient 3's medical record showed the patient was admitted to the hospital ED on 4/9/25.

Review of Patient 3's Admit to Inpatient order dated 4/10/25, showed the level of care was designated as telemetry and started at 1135 hours.

Review of Patient 3's medical record did not show evidence that an initial assessment was conducted after the patient's level of care was changed to telemetry.

During the interview and concurrent record review, the Stroke Coordinator and Director of Performance Improvement verified the findings.