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Based on interview and record review the hospital failed to ensure the triage RN [Registered Nurse] [Staff #9] provided care in a safe setting as evidenced by not properly assessing/evaluating and triaging 1 of 2 patient's [Patient #1], who was emergently brought to the ED [Emergency Department] for altered mental status, low blood pressure and atrial fibrillation. [Patient #1] suffered a cardiac arrest approximately thirty one minutes after arrival to the ED. [Patient #1] was triaged as a level 3 by Staff #9.

Findings Included:

The Patient Care Report dated 02/11/11 from the Fire Department for [Patient #1] reflected, "Patient history CHF [Congestive Heart Failure], high blood pressure, general weakness...age 81...blood pressure at 15:25 PM 56/42, heart rate 100...blood pressure at 15:45 PM 78/56, heart rate 92...oxygen saturation 93%...EKG done...A-Fib [Atrial Fibrillation]...narrative...patient at assisted living center. Staff noticed patient with [AMS]altered mental status. Patient vitals checked and B/P [Blood Pressure] found to be low. On arrival patient found to be sitting in wheelchair acting lethargic. ENRT [In route to] hospital pt [Patient] heart rate dropped with snoring respirations and loss of bladder control. Diverted to closer hospital. Pt B/P rose with Trendelenburg positioning...care transferred to hospital at 15:54 PM..." The receiving nurse Staff #9 signed the report.

The initial assessment form dated 02/11/11 timed at 16:00 PM reflected, "Arrival mode ambulance-stretcher...chief complaint altered mental status...disorientation yes...vital signs...T [Temperature] 96.4, P [Pulse] 123, R [Respirations] 20, B/P 112/97, O2 [Oxygen] 95% RA [Room Air]...triage level 3..."

The adult assessment dated 02/11/11 timed at 19:13 PM reflected, "Patient assigned to room 3...arrived by stretcher...patient moved to room at 16:00 PM...time of primary assessment 16:00 PM...psychosocial...patient demonstrates normal behavior appropriate for age and situation...is able to ambulate independently, and can perform all activities of daily living without assistance. Patient's nutritional status appears normal. The patient demonstrates the ability and willingness to learn...Safety...patient is at risk for fall as evidenced by confusion...patient is at risk for skin breakdown as evidenced by immobile due to chronic wellness, confusion, being elderly, incontinence...Brief Mental Status...patient has altered mental status...Cardiovascular...EKG was performed on 02/11/11 at 16:20 PM by nurse...after EKG was done it was taken to MD [Medical Doctor] right away and upon return to room son at the door and informed [Staff #9] his mother was not breathing...code was called and CPR [Cardiopulmonary Resuscitation] was begun..."

The ECG dated 02/11/11 timed at 16:20 PM reflected, "Nonspecific intraventricular block, ACUTE MI...abnormal ECG..."

The code flow sheet dated 02/11/11 timed at 16:31 PM CPR was started at 16:31 PM and code terminated 17:08 PM..." [Patient #1] subsequently passed away.

On 06/28/11 at approximately 12:30 PM Staff #9 was interviewed. Staff #9 was asked if he looked at the EMS report for [Patient #1]. Staff #9 stated "I never look at the report." Staff #9 stated he felt [Patient #1] was triaged appropriately. The surveyor referred to Staff #9's documentation which indicated [Patient #1] was able to ambulate, demonstrated ability/willingness to learn, at risk for falls evidenced by confusion and patient had altered mental status. Staff #9 was asked about the inconsistency of his documentation. Staff #9 did not offer an explanation.

On 06/28/11 at 2:35 PM Nursing Director of ED Staff #5 was interviewed. Staff #5 was asked based on the EMS [Emergency Medical System] patient care record and [Patient #1's] medical record what level of triage would [Patient #1] fall under. Staff #5 stated the triage nurse assessment and history of the event was inconsistent. Staff #5 stated [Patient #1] should have been triaged at a ESI [Emergency Severity Index] of 1 or 2 based on the EMS report and the patient's condition upon arrival, AMS [Altered Mental Status], vital signs, and what occurred during transport to the hospital.

On 06/29/11 at 12:08 PM Staff #13 was interviewed. Staff #13 stated he hooked [Patient #1] up to the monitor. He stated [Patient #1] did not look well. He stated he left the room to get the IV [Intravenous] supplies. Staff #13 stated when he was returning to the room Staff #9 left room to get the physician. Staff #13 stated he usually does the EKG when the patient comes in but this time the nurse did it. Staff #13 stated the ambulance paramedics told the nurse [Patient #1] was declining and did not look well.

Staff #5 provided the hospital ESI [Emergency Severity Index] 5-tier triage process currently used by the hospital on 06/28/11 at approximately 2:30 PM. The document reflected the following: "1) ESI-1 (Resuscitation)...definition...at risk of dying now if care is not received/directly to a bed...conditions include, but are not limited to...code. arrest, seizures, altered mental status, unconscious, delirious, major trauma and severe respiratory distress...2) ESI-2 (Emergent)...definition...high risk/patient condition that can not wait/directly to a bed...conditions include, but are not limited to...difficulty breathing, confused/lethargic/disoriented...3) ESI-3 (Urgent)...definition...check danger zone vital signs, two or more resources expected...conditions include, but are not limited to...moderate dyspnea, psychosis, bleed without decreased vital signs, nausea, vomiting, diarrhea, vaginal bleeding and flank pain..."

The policy entitled, "Patient Rights and Responsibilities" with a revision date of 04/01/11 reflected, "Patients have a right to receive care in a safe setting...patients have the right to appropriate assessment and management of pain..."

Based on interview and record review the hospital failed to ensure the triage RN [Registered Nurse] [Staff #9] properly assessed/evaluated and triaged 1 of 2 patient's [Patient #1] who was emergently brought to the ED [Emergency Department] for altered mental status, low blood pressure and atrial fibrillation. [Patient #1] suffered a cardiac arrest approximately thirty one minutes after arrival to the ED. [Patient #1] was triaged as a level 3 by Staff #9.

Findings Included:

The Patient Care Report dated 02/11/11 from the Fire Department for [Patient #1] reflected, "Patient history CHF [Congestive Heart Failure], high blood pressure, general weakness...age 81...blood pressure at 15:25 PM 56/42, heart rate 100...blood pressure at 15:45 PM 78/56, heart rate 92...oxygen saturation 93%...EKG done...A-Fib [Atrial Fibrillation]...narrative...patient at assisted living center. Staff noticed patient with [AMS]altered mental status. Patient vitals checked and B/P [Blood Pressure] found to be low. On arrival patient found to be sitting in wheelchair acting lethargic. ENRT [In route to] hospital pt [Patient] heart rate dropped with snoring respirations and loss of bladder control. Diverted to closer hospital. Pt B/P rose with Trendelenburg positioning...care transferred to hospital at 15:54 PM..." The receiving nurse Staff #9 signed the report.

The initial assessment form dated 02/11/11 timed at 16:00 PM reflected, "Arrival mode ambulance-stretcher...chief complaint altered mental status...disorientation yes...vital signs...T [Temperature] 96.4, P [Pulse] 123, R [Respirations] 20, B/P 112/97, O2 [Oxygen] 95% RA [Room Air]...triage level 3..."

The adult assessment dated 02/11/11 timed at 19:13 PM reflected, "Patient assigned to room 3...arrived by stretcher...patient moved to room at 16:00 PM...time of primary assessment 16:00 PM...psychosocial...patient demonstrates normal behavior appropriate for age and situation...is able to ambulate independently, and can perform all activities of daily living without assistance. Patient's nutritional status appears normal. The patient demonstrates the ability and willingness to learn...Safety...patient is at risk for fall as evidenced by confusion...patient is at risk for skin breakdown as evidenced by immobile due to chronic wellness, confusion, being elderly, incontinence...Brief Mental Status...patient has altered mental status...Cardiovascular...EKG was performed on 02/11/11 at 16:20 PM by nurse...after EKG was done it was taken to MD [Medical Doctor] right away and upon return to room son at the door and informed [Staff #9] his mother was not breathing...code was called and CPR [Cardiopulmonary Resuscitation] was begun..."

The ECG dated 02/11/11 timed at 16:20 PM reflected, "Nonspecific intraventricular block, ACUTE MI...abnormal ECG..."

The code flow sheet dated 02/11/11 timed at 16:31 PM CPR was started at 16:31 PM and code terminated 17:08 PM..." [Patient #1] subsequently passed away.

On 06/28/11 at approximately 12:30 PM Staff #9 was interviewed. Staff #9 was asked if he looked at the EMS report for [Patient #1]. Staff #9 stated "I never look at the report." Staff #9 stated he felt [Patient #1] was triaged appropriately. The surveyor referred to Staff #9's documentation which indicated [Patient #1] was able to ambulate, demonstrated ability/willingness to learn, at risk for falls evidenced by confusion and patient had altered mental status. Staff #9 was asked about the inconsistency of his documentation. Staff #9 did not offer an explanation.

On 06/28/11 at 2:35 PM Nursing Director of ED Staff #5 was interviewed. Staff #5 was asked based on the EMS [Emergency Medical System] patient care record and [Patient #1's] medical record what level of triage would [Patient #1] fall under. Staff #5 stated the triage nurse assessment and history of the event was inconsistent. Staff #5 stated [Patient #1] should have been triaged at a ESI [Emergency Severity Index] of 1 or 2 based on the EMS report and the patient's condition upon arrival, AMS [Altered Mental Status], vital signs, and what occurred during transport to the hospital.

On 06/29/11 at 12:08 PM Staff #13 was interviewed. Staff #13 stated he hooked [Patient #1] up to the monitor. He stated [Patient #1] did not look well. He stated he left the room to get the IV [Intravenous] supplies. Staff #13 stated when he was returning to the room Staff #9 left room to get the physician. Staff #13 stated he usually does the EKG when the patient comes in but this time the nurse did it. Staff #13 stated the ambulance paramedics told the nurse [Patient #1] was declining and did not look well.

Staff #5 provided the hospital ESI [Emergency Severity Index] 5-tier triage process currently used by the hospital on 06/28/11 at approximately 2:30 PM. The document reflected the following: "1) ESI-1 (Resuscitation)...definition...at risk of dying now if care is not received/directly to a bed...conditions include, but are not limited to...code. arrest, seizures, altered mental status, unconscious, delirious, major trauma and severe respiratory distress...2) ESI-2 (Emergent)...definition...high risk/patient condition that can not wait/directly to a bed...conditions include, but are not limited to...difficulty breathing, confused/lethargic/disoriented...3) ESI-3 (Urgent)...definition...check danger zone vital signs, two or more resources expected...conditions include, but are not limited to...moderate dyspnea, psychosis, bleed without decreased vital signs, nausea, vomiting, diarrhea, vaginal bleeding and flank pain..."