HospitalInspections.org

The Condition of Participation: Emergency Services was out of compliance.

Findings include:

Based on record review and interviews the Hospital failed to ensure emergency needs were met for one Patient (#1) out of a sample of 30 patients. Patient #1 was transferred to the Hospital from an outside Hospital for concerns of a ST-Segment Elevation Myocardial Infarction (STEMI) (a severe type of heart attack when blood flow to the heart is blocked). Patient #1 arrived by ambulance with heparin (a medication used for thinning the blood) running Intravenously (IV) and complaining of chest pain 5/10. Patient #1 was not seen by a provider for approximately 2.5 hours after arriving to the Hospital, and an electrocardiogram (EKG/ECG) (a recording of the heart's electrical activity) was not completed for approximately 3 hours after arriving to the Hospital. Patient #1 expired after being brought to the Catheterization ' Cath ' Lab (a clinical area that uses imaging equipment to examine the heart's arteries and chambers and treat abnormalities) 5 hours after arrival to the Emergency Department (ED).

An Immediate Jeopardy (IJ) event was identified on 9/11/24, regarding the Conditions of Participation (CoP) of Emergency Services for Patient #1.

The Hospital was notified of the IJ event on 9/11/24. The Hospital presented a completed Removal Plan to the State Agency on 9/11/24, which was determined to be acceptable. In summary, the IJ event Removal Plan was implemented on 9/11/24.

The IJ event regarding the CoP of Emergency Services was removed on 9/12/24, when the State Agency verified by interview with staff, review of all documentation, education attestations, and patient records that the Removal Plan was fully implemented.

CoP non-compliance for Emergency Services remains.

Cross reference: 482.55(a) Standard: Organization and Direction (A1101)

Findings included:

Based on record review and interviews the Hospital failed to ensure emergency needs were met for one Patient (#1) out of a sample of 30 patients. Patient #1 was transferred to the Hospital from an outside Hospital for concerns of a ST-Segment Elevation Myocardial Infarction (STEMI) (a severe type of heart attack when blood flow to the heart is blocked). Patient #1 arrived by ambulance with heparin (a medication used for thinning the blood) running Intravenously (IV) and complaining of chest pain 5/10. Patient #1 was not seen by a provider for approximately 2.5 hours after arriving to the Hospital, and an electrocardiogram (EKG/ECG) (a recording of the heart ' s electrical activity) was not completed for approximately 3 hours after arriving to the Hospital. Patient #1 expired after being brought to the Catheterization ' Cath ' Lab (a clinical area that uses imaging equipment to examine the heart ' s arteries and chambers and treat abnormalities) 5 hours after arrival to the Emergency Department (ED).

Findings include:

Review of Hospital policy titled, "SVH ED Triage Guidelines" reviewed on5/14/2021, included the following:

All patients presenting to the Emergency Department will be triaged by a specially trained Registered Nurse (RN) educated in Emergency Nursing. Immediate care and therapeutic interventions will be initiated in conjunction with the attending physician based on the needs of the patient.

Chest pain clearly not musculoskeletal or anxiety-related (possible cardiac).

ESI 1 or ESI 2 (Emergency Severity Index- a triage algorithm used to categorize patients based on acuity and resources needed:

Immediate ECG and presentation to ED attending.

Attach cardiac monitor and pulse oximetry.


Review of Hospital policy titled, "Patients Presenting to the Emergency Department with Chest Pain or Possible Acute Coronary Syndrome" reviewed on 4/27/2021, included the following:

-Identify guidelines for best practice care of the patient presenting with chest pain or possible acute coronary artery syndrome.

Implementation:

12 lead ECG-initial

Complete set of vital signs

NPO (nothing by mouth)

Consider diagnostic interventions. Attending physician available for consult.


Review of Hospital policy titled "Assessment and Reassessment of Patients" reviewed on 4/27/2021, included the following:

Assessment: Triage assessment differentiates severity of patient problems and prioritizes care by designating appropriate priority levels. The Department utilizes the Emergency Severity Index (ESI) 5 level triage system:

ESI 1 & 2: A condition requiring immediate medical attention. A time delay would be potentially harmful. This disorder is acute and potentially threatening to life and function.

ESI 3: A condition requiring medical attention within a reasonable amount of time. Possible danger exists if patient goes medically unattended.


The Hospital ' s Internal Investigation, dated 7/03/24, indicated that Patient #1 arrived to the Emergency Department (ED) by ambulance on 7/1/24 at 3:37 P.M. Patient #1 was triaged by Registered Nurse (RN)#1 at 4:10 P.M. and complained of chest pain 5/10. Patient #1 had heparin infusing IV on arrival and it was stopped after arriving to the ED and not restarted until 7:31 P.M. Patient #1 was not seen by a Physician until 5:56 P.M. Patient #1 was brought to the Cath Lab at 8:10 P.M. . and was pronounced dead at 9:19 P.M.

The Hospital's Internal Investigation indicated the Hospital failed to initiate an EKG within 5 minutes of arrival and a delay in medical screening exam.

Further review of the Internal Investigation indicated there was no documentation to support the Hospital developed or implemented any system wide corrective actions to prevent a like occurrence in the future.

Review of Ambulance run report indicated Patient #1 was being transported to an outside hospital with Cardiac-STEMI/PCI capable. Further review indicated Patient #1 had sub-sternal squeezing chest pain for duration of one day.

During the Survey on 9/6/24 at 10:00 A.M., the Surveyors reviewed the transfer call recording received from the Transfer Center on 7/1/24, which revelated Physician #1 accepted the transfer of Patient #1 for a STEMI. Further review of the recording indicated Patient #1 had a cardiac history, had concerning EKG changes, active chest pain, and initial troponin was below diagnostic limit.

Review of Patient #1's medical records included an ED Triage Form dated 7/1/2024 at 4:05 P.M. indicated Patient #1 was transferred from an outside Hospital for chest pain with concern for a Myocardial Infarction (MI). Patient #1 was assigned an ESI Level score of a 3 by RN#1. Further review indicated a physician order for a stat EKG dated 7/1/24 at 6:17 P.M.

Review of ED Physician Note, dated 7/1/2024 at 6:10 P.M., indicated Patient #1's chief complaint was concern for an MI and was brought in on a Heparin drip of 1200 units/hour. Impression indicated a STEMI and heart failure. Review of documentation of outside Hospital indicated an EKG at 1:00 P.M. showed ST elevation in V2-V6, T Inversions in V1. Further review indicated an EKG at the Hospital at 6:55 P.M. indicated progression of acute anterolateral infarct.

During an interview on 9/6/24 at 12:47 P.M., the Emergency Department Director said that a patient arriving to the Emergency Department with chest pain should have an immediate EKG within five minutes. The ED Director said if a patient arrives to the ED on IV Heparin the expectation would be for the nurse to get an order immediately from a physician to continue that medication. During an interview on 9/6/24 at 1:31 P.M. Registered Nurse (RN) #1 said she recalled taking report from the Emergency Medical Technicians (EMTs) on 7/1/2024 for Patient #1. RN #1 said she had been working alone in the Annex (a holding area generally used for patients waiting for an inpatient bed) part of the ED. RN #1 said she tried to get a physician to order the Heparin for Patient #1 but was unable to obtain an order to continue the medication. RN #1 was unable to recall if she notified a physician that Patient #1 was complaining of chest pain. RN #1 said she never got an EKG on Patient #1. RN #1 said she was taught how to triage in a classroom setting at the Hospital and everyone assigns ESI levels differently.

During an interview on 9/11/24 at 1:00 P.M. RN #3 said she took the Resource Nurse (also referred to as the Charge Nurse) assignment on 7/1/2024. RN #3 said that during shift change at 3:00 P.M., she received a report that Patient #1 would be coming to the ED as a transfer for a Non-ST segment elevation myocardial infarction (NSTEMI). RN #3 said she recalled assigning Patient #1 to RN #1. RN #3 said there should have been an EKG completed on Patient #1 immediately upon arrival but she was unsure if there was one completed. RN #3 said triage and ESI levels can have some variability but someone with a cardiac history and active chest pain should be assigned an ESI 1 or a 2.

During an interview on 9/10/24 at 11:26 A.M. Physician #1 said he doesn't recall receiving a STEMI transfer on 7/1/24. Physician #1 said he recalled accepting Patient #1 as an NSTEMI. Physician #1 said a STEMI was more urgent and time sensitive as heart muscles are at risk of damage. Physician #1 said if he was notified of a STEMI prior to the transfer to the ED, he would alert the Resource Nurse to ensure there was an EKG machine and a tech ready when the patient arrived. Physician #1 said a patient complaining of chest pain should receive an EKG within 5 minutes of arriving and the results immediately brought to a physician.