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Based on a review of the emergency department record of patient 1, it was revealed that over the course of almost 6 hours, no RN accessed a Licensed Independent Practitioner (LIP) to address patient #1's increasingly high blood pressures and level 10 pain as documented by nursing.

Patient 1 presented to the Emergency Department via Emergency Medical Services (EMS) in July 2016 at 15:47 reporting a left-sided headache that had been present for two weeks; pain of 10 where 10 is the worst pain, and was positive for a sensitivity to light. Patient #1 reported a history of Myocardial Infarction and Hypercholesterolemia, heart stent, hypertensive disorder, and Diabetes Mellitus. Patient #1 was triaged at a level three acuity which meant she was a stable patient who needed more than 2 resources to investigate and/or treat her condition.

A blood Pressure (BP) taken during a 1554 triage was 171/94 with 10/10 pain. Patient #1 remained with EMS, waiting for a room until 1800. At that time, she was taken to a room where her blood pressure (BP) was found to be 191/96 and she continued with 10/10 pain. An RN conducted an initial assessment and at 1838 rechecked the BP which was 156/92 with 8/10 pain.

At 2045 patient #1's BP was 199/95 with 10/10 pain. The Mayo Clinic defines a hypertensive crisis as a systolic of 180 millimeters of mercury (mm Hg) or higher or a bottom number (diastolic pressure) of 120 mm Hg or higher. Based on patient #1's blood pressures, patient #1 was experiencing a hypertensive crisis.

No record evidence was found to indicate that the RN notified an LIP of patient #1's elevated blood pressures, and no attempts were made to obtain pain medication for patient #1.

At 1935, patient #1 inquired of the nurse when she might be seen, and was informed that she would be seen as soon as possible. However, at 2118, patient #1 left without being seen. Based on all documentation, nursing failed to access a LIP to address patient #1's crisis level hypertensive crisis and pain.