HospitalInspections.org

During EMTALA investigation of complaint #TN44574 completed 5/14/18 to 5/16/18 at Leconte Medical Center violations were found and the facility was found to be out of compliance with Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 482 for delay in providing a Medical Screening Examination (MSE) and delay in providing treatment for one patient (#4) of 35 Emergency Department (ED) patients reviewed. The facility's failure resulted in Patient #4, who presented to the facility's ED on 1/3/18 at 9:14 PM with the complaint of Chest Pain, waiting in the ED waiting room for 24 minutes without being triaged or assessed until after he had collapsed on the lobby floor at 9:34 PM. Patient #4 expired at 10:16 PM on 1/3/18 in the ED.

Refer to A-2406.

Based on facility policy review, observations of a facility security video, medical record review, and interviews, the facility failed to provide a timely medical screening examination (MSE) for 1 patient (#4) of 35 Emergency Department (ED) patients reviewed. The facility's failure to provide a timely MSE for a patient with a complaint of chest pain resulted in the patient collapsing on the ED waiting room floor and subsequent death.

The findings included:

Review of facility policy "Emergency Medical Treatment & Labor Act (EMTALA) Guidelines" dated 1/2014, revealed "...Triage - Refers to the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be seen by a physician or other qualified medical personnel (QMP) for completion of the Medical Screening Examination...A Medical Screening Examination (MSE) will be performed for any individual that 1) presents on hospital property and requests examination or requires treatment for what may be an emergency medical condition; 2) has such a request for examination or treatment made on his or her behalf; or 3) appears to require emergency examination based on his/her appearance...Each designated emergency department will follow their normal triage and evaluation/treatment policy and procedures, perform the medical screening examination, and initially stabilize the patient...The hospital will follow reasonable registration processes for all individuals who come to the emergency department. The collection of information should not delay the medical screening examination or treatment..."

Review of facility policy "Emergency Department Nursing Standing Orders/Clinical Pathways" dated 3/2017, revealed "...Purpose: To provide a pathway to timely coordinated care of patients with specific symptoms...ED NURSING STANDING ORDERS...Chest Pain...Nursing Standing Order Set...EKG [electrocardiogram, test to assess the electrical impulse of the heart] in triage - present to provider for rapid interpretation..."

Review of a facility security video recording of the ED waiting room dated 1/3/18 revealed:
9:14:45 PM Patient #4 entered the ED, walked to a chair in the waiting room, and sat down while his wife went to the registration desk to check him in.
9:17:49 PM the patient's wife completed the sign in sheet and sat down next to the patient, with the patient and his wife in direct sight of two ED Techs working at the registration desk.
9:19:50 PM the patient walked to the bathroom (approximately 30 yards) accompanied by his wife.
9:23:16 PM ED Tech #2 left the registration desk and ED Tech #1 remained at the registration desk.
9:23:53 PM the patient and his wife returned to the waiting room from the bathroom. ED Tech #1 was working at the registration desk and was in direct sight of the patient.
9:31:24 PM the patient appears to say something to his wife and reaches his hand out to her and then his head slumps down and forward. The patient's wife spoke to him and was rubbing his shoulder as she appeared to look toward the registration desk where ED Tech #1 was working.
9:31:45 PM the patient slumped back into his chair in very obvious physical distress in sight of ED Tech #1.
9:32:32 PM ED Tech #1 appeared to look at Patient #4.
9:32:57 PM ED Tech #1 walked away from the registration desk and appeared to speak to the patient and/or his wife.
9:33:15 PM ED Tech #1 returned to the registration desk, appeared to look at something on the registration desk, and then turned toward the triage room window.
9:33:36 ED Tech #1 appeared to speak to someone and then turned back to the registration desk.
9:33:48 PM the patient slumped back in his chair while his wife was rubbing his chest and speaking to him. His wife appears to look at the ED Tech at the registration desk.
9:34:13 ED Patient #4 remains slumped back in his chair.
9:34:28 ED Tech #1 appeared to speak to someone at the triage window.
9:34:42 PM ED Tech #1 left the registration desk and went into the ED treatment area.
9:35:07 PM ED Tech #1 returned to the waiting room with a wheelchair.
9:35:18 to 9:35:39 PM ED Tech #1, the patient's wife, and 3 other unknown visitors in the ED attempted to put Patient #4 into the wheelchair but the patient was unable to stand and transfer to the wheelchair, the patient then collapsed and was lowered onto the floor.
9:36:03 two nurses entered the waiting room lobby, walked over to the patient, and one nurse appeared to speak into a radio or phone.
9:36:20 two nurses remain with the patient while the patient appears limp on the floor.
9:36:32 ED Physician #1 entered the waiting room lobby and examined the patient.
9:37:42 ED Tech #1 arrived with a stretcher and the patient was placed on the stretcher.
9:38:17 PM the patient was taken back into the ED treatment area and was out of sight of the video cameras (24 minutes after arrival).

Medical record review revealed of an "EMERGENCY SIGN-IN SHEET" dated 1/3/18 at 9:15 PM revealed the wife wrote the primary reason for Patient #4's visit was "...chest pain..." Further review revealed Patient #4 was registered in the computer on 1/3/18 at 9:22 PM by ED Tech #1.

Medical record review of a Physician's Physical Exam dated 1/3/18 at 9:34 PM revealed "...Circulatory: IRREGULAR, THREADY, BRADYCARDIC PULSE, LOST PULSE..." Continued review revealed "...History of Present Illness...Exam started at 21:38 [9:38 PM]...PT [patient] PRESENTS TO ED C/O [complains of] CHEST PAIN ONSET PRIOR TO ARRIVAL. PHYSICIAN CALLED TO LOBBY FOR POORLY RESPONSIVE PT. ON PHYSICIAN ARRIVAL, PT ON HIS BACK IN LOBBY POORLY RESPONSIVE. CHEST PAIN RADIATES DOWN LEFT ARM, PER PT'S WIFE..."

Medical record review of a Nurse's Triage and Nursing History dated 1/3/18 at 9:50 PM revealed "...Entered room code in progress...assigned to bed ED1..."

Medical record review of a Physician's Progress Notes dated 1/3/18 at 10:16 PM which revealed "...ACLS [Advanced Cardiac Life Support] PROTOCOLS WERE FOLLOWED WITH NO RETURN OF SPONTANEOUS CIRCULATION. PATIENT EXPIRED IN THE DEPARTMENT AT 01/03/2018 22:16 [10:16 pm] EST..."

Interview with ED Tech #2 on 5/14/18 at 5:10 PM, in the administration conference room, revealed he was working on 1/3/18 when Patient #4 presented to the ED. Further interview revealed he never saw or treated Patient #4 because his shift had ended and ED Tech #1 was coming on duty. Continued interview revealed there was a surge of patients in the ED and they had approximately 5 patients come in at the same time as Patient #4. Further interview he left the ED shortly after Patient #4 arrived and he was not there when the patient collapsed.

Interview with ED Tech #1 on 5/15/18 at 7:50 AM, in the administration conference room, revealed he was the ED Tech working the registration desk on 1/3/18 when Patient #4 presented to the ED. Further interview revealed "...it got very busy...there were a bunch of sign in sheets on the desk to be entered, 6 or 7 to catch up on...then several patients came in at once..." Continued interview revealed Patient #4 arrived with his wife and while his wife filled out the registration form, the patient sat down in the back of the waiting room. Further interview revealed "...[ED Tech #2] was still beside me, I told him the patient needed an EKG, but when we looked the patient had gone to the bathroom..." Further interview revealed "...when he [Patient #4] came back from bathroom, he looked bad, his color wasn't good...I told the triage nurse about him and pointed him out to her...It was all very busy and she was trying to get report from the nurse going off [duty]...we were signing in more people and I was keeping an eye on him, but he looked worse...I went to see if he had been triaged yet...I told the triage nurse he looked rough and we needed to get him next...I saw him slumped in his chair and I went to check on him and he had a carotid [pulse] and he was conscious but not responsive...he had a pulse and respirations...I got a wheelchair and then I got a stretcher, several nurses and [Physician #1] responded...we picked him up and put him on the stretcher and took him into the ED...we had to clear a patient out of room #1 and put [Patient #4] into room #1...I went back up front [front registration desk]..."

Telephone interview with Registered Nurse (RN) #1 on 5/15/18 at 8:00 AM revealed she was the triage nurse on duty when Patient #4 presented to the ED on 1/3/18. Further interview revealed she arrived late for work that night and was in the process of taking report from the RN going off duty. Continued interview revealed "...it was crazy busy...a lot was going on...[ED Tech #1] told me there was a patient...looking pretty bad..." Further interview revealed RN #1 told ED Tech #1 to check on the patient but the patient was in the bathroom. Continued interview revealed she told the ED Tech to ask the patient if he had been triaged and "...If not triaged we will get him next..." Further interview revealed the ED Tech told her (unknown time) the patient was down on the floor and the ED Tech went to get a wheelchair for the patient. Continued interview revealed she next heard the ED Tech call for a stretcher and additional help with the patient and at this time RN #1 went out to see the patient in the waiting room. Further interview revealed Physician #1 and "...several people..." came out with a stretcher and transferred the patient back into the ED. Continued interview revealed RN #1 was no longer doing triage.

Interview with Physician #1 on 5/15/18 at 12:30 PM, in the ED Decontamination room, revealed he was the ED Physician who treated Patient #4 on 1/3/18. Further interview revealed Physician #1 was called to the waiting room lobby and found the patient lying on the floor. Continued interview revealed the patient had no pulse and was breathing agonally (a gasping/abnormal pattern of breathing) when assessed by the physician. Further interview revealed resuscitation was attempted but unsuccessful and the patient expired.

Interview with the ED Manager on 5/15/18 at 1:52 PM, in administration conference room, revealed the ED experienced a surge of patients at the time Patient #4 arrived on 1/3/18. Further interview revealed the facility did not have a formal "surge response policy," at that time, and was currently developing one, but it had not been approved. Further interview revealed the facility had an informal surge response process, which involved notification to administration by ED staff via phone call or text message of the ED situation by ED staff. Further interview revealed on 1/3/18 the facility's 30 bed ED had 54 patients present in the ED and a Surge notification page was sent out on 1/3/18 at 7:21 PM. Continued interview revealed the ED Manager received a text message on /3/18 at 7:21 PM stating "...4 admit holds...2 TF [transfers]...5 psych holds...20 [patients] in lobby...short staffed..." Further interview with the ED Manager and review of the ED Staffing on 1/3/18 revealed the facility was short 1 ED tech for the evening shift.

Interview with the facility's Risk Manager on 5/15/18 at 4:30 PM, in the conference room, revealed the facility identified the treatment of Patient # 4 on 1/3/18 as a safety event and had investigated the event. Further interview revealed the facility identified areas of improvement included:
1. Processes for managing flow of patients in the ED
2. A formal process for responding to surges in patient volume in the ED.
3. Employee's understanding of triage procedures and managing acutely ill patients.
Further interview with the risk manager revealed the facility had put the following interventions in place to address the identified problems:
1. The 3 Employees (triage nurse and both ED techs) involved in the event were suspended during the investigation. The employees received education on Triage Procedures, Chest Pain Protocols, Performing and managing EKGs, Lobby Management, managing acutely ill patients, and communication skills. The triage nurse was removed from performing triage during the investigation and only nurses who have completed a training course on triage and with experience in triage are used as triage nurses. All ED employees were trained on EMTALA requirements, Chest Pain protocols, management of acute patients, and lobby management.

2. Risk Management and Quality Improvement evaluated the process flow/throughput of patient flow through the ED. A management engineer was consulted to review the ED process for possible improvements. The evaluation of the ED process begun on 2/5/18, was currently ongoing, and continuous for re-evaluation and improvements.

3. The ED sign in sheets were being evaluated for changes and updating.

4. Triage education was provided to all the ED nurses by the facility Educator and was completed by 2/13/18.

5. Education on Lobby Management was provided to the ED Techs with a goal to improve efficiency and speed up flow in the ED waiting room. ED Techs were educated on roles and expectations when doing quick registration of patients. Additional education on assessments, communication, and maintaining environment were included as well.

6. A Mid-level provider (Physician Assistant/Nurse Practitioner) has been hired and placed in Triage area starting 2/28/18 to reduce the door to provider time and to reduce the time for completion of a MSE.

7. The ED manager developed a handoff sheet for ED techs for front desk and for triage nurses to use during shift change. Staff was educated on use of the handoff sheet and it was put into use on 2/28/18. Form facilitated communication and coordination of shift change. Observations during the investigation revealed the handoff sheet was currently used by staff.

8. A multi-level ED surge plan is being developed that will be rolled out when completed, to improve the facility's response to patient surges in the ED. At the time of this investigation the new ED Surge Plan had not been approved for use.

9. All Triage and other ED nurses were educated to go into the lobby and evaluate patients in person to determine order of acuity. The goal was for a quick assessment and to improve the triaging of patients by degree of emergent presentation.

10. The ED Manager was currently monitoring 20 records per month for EMTALA compliance, and EKG times for chest pain patients were tracked and reported to Quality Assurance monthly.

Telephone interview with Patient #4's wife on 5/22/18 at 9:45 AM revealed the patient began having pain in his chest on 1/3/18 at approximately 8:30 PM and the wife gave him one nitroglycerin tablet (medication for chest pain) and he became sick after taking it. Further interview revealed the wife took the patient to the ED at 9:15 PM and told the ED staff at the registration desk "...he [Patient #4] is having chest pain radiating down his left arm...I wrote this on the sheet...there were about 12 others [patients] ahead of us with flu symptoms, throwing up in buckets and trash cans...we sat there [in waiting room lobby] and they called people back with the flu ahead of us...one time a nurse stuck her head out the window and asked the young kid [ED Tech] at the desk how he [ED Tech] was doing and the kid answered he was ok and just putting them [registering patients] in the computer in the order they came in...around 9:45 he [Patient #4] looked at me and said 'honey I hope they are going to call me soon,' I said me too...he fell over on me, his eyes rolled back into his head, and he made a gurgling sound and went limp in his chair...no one at counter came to help me, another patient came and tried to help me...they paged the doctor three times before he came out with 2 nurses...he [Patient #4] was laying on the floor and the doctor felt for a carotid and asked the nurse do you have a pulse, the doctor said we need to get him back and started to pick him up...they took their sweet time getting him to the room...about 15-20 minutes later they told me he had passed..."