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Based on interviews and records reviewed, the Hospital failed to ensure physician orders were followed for 1 patient (Patient #2) out of a total sample of 10 patients. The Hospital failed to ensure an Electrocardiogram (ECG) was completed as ordered for Patient #2.

Cross Reference:

482.55(a): Organization and Direction (A-1104)

Based on interviews and records reviewed, the Hospital failed to ensure physician orders were followed for 1 patient (Patient #2) out of a total sample of 10 patients. On 1/3/25 Patient #2 arrived at the Emergency Department (ED) via ambulance with reports of auditory hallucinations and feeling more anxious. After Patient #2 ' s arrival to the ED on 1/3/25, Physician #1 ordered an Electrocardiogram (ECG) for Patient #2 which was not completed by staff.

Findings included:

Patient #2 arrived at the ED on 1/3/25 at 7:54 A.M. via ambulance for complaints of mania, hearing voices, and not taking his/her medications for 3 days. Patient #2 ' s documented vital signs on 1/3/25 at 8:14 A.M. indicated a pulse rate of 108 (normal rate is between 60-100 beats per minute). Review of Patient #2 ' s ED Provider Note filed on 1/4/25 at 7:18 A.M. indicated that Physician #1 evaluated the Patient on 1/3/25 at 9:53 A.M. and ordered an ECG (a non-invasive test that measures the heart ' s electrical activity) to evaluate cardiac conduction. The Note further indicated that Physician #1 determined Patient #2 was medically stable for a psychiatric evaluation by the crisis team, who determined that Patient #2 required an involuntary inpatient psychiatric admission.

Further review of Patient #2 ' s medical record failed to indicate that the ECG ordered for Patient #2 on 1/3/25 at 9:57 A.M. was completed as ordered.

Patient #2 was moved from the main ED to a room in the ED Annex (an area for medically stable patients awaiting psychiatric bed placement) on 1/3/25 at 4:07 P.M. Patient #2 was reassessed, and vital signs were obtained on 1/3/25 at 8:47 P.M. and he/she was administered medications as ordered by Registered Nurse (RN) #1.

On 1/4/25 at 6:05 A.M., RN#1 entered Patient #2 ' s room to administer his/her early morning medication and observed Patient #2 to be apneic (not breathing), cyanotic (skin has a bluish tint due to low oxygen blood levels) and pulseless. A Code was called, and cardiopulmonary resuscitation (CPR) was initiated. Review of ED Provider Note written by Physician #2 on 1/4/25 at 7:15 A.M. indicated that Patient #2 ' s time of death was called on 1/4/25 at 6:28 A.M. The Medical Examiner ' s office was contacted repeatedly and declined Patient #2 ' s case.

During an interview on 4/3/25 at 9:54 A.M., Physician #1 said he performed the medical exam for Patient #2 on 1/3/25. The Physician said he couldn ' t remember specifically why he ordered the ECG for Patient #2 but that in general he will order an ECG if a patient has a heart rate over 100. He said he also may have ordered an ECG if he anticipated a patient might be restarted on an antipsychotic medication. Physician #1 said his expectation was that if patient orders are not followed and if an order can ' t be completed, he would expect staff to inform him.

During an interview on 4/3/25 at 3:38 P.M., the ED Clinical Nurse Coordinator said after this event he met with RN #1 to debrief. The ED Clinical Nurse Coordinator said that he had a general discussion with RN#1 regarding following physician orders. The ED Clinical Nurse Coordinator said this was not discussed with other nurses, nor was there any written documentation of what was discussed or formal re-education completed regarding following orders.

During an interview on 4/08/25 at 9:11 A.M., RN#1 said he worked from 7:00 P.M.- 7:00 A.M. on 1/3/25-1/425 and was assigned to Patient #2 in the Annex. RN #1 said he received verbal report from the off-going nurse regarding Patient #2 and said that verbal report indicated Patient #2 was medically stable. RN#1 said he was not aware of any outstanding labs or orders, nor were any reported to him. He said Patient #2 was alert and oriented and had no complaints. RN#2 said he administered Patient #1 his/her 9:00 P.M. medications as ordered. RN #2 said he remembered hearing Patient #2 snoring during the night and seeing him/her move around in the med. RN #2 said he went to give Patient #2 his/her 6:00 A.M. medications on 1/4/25 and attempted to wake him/her with no response. RN #1 said he turned the light on and did a pulse check, and when he was unable to feel a pulse, he told the patient care tech to call a Code, and he began CPR. RN #1 said there was a robust response to the code but unfortunately Patient #2 was unable to be resuscitated. RN #1 said after the event, he participated in the hospital ' s risk review and that he remembered learning that an ECG was ordered for Patient #2, and the ECG was not completed but said he was unaware of any education being completed regarding the ECG not being completed.

During an interview on 4/08/25 at 11:20 A.M. the Executive Director of Risk Management said the Hospital reviewed Patient #2 ' s medical record and event and identified an ECG ordered was not done. She said the Hospital did not have any documentation to support system wide corrective measures were developed or implemented in response to staff failing to complete a physician ' s order.