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Based on a review of medical records, polices and procedures and other pertinent documents, it was determined that the hospital failed to provide timely evaluations and reassessments including vital signs and pain management for Patient #2 (P2), Patient #3 (P3), Patient #7 (P7), Patient #8 (P8) and Patient #10 (P10). This was evident for 4 out of 10 emergency department (ED) medical records reviewed.

Patient #2 (P2) was a 70+ year old patient who was transported to the ED by ambulance from a nursing home for evaluation after a syncopal episode (fainting or passing out). P2 was triaged by nursing staff approximately 20 minutes after arrival to the hospital. Two hours later nursing documented that the EMS personnel were taking the patient to another hospital for evaluation. No documentation was found during that two hours to support that repeat vital signs were completed, that a provider was aware of or had evaluated the patient or that a nursing assessment other than vital signs had been completed.

Surveyors reviewed the policy titled Adult Emergency Department (AED) Nursing Protocols dated June 2021. The policy is broken down in sections based on a patient's presenting symptoms. Under section B. Indication for Use it states, "1. Upon completion of triage, a primary AED nurse, or triage nurse, may initiate any of the following patient complaint specific clinical care protocols." Section II. Outlines the required orders and tests based on the patient complaint. The following sections pertain to P3, P7, P8 and P10.

C. Chest pain - 1. Obtain EKG within 10 minutes of arrival. Hand directly to physician. Obtain labs
2. Establish IV access
3. Chest radiograph (chest x-ray)
E. Fever & Cough
1. Begin 2 liters of oxygen via nasal cannula to maintain oxygen > 95%
2. Obtain chest radiograph (chest x-ray)
3. Administer Acetaminophen for fever > 38.0 (100.4)

J. Seizure
1. Inclusion criteria: complaint of recent seizure activity and/or arriving via
EMS post-ictal with stated complaints of seizure
3. Patient care orders: obtain labs, establish IV access, initiate oxygen, obtain
EKG

Patient #3 (P3) was a 60+ year old patient who presented to the ED with complaints of chest pain and shortness of breath. Vital signs were completed within 10 minutes of arrival and P3's blood pressure was noted to be well outside the normal range of less than 120/80. P3's pain was described as 'ongoing, continuous with aching chest pain.' Approximately nine hours after P3 presented to the ED, his/her disposition was set to 'left prior to completing treatment.' No documentation was found during that nine hours to support that an EKG was completed per hospital protocol for the symptom of chest pain, that vital signs were reassessed or that P3's pain was addressed.

Patient #7 (P7) was a 40+ year old patient who was brought to the emergency department (ED) by ambulance with complaints of cough, fever, and shortness of breath. P7's medical history was significant for diabetes, a chronic heart condition in which fluid accumulates around the heart, high blood pressure and an internal pacemaker (device implantable inside the body, able to perform defibrillation, cardioversion and pacing of the heart).The triage vital signs and assessment were documented over an hour after the patient arrived in the ED. No pain score was documented in the medical record. It was noted that the patient had a fever over 102 degrees.

A telemedicine evaluation was documented an hour after the nursing triage which was two hours after P7 arrived at the ED. Stat (immediately) orders were placed for an EKG (recording of the electrical signal from the heart to check for different heart conditions), chest x-ray and bloodwork. An hour later P18 was listed as 'dismissed' from the ED without completion of the above orders. No additional document was found in the chart to explain the disposition of the patient or why the stat orders were not completed.

P7 presented to the ED two months later with complaints of chest pain, shortness of breath and a productive (mucous) cough. P7's medical history was significant for diabetes, a chronic heart condition in which fluid accumulates around the heart, high blood pressure and an internal pacemaker (device implantable inside the body, able to perform defibrillation, cardioversion and pacing of the heart). Nursing staff completed a triage assessment including vital signs within an hour of P18's arrival to the ED. A fingerstick glucose check was also completed and found to be almost 300 (normal range is 80-130 per the American Diabetes Association). The patient's pain level was documented as a 7 out of 10.

A telemedicine evaluation was documented at approximately the same time and stat orders were placed for an EKG, a chest x-ray and bloodwork. The next timestamped note in the record was over three hours later which stated, "Room call." Nursing staff documented that P7 was called three times with no response and eventually 'dismissed' from the ED approximately seven hours after he/she arrived and requested treatment. No documentation was found during the three hours from the time the stat orders were placed to the first patient call to support that the orders were completed, that P7 was reassessed or that repeat vital signs were performed. Furthermore, no documentation was found to support that the patient's reported pain level of 7 out of 10 was addressed.

Patient #8 (P8) was a 30+ year old patient who was transported to the emergency department (ED) by ambulance for evaluation after multiple seizures per the patient's family member. The family member also stated P8 had been altered and confused for past couple of days. A set of vital signs were documented shortly after P8 arrived in the ED; however, the nursing triage assessment was not documented until approximately one hour later. No pain score was documented.

A telemedicine evaluation was completed approximately 30 minutes after the nursing assessment. At that time, bloodwork, an EKG, and a urine test were all ordered stat (immediate). Approximately 1 ½ hours later, P8's disposition was listed as "set to discharge." No additional documentation was found in the medical record to explain why the disposition of the patient was set to discharge or why the stat orders had not been completed.

Patient #10 (P10) was a 40+ year old patient who presented to the emergency department (ED) with complaints of chest pain and worsening shortness of breath. A nursing triage assessment was completed approximately 30 minutes later and an EKG was completed at that time. The EKG results were listed as "abnormal" compared to P10's previous EKG two months prior. P10 rated his/her chest pain as an 8 out of 10. No bloodwork was obtained as required by the nursing protocols.

Five hours after P10 arrived at the ED, the medical record noted "dashboard physician assigned", and then "provider deficiency created" and finally "remove attending." No other documentation was found to support that P10 was called to a bed or evaluated by a provider. The final disposition noted was listed as "left prior to completing treatment"; however, this was not until approximately 12 hours after P10 presented to the ED requesting treatment. Furthermore, no documentation was found to support that P10's pain was addressed.

Based on a review of medical records, polices and procedures and other pertinent documentation it was determined that the hospital failed to 1.) provide timely emergency care for Patient #4 (P4) who presented to the emergency department with signs and symptoms of a stroke, and 2.) follow the hospital's policy for the rapid facilitation of critical tests for Patient #7 (P7), and Patient #8 (P8) as evidenced by stat (immediate) orders not being completed.

1.) Surveyors reviewed the hospital document titled, "The Maryland Stroke and Brain Attack Center Adult Emergency Response to Acute Stroke Patients Guideline." Under the section 'Procedure, d. the patient will be transported on the EMD stretcher to CT with ED staff.' Additionally, according to the workflow analysis on page 2 of this document, after the hospital consults with emergency medical staff (EMS), the next step is for the charge nurse or designee to call CT with an estimated time of arrival (ETA). It was confirmed by the director of regulatory compliance that this document was provided to nursing and physician staff for training.

P4 was a 40+ year old who presented via ambulance to the ED with stroke-like symptoms. P4 had altered mental status (AMS), right sided weakness, facial droop, incontinence, and slurred speech. Medical history of patient includes hypertension, diabetes, and alcoholic cirrhosis. Per family, P4's last known well time (LKWT) was 2 days prior. Family called 911 requesting a well check at the patient's home and P4 was found on the floor of his/her home by emergency medical services (EMS upon arrival.

On arrival to the hospital, EMS personnel in the hallway just outside of the entrance of the doors leading the main ED. P4 remained in the hallway with EMS personnel for 2 hours before an ED triage RN came out to assess patient. Vital signs and a glucose fingerstick were completed at that time. Per nursing documentation, an ED provider was made aware of the patient's altered mental status and facial droop. P4 was evaluated and a medical screening was completed approximately 30 minutes after the patient was triaged. Bloodwork, an electrocardiogram (EKG), chest Xray and a computerized tomography (CT) scan were ordered. Results of the CT showed that P4 had an intracranial hemorrhage (ICH - bleeding inside the brain). Care was initiated in the ED and P4 was admitted to the Neuro-intensive care unit (ICU) treatment.

According to the American Stroke Association guidelines, ICH is a medical emergency. Rapid diagnosis and management of patients with ICH is crucial. Rapid neuroimaging with CT or MRI is the recommendation to distinguish ischemic stroke from ICH (Hemphill et al., 2015).

2.) Surveyors reviewed the policy titled, Critical Tests and Critical Test Results dated August 2022. Under section II. Responsibility - Nurses it states, "Nurses are responsible for collecting and sending lab specimen(s) in a manner that facilitates rapid conduct of a critical test" and "Nursing and/or unit staff notifies the appropriate diagnostic service and/or requests patient transportation in a manner that facilitates rapid conduct of a critical test."

P7 was a 40+ year old patient who was brought to the emergency department (ED) by ambulance with complaints of cough, fever, and shortness of breath. P7's medical history was significant for diabetes, a chronic heart condition in which fluid accumulates around the heart, high blood pressure and an internal pacemaker (device implantable inside the body, able to perform defibrillation, cardioversion and pacing of the heart).The triage vital signs and assessment were documented over an hour after the patient arrived in the ED. No pain score was documented in the medical record. It was noted that the patient had a fever over 102 degrees.

A telemedicine evaluation was documented an hour after the nursing triage had been completed. Stat (immediately) orders were placed for an EKG (recording of the electrical signal from the heart to check for different heart conditions), chest x-ray and bloodwork. An hour later P18 was listed as 'dismissed' from the ED without completion of the above orders. No additional document was found in the chart to explain the disposition of the patient or why the stat orders were not completed.

Two months later, P7 returned to the ED with complaints of chest pain, shortness of breath and a productive (mucous) cough. Nursing staff completed a triage assessment including vital signs within an hour of P7's arrival to the ED. A fingerstick glucose check was also completed and found to be almost 300 (normal range is 80-130 per the American Diabetes Association).

A telemedicine evaluation was documented at approximately the same time and stat orders were placed for an EKG, a chest x-ray and bloodwork. The next timestamped note in the record was over three hours later which stated, "Room call." Nursing staff documented that P7 was called three times with no response and eventually 'dismissed' from the ED approximately seven hours after he/she arrived and requested treatment. No documentation was found during the three hours from the time the stat orders were placed to the first patient call to support that the orders were completed.

P8 was a 30+ year old patient who was transported to the emergency department (ED) by ambulance for evaluation after multiple seizures per the patient's family member. The family member also stated P8 had been altered and confused for past couple of days. A set of vital signs were documented shortly after P8 arrived in the ED; however, the nursing triage assessment was not documented until approximately one hour later. No pain score was documented.

A telemedicine evaluation was completed approximately 30 minutes after the nursing assessment. At that time, bloodwork, an EKG, and a urine test were all ordered stat (immediate). Approximately 1-2 hours later, P8's disposition was listed as "set to discharge." No additional documentation was found in the medical record to explain why the disposition of the patient was set to discharge or why the stat orders were not completed.

(Hemphill, C.J., Greenberg, S., Anderson, C., Becker, K., Bendok, B., Cushman, M., Fung, G., Goldstein, J., Macdonald, L., Mitchell, P., Scott, P., Selim, M., & Woo, D. (2015). Guideline for the management of spontaneous intracerebral hemorrhage; A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46(7), Issue 7, 2032-2060. https://doi.org/10.1161/STR.0000000000000069)