HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure all licensed nurses provided patient care services according to hospital's policies and procedures for four (4) of 31 sampled patients (Patient 4, Patient 14, Patient 13, Patient 23) when:

1. Patient 4 on Insulin drip (medication to treat high blood glucose levels via the veins) was not checked for blood glucose/sugar level every hour as ordered by the physician.

2. The crash cart (containing emergency medications and equipment used to revive patients who are not breathing and the heart stops beating) used for Patient 14 was left open and unattended.

3. A time-out (the surgical team's short pause, just before incision, to confirm that they are about to perform the correct procedure on the correct body part of the correct patient) as indicated on the Universal Protocol for Wrong Site Surgery and Attachments was not conducted prior to a placement of an emergency central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided/threaded into a large vein above the right side of the heart) and an arterial line (a flexible tube into the opening of an artery to provide a continuous display of a person's Euro (Trademark)s blood pressure with access to frequent arterial blood sampling) for Patient 13.

4. A comprehensive pain assessment, including location of pain for proper treatment, for Patient 23 was not completed.

This deficient practice had the potential to result in:

1. Decline in Patient 4's health from unchecked blood glucose when Patient 4 was started on an insulin drip (medication used to treat high blood glucose directly to the blood stream). If left unmonitored, could result in untherapeutic levels of the medication, which is life-threatening.

2. Visitors' access to and loss of unsecured life-saving medications that were stored in an unlocked crash cart at Patient 14's bedside.

3. Incorrect site placement of invasive, life-saving catheter or tubes, inside Patient 13.

4. Harm to Patient 23's quality of life having two consecutive, incomplete pain assessment documentation. If improperly treated, could lead to physical or psychological harm.

Findings:

1. During a concurrent interview and record review on 8/3/22, at 10:00 a.m., with Nurse Informatic (NI), Patient 4's "Order Sheet,"t dated 8/1/22 was reviewed. The Order Sheet indicated, "Insulin regular, continuous IV, notify Medical Doctor (MD) if BG falls below 200." Patient 4's MD Orders, dated 8/1/22 was reviewed. The MD Orders indicated, "Blood Glucose by Nursing, Every hour." Patient 4's "Point of Care Tests (POC)," dated 8/1/22 was reviewed. The POC indicated, Patient 4's BG at 7:36 p.m. was 281. The POC indicated, the following BG at 9:37 p.m. was 227. NI stated, there was a missing BG level between 7:36 and 9:37 for Patient 4.

During a review of Patient 4's "Admission H&P" (H&P), dated 8/1/22, the "H&P" indicated, Patient 4 was admitted for complaint of left flank (space between the ribs and hip) pain. The "H&P" indicated, Patient 4 had a complicated history of pancreatic (a digestive organ that produces insulin) inflammation (immune system response).

During a review of the facility's P&P titled, "Insulin Administration," dated 12/12/17, the P&P indicated, "Policy: 1. The physician's orders will be checked against the Medication Administration Record (eMAR)."

2. During an observation on 8/2/22, at 12:45 p.m., there was one visitor at patient's bedside in patient's room in Cardiac Care Unit (CCU, unit for patient with heart problems).

During a concurrent observation and interview on 8/2/22, at 12:48 p.m., with Registered Nurse (RN) 1, in Patient 14's room in CCU, a crash cart was unlocked, with defibrillator pads (an essential part of any lifesaving Automated External Defibrillator machine) attached to Patient 14's chest and connected to the Electrocardiography (EKG, displays the electrical signal from the heart to check for different heart conditions) monitor. The EKG monitor on the crash cart was turned off. RN 1 stated, "The crash cart has been here since night shift. It (the crash cart) was used and left at bedside for easy access because the patient is very unstable."

During an interview on 8/2/22, at 12:43 p.m., with charge nurse (CN), CN stated, "I checked the crash cart in the morning, at the start of my shift. All medications are ready to go for another code. The crash cart has been here since night shift because he is very unstable. If I need another crash cart, I can grab the other crash cart from the other side of the CCU." CN stated, the crash cart will be moved out of the patient room, "Either when the patient crashes again and we need to change out drugs, or if he stabilizes."

During a review of the facility's P&P titled, "Cardiopulmonary - Code Blue and/or Code White Response," dated 3/22/21, the P&P indicated, "8. Emergency Crash Cart Checks,
A. 1. The cart shall be checked to assure that it is locked and that the earliest expiration dates of the supplies and medications are clearly visible on the exterior of the cart." Also "3. Assure supplies outside the cart are available and locks are in place."

3. During a concurrent interview and record review on 8/3/22, at 9:00 a.m., with STEMI Coordinator (SC), Patient 13's "Intakes & Output (I&O)/iNet (where facility document time-out for procedures)," dated 7/22/22, at 3:23 a.m. and 3:28 a.m. were reviewed. The I&O's indicated, Patient 14 did not have a time-out (the surgical team's short pause, just before incision, to confirm that they are about to perform the correct procedure on the correct body part of the correct patient) documented for placement of an emergency central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided/threaded into a large vein above the right side of the heart) and an arterial line (a flexible tube into the opening of an artery to provide a continuous display of a person's blood pressure with access to frequent arterial blood sampling). SC stated, there was no nursing documentation of the procedure in Patient 13's medical records.

During a review of the facility's P&P titled, "Universal Protocol for Wrong Site Surgery and Attachments," dated 3/8/22, the P&P indicated, "Procedure 1. P: "Time-out" must be performed immediately before starting the procedure. The "time-out" process shall be conducted in the location where the procedure will be done and shall involve the entire operative procedural team. All members of the team shall engage in the time out process and individually respond to verify the following using the consent:
(1) Correct patient identity
(2) Confirmation that the correct side and site are marked
(3) Consent form is accurate
(4) Agreement on the procedure to be done
(5) Correct patient position (critical step for the spine procedure)
(6) Correct implants present
(7) Relevant images and results are properly labeled and displayed
(8) Pre-op antibiotic given
(9) Safety precautions based on patient history or medication use."

The P&P indicated, "Procedure 1. S: All components of the above process shall be completed and documented in the Electronic Health Record (see prior to the start of the procedure)."

4. During a concurrent interview and record review on 8/4/22, at 11:00 a.m., with STEMI Coordinator (SC), Patient 23's "Pain Assessment (a broad concept involving clinical judgment based on observation of the type, significance and context of the individual's pain experience)," dated 7/18/22 was reviewed. The "Pain Assessment" indicated, Patient 23's pain level (pain scales, a numerical scale from 0 [zero] to 10, Zero means no pain, and as 10 is the worst possible pain) was assessed as a, "10 = worst possible pain," at 1:48 a.m. The "Pain Assessment" indicated that Patient 23's pain level was assessed as a "9" at 5:53 a.m. SC stated, there was no other description of Patient 23's pain level documented in her (Patient 23) medical records. SC stated, there were incomplete documentation for consecutive pain assessments performed on Patient 23 at 1:48 a.m. and 5:53 a.m.

During a review of Patient 23's, "Admission H&P" (H&P), dated 7/18/2022, the "H&P" indicated, Patient 23 was admitted for complaints of severe left leg pain related to recently amputated (surgically removed) left foot operation. The "H&P" indicated, Patient 23 has a complicated history of peripheral artery disease (a condition that blocks blood from the heart to the legs).

During a review of the facility's P&P titled, "Pain Management", dated 11/19/18, the P&P indicated, "Procedure, A. 2. Should the patient express the presence of pain, a comprehensive pain assessment will be completed using the following criteria: location of pain, intensity of pain, using a 0-10 pain scale, quality of pain, using the descriptive words of the patient, alleviating factors, aggravating factors, how the pain effects the patient's quality of life, associated symptoms, barriers to effective pain relief, physical examination of the pain site, and the patient's goal for relief."

Based on interview and record review, the facility failed to immediately draw within 15 minutes ordered laboratory test (diagnostic exam used to help diagnose or screen for a specific disease or condition) by the Emergency Department Medical Doctor (EDMD) in accordance with the hospital's policies for three of 31 patients (Patient 1, Patient 6, and Patient 22).

This deficient practice resulted in delay in carrying out the EDMD orders and delayed laboratory result to for Patient 1, Patient 6, and Patient 22.

Findings:

1. During a review of Patient 1's "ED (Emergency Department) Note-Physician" (ED Note), dated 5/24/22, the "ED Note" indicated, Patient 1 "with h/o DM (diabetes mellitus, a disease that results in too much sugar in the blood), s/p gastric bypass (weight-loss surgery that involves creating a small pouch from the stomach and connecting to the small intestine), s/p hysterectomy (removal of the uterus), presents to the ED via Emergency Medical Services (EMS with husband for worsening SOB".

During a review of Patient 1's MD Orders, dated 5/24/22, the MD Orders indicated, "Blood Culture (a test that checks for microorganisms), Stat collect (urgent or immediate)" and "Lactic Acid Level (indicates severity of a condition), Blood, Stat collect" at 12:54 p.m. The MD Orders indicated, "Complete Blood Count With Auto Differential (level of blood cells)", "Comprehensive Metabolic Panel (CMP, indicates chemical balance and metabolism), Blood, Stat collect", "Lipase Level (used to diagnose pancreatic disorders), Blood, Stat collect", and "Troponin I (indicates heart damage if present in the blood), Blood, Stat collect" at 12:53 p.m.

During a review of Patient 1's Lab Results, dated 5/24/22, the Lab Results indicated, the STAT lab orders were collected at 2:10 p.m., a delay of one hour and 17 minutes.

During an interview on 8/2/22, at 3:15 p.m., with Director of Emergency Department (DED), DED stated, no patient care, except for triage (the sorting of patients according to the urgency of their need for care) and medical screening examinations, may be performed while a patient is lying on a stretcher in the ambulance waiting area, per EMS policy. DED stated, patient care includes blood draws (procedure of removing blood from a vein) for laboratory/diagnostic studies. DED stated, lab delays can sometimes be unavoidable. DED stated, patient care was performed once the patient can be safely transferred out of the stretcher and the facility's ED can assume care from EMS.

2. During a review of Patient 6's "ED Note-Physician" (ED Note), dated 6/23/22, the "ED Note" indicated, Patient 6 was brought in by ambulance from a long-term care facility for evaluation of failure to thrive (arrested physical growth and development).

During a concurrent interview and record review on 8/3/22 at 10:30 a.m., with Nurse Informatic (NI), Patient 6's "Order Sheet," dated 6/23/22 was reviewed. The Order Sheet indicated, "CMP, Blood, Stat" and "CBC w/auto Diff, Blood, Stat" at 6:43 p.m. Patient 6's "Result Details," dated 6/23/22 was reviewed. NI stated, there was a delay in carrying out Patient 6's lab orders when the Result Details indicated, labs were collected at 10:14 p.m.

During an interview on 8/4/22, at 11:50 a.m., with laboratory manager (LM), LM stated, the facility's lab department had sick calls on 6/23/22 and there was only one staff performing blood draws in the ED during the evening shift, which caused a delay of three hours and 31 minutes between the order and collect times

3. During a review of Patient 22's, "Admission H&P" (H&P), dated 8/1/2022, the "H&P" indicated, Patient 22 was admitted to the facility's Emergency Department for complaints of sudden right- sided weakness, numbness, and dizziness.

During a concurrent interview and record review 8/4/2022 at 10:50 a.m., with STEMI Coordinator (SC), Patient 23's MD Orders, dated 8/1/2022 was reviewed. The MD Orders indicated, "Completed Metabolic Panel (CMP, indicates chemical balance and metabolism), Blood, Stat collect (urgent or immediate)", "Troponin 1 (indicates heart damage if present in the blood), Blood, Stat collect, "Prothrombin Time (PT, a measure of how quickly the blood clots), Blood, Stat collect, Partial Prothrombin Time (PTT, one's response to anti-clotting therapy), Blood, Stat collect", and "Complete Blood Count (CBC, level of blood cells), Blood, Stat collect" at 1:32 p.m. SC stated, the STAT laboratory (lab) orders were not drawn in a timely manner based on the hospital's lab draw policy for priority STAT labs.

During a review of Patient 22's Lab Results, dated 8/1/22, the Lab Results indicated, the STAT lab orders were collected at 2:35 p.m., a delay of one hour and three minutes from the time labs were ordered.

During a review of the facility's policy and procedure (P&P) titled, "Specimen Collection and Preparation", dated 7/10/2018, the P&P indicated, "A. Phlebotomy Service: 1. f. The priority indicated when an order is placed will determine the phlebotomy draw time. Priorities: (S) STAT- Used when tests are to be drawn immediately Phlebotomy staff should respond within 15 minutes."

Based on interview and record review, the facility failed to ensure:

1. Emergency care services and other department care services (laboratory services) were integrated for laboratory test (diagnostic exam used to help diagnose or screen for a specific disease or condition) to be collected and processed to obtain test result timely (within 15 minutes) as ordered by the physician according to facility's policy and procedure (P&P-"Admission to the Emergency Department" and "Specimen Collection and Preparation") for three of 31 sampled patients (Patient 1, Patient 6, Patient 22). This deficient practice reuslted in delay in carrying out ED Medical Doctor's orders and delayed laboratory resuls for Patient 1, Patient 6, and Patient 22.

2. Patient 1 received pain medication for the abdomen pain on admission to the emergency department (ED).

3. Patient 1, who had an order for a stat (immediate) CT scan (Computerized Tomography, radiology exam) Abdomen and Pelvis W/(with) Contrast (iodine, used to help visual an organ) was completed.

(refer to A-1103).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the Condition of Participation for Emergency Service was met.

Based on interview and record review, the facility failed to ensure:

1. Emergency care services and other department care services (laboratory services) were integrated for laboratory test (diagnostic exam used to help diagnose or screen for a specific disease or condition) to be collected and processed to obtain test result timely (within 15 minutes) as ordered by the physician according to facility's policy and procedure (P&P-"Admission to the Emergency Department" and "Specimen Collection and Preparation") for three of 31 sampled patients (Patient 1, Patient 6, Patient 22).

2. Patient 1 received pain medication for the abdomen pain on admission to the emergency department (ED).

3. Patient 1, who had an order for a stat (immediate) CT scan (Computerized Tomography, radiology exam) Abdomen and Pelvis W/(with) Contrast (iodine, used to help visual an organ) was completed.

These deficient practices resulted in delay in carrying out Emergency Department Medical Doctor (EDMD) orders and delayed laboratory results for Patient 1, Patient 6, and Patient 22. Patient 1 did not get pain medication for her abdominal pain and did not have the ordered CT scan done. Patient 1 had a drastic change of condition from admission examination at 12:48 p.m. that resulted to Patient 1 having a code blue (a medical emergency involving cardiac or respiratory arrest) at 2:26 p.m. and died at 3:03 p.m. This deficient practice had the potential to result in decline or harm to Patient 6 and Patient 22 ' s health from delay of treatment.

On 8/5/22, at 2:37 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Quality Officer (CQO), Risk Manager (RM), and Director of Emergency Department (DED) for delay of care due to carrying out of EDMD orders and delayed laboratory results in the ED.

On 8/6/22, at 8:50 p.m., the IJ situation was lifted on-site, in the presence of CQO and DED, after verifying an acceptable IJ removal plan. The IJ removal plan indicated the following:

1. For patients unable to be transferred out of emergency medical services stretcher, the charge nurse will check on the patients in the ambulance waiting area at least two times every hour and communicate with the ambulance staff regarding any update on the patients ' condition and vital signs (medical signs indicating the status of the body ' s vital functions). The charge nurse will then update the MD.

2. The Phlebotomists (staff who obtain blood samples from patients) will receive and act upon the laboratory (lab) orders when written, in accordance with the facility ' s "Specimen Collection and Preparation" policy.

3. The hospital staff will communicate with the ambulance staff about whether the patient requires immediate specimen (sample) collection or diagnostic studies.

4. If ambulance staff will not allow the phlebotomist to obtain labs from the patient prior to transfer of patient care, the phlebotomist will escalate the refusal to the charge nurse, and the charge nurse will notify the ordering MD and nursing supervisor, who will continue to discuss the patient ' s care with the ambulance staff.

5. The RM will review with CNO, CQO, and DED for possible escalation to California Department of Public Health (CDPH, the state agency responsible for public health) and the ambulance agency.

6. Meetings will be held between hospital and ambulance staff leadership to discuss ways to promote patient care under the circumstance facing each organization.

7. ED MDs, nursing, lab, and radiology services staff, and house supervisors were educated on policies including emergency medical treatment and active labor act (EMTALA, a federal law requiring any person coming to an ED to be stabilized and treated, regardless of their insurance status or ability to pay).

8. The DED will monitor 20 patient medical records every month for timely completion of MD orders, including labs and diagnostic studies for three consecutive months at 100% compliance

Findings:

1. During a review of Patient 1's "ED Triage Form" (Triage Note), dated 5/24/22, at 12:33 p.m., the Triage Note indicated, Patient 1 complained of abdominal pain, level 7/10 (0 indicating no pain, 10 indicating severe pain).

A review of Patient 1's medical records indicated no pain medication was given to Patient 1.

During a review of Patient 1's "ED (Emergency Department) Note-Physician (ED Note) Final Report," note created dated 5/24/22 at 12:46 p.m. , the ED Note indicated, Patient 1 "with history of (h/o) DM (disease that results in too much sugar in the blood), status post (s/p) gastric bypass (weight-loss surgery that involves creating a small pouch and connecting directly to the small intestine), s/p hysterectomy (removal of uterus), presents to the ED via EMS (Emergency Medical Services) with husband for worsening SOB (shortness of breath)...onset yesterday. Associated symptoms included nausea and vomiting x2 (two times) ....Patient had gastric bypass 2 weeks ago and has been c/o (complaining of pain) and constipation (only on bowel movement in last 2 weeks) ....Patient had been feeling slightly improved however last night patient has been having worsening lethargy and abdominal distention." The ED Note indicated, "Charge nurse notified EDMD patient was in EMS rig (ambulance). Patient 1 was examined in EMS ambulance by EDMD" at 12:48 p.m. The ED Note indicated, "Family at bedside patient sitting in a wheelchair with EMS at bedside. Patient more unresponsive and slightly cyanotic to the face. Charge nurse was immediately notified to have patient brought back to the emergency department for further resuscitation," at 2:05 p.m. The ED Note indicated, endotracheal intubation (insertion of a flexible plastic tube into the windpipe to maintain an open airway) was performed at 2:23 p.m. The ED Note indicated, code blue (a medical emergency involving cardiac or respiratory arrest) was paged overhead and cardiopulmonary resuscitation (CPR, chest compressions) was initiated at 2:26 p.m. The "ED Note" indicated, time of death was called at 3:03 p.m.

During a review of the Patient 1's "ED (Emergency Department) Note-Physician (ED Note) Final Report," note created dated 5/24/22 at 12:46 p.m., indicated physician impression and plan include treatment for shortness of breath, abdominal distention, sepsis (The body's extreme response to an infection. It is a life-threatening medical emergency). The physician ordered the following laboratory tests:

a. Blood Culture (test that checks for microorganisms),

b. Complete Blood Count with Auto Differential (level of blood cells),

c. Comprehensive Metabolic Panel (CMP, indicates chemical balance and metabolism),

d. Lipase Level (indicates inflammation of the pancreas).

During a review of Patient 1's EDMD Orders, dated 5/24/22, the MD Orders indicated, "Blood Culture, Stat collect (urgent or immediate)" and "Lactic Acid Level (indicates severity of a condition), Blood, Stat collect," at 12:54 p.m. The MD Orders indicated, "Complete Blood Count with Auto Differential s)", "Comprehensive Metabolic Panel , Blood, Stat collect", "Lipase Level , Blood, Stat collect", and "Troponin I (indicates heart damage if present in the blood), Blood, Stat collect" at 12:53 p.m. The MD order indicated by using approved criteria (The MD Orders indicated, "CT (Computerized Tomography, radiology exam) Abdomen and Pelvis W/(with) Contrast (iodine, used to help visual an organ), Stat." at 12:53 p.m.

During a review of Patient 1 ' s medical record indicated no CT abdomen and pelvis with contrast was done.

During a review of Patient 1 ' s Lab Results, dated 5/24/22, the Lab Results indicated, the STAT lab orders were collected at 2:10 p.m. (drawn one hour and 17 minutes after MD ordered). The results indicated:

a. White blood cell (WBC, normal level 4,500 [4.5] to 11,000 [11.0] per microliter [unit of measurement], elevated level indicates infection) was 36.8 high (H).

b. Glucose level (blood sugar, normal level 100 to 125 milligram per deciliter [mg/dL], elevated level indicates DM and can occur due to the stress from a surgery) was 300 (H).

c. Blood Urea Nitrogen (BUN, normal level 7 to 21 mg/dL, test reveals information of how well the kidney is working) was 56 (H)

d. Creatinine level (a waste product that comes from the normal wear and tear on muscles of the body, normal level 0.7 to 1.3 mg/dL, elevated can be a result of dehydration or kidney not working well) was 2.38 (H).

During an interview on 8/4/22, at 2:30 p.m., DED stated, on 5/24/22, the facility's ED had no space or bed to place Patient 1. DED stated facility unable to assume responsibility of patient care until in a bed, and space was available. DED stated patients remain on telemetry monitoring (observation tool to check one ' s heart rhythm) while on the EMS stretcher.

During an interview on 8/3/22, at 3:00 p.m., with DED, DED stated, he (DED) was present in the ED on 5/24/22. DED stated, Patient 1's vital signs (medical signs indicating the status of the body ' s vital functions) were stable on room air and Patient 1's emergency severity index (ESI, a five-level ED triage algorithm that classifies patients into five groups from 1 [most urgent] to 5 [least urgent] on the basis of acuity and resource needs) was 3 upon arrival to the ED. DED stated, Patient 1 later became cyanotic (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), that six ED staff assisted with transferring Patient 1 from the EMS stretcher onto an ED bed, moved another patient out of ED room 4 and moved Patient 1 in where they performed chest compressions (CPR, cardiopulmonary resuscitation) for 30 minutes.

During an interview on 8/4/22, at 3:00 p.m., with MD, MD stated, Patient 1 was alert, verbal, and following commands during initial medical screening examination (MSE, determines emergency medical condition and its treatment). MD stated, Patient 1 later became fatigued and less responsive. MD stated, Patient 1's last blood pressure (force that moves blood through the circulatory system) taken by EMS was about 100/60 (normal level systolic pressure [measures the force the heart exerts on the walls of the arteries each time the heart beats) less than 120 and a diastolic pressure [the pressure when the heart relaxes and fills with blood] of less than 80).

A review of the facility's policy and procedure (P&P) titled, "Admission to the Emergency Department," approved date 1/18/22, indicated facility, "To provide prompt medical/assessment and treatment of patients who present for evaluation of illness and/or injury." The procedure included, "Reassessment of the patient will occur throughout the ED stay as indicated by condition and acuity." The P&P indicated, "If the patient is stable, a. Patients may complete the registration process if the treatment area or at the registration area if not treatment area is available dependent up to the status ....b. Patient medical treatment will not be delayed." The P&P indicated that when "Medical Screening Examination," is completed, the physician will request that authorization for further service be obtained. The ED registration clerk will the ask the patient for financial information, insurance information."

2. During a review of Patient 6's "ED Note-Physician" (ED Note), dated 6/23/22, the ED Note indicated, Patient 6 was brought in by ambulance from a long-term care facility for evaluation of failure to thrive (arrested physical growth and development).

During a concurrent interview and record review on 8/3/22, at 10:30 a.m., with Nurse Informatic (NI), Patient 6's "Order Sheet," dated 6/23/22, was reviewed. The Order Sheet indicated, "CMP, Blood, Stat" and "CBC w/auto Diff, Blood, Stat" at 6:43 p.m. Patient 6's "Result Details," dated 6/23/22, was reviewed. NI stated, there was a delay in carrying out Patient 6's lab orders when the Result Details indicated, labs were collected at 10:14 p.m. (drawn 3 hours and 31 minutes after MD order).

During an interview on 8/4/22, at 11:50 a.m., with laboratory manager (LM), LM stated, the facility ' s lab department had sick calls on 6/23/22 and there was only one staff performing blood draws in the ED during the evening shift. LM stated, there are usually two staff to ensure blood draws were done in a timely manner.

3. During a review of Patient 22's, Admission History and Physical (H&P), dated 8/1/2022, the H&P indicated, Patient 22 was admitted to the facility's Emergency Department for complaints of sudden right-sided weakness, numbness, and dizziness. The H&P indicated, Patient 22 had a past medical history of diabetes mellitus II (disease that makes one ' s body unable to control the amount of glucose [natural sugar] in the blood) and hyperlipidemia (condition when the body has high cholesterol [fat-like substance]).

During a concurrent interview and record review on 8/4/2022, at 10:50 a.m., with STEMI (ST-Segment Elevation Myocardial Infarction [most severe type of heart attack] Coordinator (SC), Patient 22 ' s MD Orders, dated 8/1/2022 was reviewed. The MD Orders indicated, "Completed Metabolic Panel (CMP, indicated chemical balance and metabolism), Blood, Stat collect (urgent or immediate)", "Troponin 1 (indicates heart damage if present in the blood), Blood, Stat collect, Prothrombin Time (PT, tests how quickly blood clots), Blood, Stat collect, Partial Prothrombin Time (PTT, one ' s response to anti-clotting therapy), Blood, Stat collect", and "Complete Blood Count (CBC, level of blood cells), Blood, Stat collect" at 1:32 p.m. SC stated, the STAT laboratory (lab) orders were not drawn in a timely manner based on the hospital ' s lab draw policy for priority STAT labs.

During a review of Patient 22's Lab Results, dated 8/1/22, the Lab Results indicated, the STAT lab orders were collected at 2:35 p.m. (drawn 1 hour and 3 minutes after MD ordered).

During a review of the facility's policy and procedure (P&P) titled, "Specimen Collection and Preparation," dated 7/10/2018, the P&P indicated, "A. Phlebotomy Service: 1. f. The priority indicated when an order is placed will determine the phlebotomy draw time. Priorities: (S) STAT-Used when tests are to be drawn immediately Phlebotomy staff should respond within 15 minutes."