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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Emergency Services was out of compliance.

Based on document review and interviews, the facility failed to ensure patients who presented to the emergency department (ED) for emergency medical care were assessed according to facility policy and protocol in two of ten medical records reviewed for patients seen in the ED (Patients #2 and 7). In addition, the facility failed to ensure patients with pain were being reassessed post-medication administration in four of thirteen medical records reviewed. (Patients #4, #5, #7 and #13)

Findings include:

Facility policies:

According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, the purpose is to outline the standards of care for assessment and maintain an accurate record of patients' assessments, progress, treatments, medications, and condition within the electronic health record. Patients screened as an ESI 1 and ESI 2 by the triage registered nurse (RN) were assessed by nursing staff within 30 minutes of arrival. Patients screened as an ESI 3 were assessed by nursing staff within one hour of arrival.

According to the Emergency Medical Treatment and Active Labor Act (EMTALA) policy, the facility will provide an appropriate medical screening examination (MSE) within the capability of the ED to determine whether or not an emergency medical condition exists. The facility will not delay the provision of an MSE to inquire about the individual's method of payment or insurance status. The facility may follow reasonable registration processes when examination or treatment is required, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage an individual from remaining for further evaluation.

According to the facility's pain management policy, a patient's pain will be reassessed within one hour of administration of pain medication using an appropriate pain scale.

Reference:

According to the Trauma Team Activation guideline, the purpose is to ensure each trauma team member clearly understands the two top levels of trauma team activation (Full and Partial Teams). The full and partial consultation criteria for anatomic/mechanism included pulseless extremity.

1. The facility failed to ensure patients who presented to the ED for emergency medical care were assessed according to facility policy and protocol.

A. Document review

i. A review conducted of Patient #2's medical record revealed Patient #2 presented to the ED on 10/27/24 at 5:38 p.m. with a laceration (skin wound) to their right arm. The record revealed RN #1 triaged Patient #2 at 5:46 p.m. (eight minutes after the patient presented to the ED). RN #1's assessment of Patient #2 revealed Patient #2's circulation was within defined limits (WDL) (normal). At 5:49 p.m., RN #1 designated Patient #2 as an ESI 3 (urgent) and placed the patient in a room.

At 5:50 p.m. (12 minutes after arrival), a physician assistant (Provider) entered the room to evaluate Patient #2. At 5:52 p.m. (14 minutes after arrival) and while the patient was in the room, RN #1 documented Patient #2's parent had applied a tourniquet at 5:05 p.m. (47 minutes earlier) after seeing pulsatile bleeding (indicating an arterial bleed). At this time, RN #1 changed Patient #2's ESI from a 3 to a 2 (emergent) although this was then changed at 5:57 p.m. back to ESI 3 (urgent). At 5:57 p.m. (19 minutes after arrival), Patient #2 was transferred out of the room to a trauma room in the ED.

The Provider's note revealed the Provider entered the room at 5:50 p.m. and observed Patient #2's hand was blue and there was a tourniquet on their right upper arm. The Provider documented that at this point, Patient #2 was made a partial trauma (indicating a team with a trauma surgeon, emergency physician, trauma ED nurse, ED technician, radiology technician, and laboratory technician) given the presence of a tourniquet. The Provider also documented a 1.5 centimeter laceration on the forearm, pulsatile bleeding when the tourniquet was removed, and a lack of movement or sensation in the blue right hand before the removal of the tourniquet.

The ED physician's note documented the Provider had recognized the presence of the tourniquet upon examination of Patient #2. This physician also documented that at this time, a partial trauma activation was called per facility protocol.

This review of Patient #2's medical record, which revealed an assessment of an extremity as WDL (although it was bound by a tourniquet and later described as pulseless and blue) was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, the facility had standards of care for patient assessment and staff maintained an accurate record of the patients' assessments and condition. This was also in contrast to the Trauma Team Activation guideline which read, the trauma team was activated for multiple conditions, including a pulseless extremity.

The review of the record also revealed contradictory information in Patient #2's ED Care Timeline which revealed a trauma activation was called at 5:38 p.m. (the time of Patient #2's arrival) with a trauma team assuming care at this time. However, per the ED Care Timeline and the provider notes, Patient #2 was recorded to be in triage, roomed in a quickstart room, and moved to a trauma room before the trauma team assumed care. During an interview on 3/4/25 at 12:39 p.m. with RN #2, RN #2 stated the electronic medical record (EMR) was known to have issues that resulted in inaccurate timelines when inputting information after an event. They stated this compromised their ability to accurately record the course of a patient's care in the medical record.

ii. A review of Patient #7's medical record revealed Patient #7 presented to the ED on 12/29/24 at 5:02 p.m. for back pain. The triage notes revealed RN #1 documented Patient #7 had pre-existing back pain and had also slipped two weeks ago when getting out of the car. At 5:17 p.m. (15 minutes after arrival), RN #1 documented an assessment of Patient #7 which included airway, breathing, circulation, and disability, scoring all WDL. At 6:09 p.m., after Patient #7 was roomed, another ED RN documented a neurological assessment and a Glasgow Coma Scale (to evaluate consciousness), both of which were WDL. This review of Patient #7's record failed to reveal a nursing assessment of Patient #7's musculoskeletal system, although the patient presented with back pain.

This lack of nursing assessment was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, the facility had standards of care for patient assessment and staff maintained an accurate record of the patients' assessments and condition.

This lack of assessment was also in contrast to an interview conducted on 3/5/25 at 12:41 p.m. with ED assistant nurse manager (Manager) #11 who stated the primary nursing assessment was important to document the patient's baseline status and the focused nursing assessment was important for understanding the patient's complaint and presentation.

B. Interviews

i. On 3/4/25 at 12:05 p.m., an interview was conducted with RN #1, who provided care to Patient #2 as the triage nurse. RN #1 stated registration relied on "buzz words" from patients to be able to alert triage staff of emergent complaints. They stated as a triage nurse, their responsibility was to take vital signs and determine acuity based on the number of resources required to care for the patients.

RN #1 stated for patients with trauma, it was important that the triage RN alerted the charge nurse and provider as quickly as possible. They stated any patient with a tourniquet was automatically deemed a trauma patient per facility protocol. This statement was in contrast to a review of Patient #2's record which revealed RN #1, the triage nurse for Patient #2, failed to recognize Patient #2 had on a tourniquet, scored Patient #2 as an ESI 3, and failed to call a trauma alert.

RN #1 stated Patient #2 wore a jacket when they presented to the ED, which was why they did not recognize the patient had on a tourniquet. They stated the patient and their parent had not mentioned the tourniquet to registration or nursing staff. However, the medical record for Patient #2 revealed that although RN #1 had evaluated Patient #2 as having normal circulation at 5:46 p.m. with a tourniquet encircling their right arm, at 5:52 p.m. (six minutes later), Patient #2's hand was blue and pulseless in the quickstart room.

RN #1 stated they attributed the delay in Patient #2 receiving emergency care for an emergency medical condition to a lack of transparency by the patient and their parent, rather than RN #1's inaccurate and incomplete nursing assessment.

ii. On 3/4/25 at 12:29 p.m., an interview was conducted with RN #2. RN #2 stated acuity was determined by severity, with ESI 1 being used for stroke, trauma, and partial trauma, a compromised airway, breathing, and circulation, indicating the need for immediate evaluation and treatment. They stated ESI 2 was for unstable patients with concerns for airway, breathing, and circulation. RN #2 stated ESI 3 was used for most walk-in patients who were more stable than those with an ESI 1 or 2.

RN #2 stated Patient #2's tourniquet was not recognized in the ED immediately as the patient was wearing a jacket. They stated parents were expected to be forthcoming with details about their children's medical history, and that without the parent informing staff, they had no way to know the tourniquet was present. RN #2 stated a patient with a tourniquet was always alerted as a trauma as this reflected a compromised circulatory system. They stated an arterial bleed, which Patient #2 had as a result of their laceration, could result in patient decompensation, and fast action was needed to save the patient and the limb.

iii. On 1/14/25 at 9:07 a.m. and on 3/4/25 at 3:14 p.m., interviews were conducted with nurse manager (Manager) #8. Manager #8 stated staff were educated during shift change for two weeks after the incident with Patient #2. They stated staff were educated to evaluate the full extremity in the case of a laceration. This statement was in contrast to interviews with RN #1 and RN #2, both of whom stated Patient #2 and their parent were responsible for not disclosing the tourniquet and failed to recognize the lack of nursing assessment.

iv. On 3/5/25 at 1:06 p.m., an interview was conducted with ED medical director (Director) #10. Director #10 stated they felt the care provided to Patient #2 was reasonable. They stated if the staff had been informed by the patient or their parent of the presence of the tourniquet, the staff would have acted with more urgency as tourniquets could cause tissue damage within 90 minutes to three hours after application.


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2. The facility failed to ensure pain was addressed in patients following pain medication administration.

A. Medical Record Review

i. A review of Patient #4's medical record revealed the patient arrived in the emergency department (ED) on 12/25/24 at 6:15 a.m. with hip pain. According to the ambulance report, 50 micrograms (mcg) of Fentanyl (rapid-acting pain medication) were given in the ambulance before arrival in the ED. Upon arrival to the ED, Patient #4 rated their pain at a level of ten out of ten on the pain scale. Patient #4's provider ordered Dilaudid (used to relieve severe pain) at 6:26 a.m., however, Patient #4 did not receive pain medication until 8:54 a.m. Patient #4 rated their pain at a level of seven out of ten at that time. A pain reassessment was not completed to determine if Patient #4 had pain relief. There was no further medication administration or assessments of pain completed in the ED before transferring the patient to the oncology floor at 12:39 p.m

ii. A review of Patient #5's revealed they arrived in the ED on 1/3/25 at 2:29 p.m. with flank pain that had started the previous night rating their pain a level of five out of ten. Patient #5's provider ordered Toradol (used to relieve moderate to severe pain) for pain management at 2:40 p.m. Patient #5 received Toradol at 2:45 p.m. There was no reassessment completed to determine the effectiveness of the pain medication administered.

Patient #5's provider ordered oxycodone (used to treat severe pain) at 4:38 p.m. The pain medication was administered at 4:40 p.m. Patient #5's pain was subsequently reassessed at 5:51 p.m. and rated at a level of two out of ten. Patient #5's provider ordered oxycodone for pain control at 7:28 p.m. With a reported pain score of five out of 10, the patient was given oxycodone at 7:30 p.m. No further pain assessment was completed until after Patient #5 was transferred to the oncology unit at 9:06 p.m.

iii. A review of medical records for Patient #7 revealed they arrived in the ED on 12/29/24 at 5:02 p.m. for back pain at a level of ten out of ten on the pain scale reported during the initial assessment. Patient #7 had a history of back pain and their provider ordered Ketamine at 11:30 p.m. and administered it to Patient #7 at 11:36 p.m. There was no reassessment of pain completed until 1:15 a.m.

iv. A review of patient care records revealed Patient #13 arrived in the ED on 3/1/25 at 8:32 a.m. with intense abdomen pain rated a six out of 10. Patient #13's provider ordered Dilaudid for pain at 11:07 a.m. The medication was given at 11:14 a.m. There was no reassessment of pain completed to determine the effectiveness of the medication until 1:33 p.m.

The record reviews were in contrast to the Pain Management policy which read, that reassessing a patient's pain was part of the scope of care in treating pain after receiving pain medications.

B. Interviews

i. On 3/5/25 at 12:41 p.m., an interview was conducted with the ED RN manager (Manager) #1. Manager #1 stated the facility conducted a recent audit regarding pain assessments, however, the audit was focused on the inpatient units and not the emergency department. Manager #1 stated even though their department was not part of the process, they would have liked to focus on it since it was an important topic.

ii. On 1/14/25 at 2:07 p.m., an interview was conducted with RN #18. RN #18 stated they were previously used to assessing for pain every two hours and recently realized it was 60 minutes. RN #18 stated patients had increased risks of not wanting to participate in activities or therapies if pain was not addressed as well as there being a risk of extended hospital stays.

iii. On 1/14/25 at 2:36 p.m., an interview was conducted with RN# 17. RN #17 stated education was provided for the assessment and reassessment of pain after the administration of scheduled medications. RN #17 stated some of the fallouts they were seeing were pain reassessment alerts not being generated by the electronic medical record documentation system, causing staff to not reassess pain on time. RN#17 emphasized that addressing pain promoted faster recovery and made patients feel valued and heard.

iv. On 1/14/25 at 2:34 p.m., an interview was conducted with RN# 16. RN #16 stated they were provided with education on pain assessment and reassessment for scheduled and as-needed medications using the rule of thirty minutes after the administration of Dilaudid and oxycodone and an hour after the administration of Tylenol. They emphasized controlling pain promoted a faster healing process.

Based on interviews and document review, the facility failed to ensure radiological services were performed safely for a patient with an implanted device. Specifically, the facility failed to ensure all magnetic resonance imaging (MRI) parameters were met for a patient (Patient #8).

Findings include:

Facility policy:

According to the MRI Quality, Safety, Emergency Procedure and Regulatory Compliance policy, implants could have a designation of magnetic resonance (MR) safe/MR conditional. The MRI technologist will utilize available resources to determine devices and implants as MR safe/MR conditional/MR unsafe. MRI produces thermal loads in the body and has the possibility to produce focal (localized) radiofrequency (RF)-related thermal injury. Each facility should have processes in place to monitor thermal loading (increased heat) and prevent focal thermal injury to patients. Education to patients about thermal considerations should occur prior to scanning. The MRI technologist should monitor the specific absorption rate (SAR) to minimize the potential for excessive thermal loading during scanning.

References:

According to the MRI Procedure Information Abbott Medical MR Conditional Deep Brain Stimulation (DBS) System for the Infinity 6660, before an MRI scan, determine the patient's body temperature. If the patient has a fever, you should not perform an MRI scan.

1. The facility failed to ensure all magnetic resonance imaging (MRI) parameters were met for a patient.

A. Document review

i. A review conducted of Patient #8's medical record revealed on 12/31/24, Patient #8 presented to the facility for MRIs of their cervical (upper) and lumbar (lower) spine due to back pain. The review revealed Patient #8 had a deep brain stimulator (DBS) Infinity 6660 to treat essential tremors. The review revealed the MRI technicians had determined Patient #8 was eligible to undergo MRI scanning as long as certain parameters (MRI conditions) were met before and during the scan.

During an interview on 3/4/25 at 10:47 a.m. with lead MRI technician (Lead) #4 reviewing Patient #8's record, Lead #4 stated the MRI technicians followed the DBS MRI conditions to ensure Patient #8's safety. They stated determining Patient #8's temperature before their MRI was a condition for this type of implant, although this information was not in their record.

This lack of assessment was in contrast to the MRI Procedure Information Abbott Medical MR Conditional Deep Brain Stimulation System which read, before an MRI scan, staff were to assess a patient's body temperature. If the patient had a fever, an MRI scan was not safe to be performed.

This lack of assessment was also in contrast to the MRI Quality, Safety, Emergency Procedure and Regulatory Compliance policy which read, some implants were designated MR safe/MR conditional and the MRI technologist utilized resources to determine if implants were MR safe/MR conditional/MR unsafe. MRI produced thermal loads (increased heat) in the body and could produce focal RF-related thermal injury.

ii. A review of the grievances revealed Patient #8 had submitted a grievance related to their MRI scan. They stated they felt they had experienced internal burns as a result of the procedure. The facility responded to the patient and stated all protocols were followed which was in contrast to a review of Patient #8's medical record and MRI procedure information for this device.

B. Interviews

i. On 1/14/25 at 10:01 a.m. and on 3/4/25 at 10:47 a.m., interviews were conducted with Lead #4. Lead #4 stated staff screened patients for implants before medical imaging. They stated if the patient had an implant, staff investigated if the patients' devices were able to be safely scanned by the MRI machines at their facility. Lead #4 stated some implants required certain conditions or parameters to be met before scanning to ensure patients' safety. They stated implants created an increased risk of burns or movement of the implants (resulting in possible bleeds or ruptures) during an MRI, especially if the conditions were not met.

Lead #4 stated determining Patient #8's temperature before their MRI was a condition for this type of implant although their review of Patient #8's record failed to reveal a record of their body temperature. They stated this condition was important to ensure patients did not have an elevated body temperature due to an elevated risk for thermal injury to the patient.

ii. On 3/5/25 at 1:32 p.m., an interview was conducted with the director of radiology (Director) #5. Director #5 stated there were specific processes for safely imaging patients with implants. They stated the MRI technician was responsible for determining the conditions for safety and ensuring those conditions were met during the scanning. Director #5 stated the proper parameters were met for Patient #8. This was in contrast to a review of Patient #8's medical record which failed to reveal an assessment of their body temperature.

iii. On 3/5/25 at 1:32 p.m., an interview was conducted with radiologist (Radiologist) #6. Radiologist #6 stated if all of the MRI conditions were not met, including an assessment of a patient's temperature if required, there was an increased risk of displacement, heating, and malfunction of the implant.

Radiologist #6 stated thermal injuries due to overheating were unlikely to be visible externally and proving causation would be difficult. They stated staff would only be aware of patient injury if the patients' actions revealed damage to an area of the brain.