HospitalInspections.org

Based on a review of the clinical record, the director of the nursing service failed to effectively supervise the operation of the service as nursing personnel did not follow facility policy and procedure as related to assessment and reassessment of patients.

Findings were:

A review of the clinical record for patient #1 revealed that the patient, a 20-year-old female, presented to the emergency department at 9:14 am on 3-10-21 via private vehicle with a complaint of chest pain and jaw pain that had begun the previous evening. Patient #1 was triaged at 9:29 am. Patient #1 rated her pain as a 4 on a 0-10 pain scale and described it as sharp and stabbing. Her triage vital signs were as follows:

* BP 150/110
* T 97.4°
* P 83
* O2 Sat 99% on room air

Patient #1 weighed 162 lbs and was 5'7" tall. She denied having any allergies and no medical history was noted. The patient was assigned an ESI II level.

Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI: "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."

Patient #1's vital signs were checked at the following times:

9:29 am
* P 150/110 (manual)
* P 83
* T 97.4°
* R 20
* O2 Saturation 99% on room air

10:51 am
* BP 129/87 (electronic)
* P 91
* T 98.0°
* R 20
* O2 Saturation 100% on room air

12:55 pm
* P 149/100 (electronic)
* P 77
* T 97.3°
* R 17
* O2 Saturation 99% on room air

Facility policy "955.0 Patient Rounds" states, in part:

"All patients in an EC treatment area will have vital signs performed and documented every 2 hours or more often as clinical condition warrants.

A. All patients presenting with a diastolic blood pressure of 90 or greater will have a repeat manual blood pressure taken as appropriate (especially after antihypertensive medication administration) and prior to discharge."


The clinical record contained no documentation that patient #1's blood pressure was rechecked after the 9:29 am vital sign assessment, the 12:55 pm vital sign assessment or prior to her departure from the emergency department.


Nursing notes (regarding patient #1) stated, in part:

* 3-10-21 at 9:29 am - "Pt c/o chest pain and jaw pain that began last night."

* 3-10-21 at 10:47 am - "Pt to triage desk stating she feels SOB. Pt assessed by Staff #8 (NP) and VS taken. Pt returned to lobby."

* 3-10-21 at 2:22 pm - "Pt approached triage desk asking to leave. Pt LWBS [left without being seen] w/no acute distress noted."

At 2:24 pm, patient #1 left the emergency department of UMC without being seen, after signing and dating a form titled "Patient Refusal of Services - EC". Patient #1 had checked the box marked "Leaving before appropriate medical screening examination (LWBS) [left without being seen]."

The above was confirmed in an interview with the Chief Medical Officer and other administrative staff on 4-21-21.

Based on a review of the clinical record and facility policies, the facility failed to provide an appropriate medical screening exam to a patient that presented to its emergency department for treatment.

Findings were:

A review of the clinical record for patient #1 revealed that the patient, a 20-year-old female, presented to the University Medical Center [UMC] emergency department at 9:14 am on 3-10-21 via private vehicle with a complaint of chest pain and jaw pain that had begun the previous evening. Patient #1 was triaged at 9:29 am. Patient #1 rated her pain as a 4 on a 0-10 pain scale and described it as sharp and stabbing. Her triage vital signs were as follows:

* BP 150/110
* T 97.4°
* P 83
* O2 Sat 99% on room air

Patient #1 weighed 162 lbs and was 5'7" tall. She denied having any allergies and no medical history was noted. The patient was assigned an ESI II level.

Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI: "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."

Due to patient #1's presenting symptoms, the UMC emergency department chest pain care set (standing orders for chest pain) was begun at 9:36 am. The following components of the care set were performed:

* EKG 12-lead
* CBC with differential
* Beta HCG Serum Qualitative
* CMP
* Troponin T High Sensitivity
* Chest x-ray portable

Results of the above tests were within normal limits with the exception of the following:

* RBC 5.52 M/UL (normal range 3.93-5.22)
* Hemoglobin 16.1 G/DL (normal range 11.2-15.7)
* Hematocrit 47.4% (normal range 34.1-44.9)


Patient #1's vital signs were checked at the following times:

9:29 am
* BP 150/110 (taken manually)
* P 83
* T 97.4°
* R 20
* O2 Saturation 99% on room air

10:51 am
* BP 129/87 (electronic)
* P 91
* T 98.0°
* R 20
* O2 Saturation 100% on room air

12:55 pm
* P 149/100 (electronic)
* P 77
* T 97.3°
* R 17
* O2 Saturation 99% on room air

The clinical record contained no documentation that the patient's blood pressure was rechecked after the 9:29 am vital sign assessment and the 12:55 pm vital sign assessment or prior to her departure from the UMC emergency department.

UMC nursing notes stated, in part:

* 3-10-21 at 9:29 am - "Pt c/o chest pain and jaw pain that began last night."

* 3-10-21 at 10:47 am - "Pt to triage desk stating she feels SOB. Pt assessed by Staff #8 (NP) and VS taken. Pt returned to lobby."

* 3-10-21 at 2:22 pm - "Pt approached triage desk asking to leave. Pt LWBS [left without being seen] w/no acute distress noted."

At 2:24 pm, the patient left the emergency department of UMC without being seen, after signing and dating a form titled "Patient Refusal of Services - EC". The patient had checked the box marked "Leaving before appropriate medical screening examination (LWBS) [left without being seen]." This occurred five hours and 10 minutes after her arrival to the emergency department.

The clinical record provided no documentation that the patient was ever placed in an exam room or that a qualified medical practioner conducted and appropriate and timely medical screening examination.

Following her departure from UMC, the patient presented at Exceptional ER Lubbock (a free-standing emergency medical center) at 5:28 pm. The patient stated a chief complaint of chest pain radiating to the neck and jaw. She rated the pain as a 7 on a 0-10 pain scale and described it as "sharp".

The patient gave a medical/surgical history of hypertension and chronic kidney disease and had a history of a right nephrectomy (kidney removal). She stated that she took the following medications:

* Lisinopril (used to treat high blood pressure)
* Minocycline (antibiotic, no reason given for its use)
* Zoloft (used to treat depression)

Her blood pressure was as follows:
* 5:28 pm 169/117
* 5:45 pm 150/94
* 7:30 pm 154/109
* 7:52 pm 126/86
* 8:07 pm 159/105

The following tests, interventions and medications were ordered:
* EKG
* Intravenous access
* Cardiac panel
* CBC with differential
* D-Dimer
* Liver function tests
* Met 8 (basic metabolic panel)
* Urinalysis
* HCG
* Morphine sulfate 4 mg IV
* Nitroglycerin 0.4 mg sl
* Ondansetron 2 mg IV
* Toradol 30 mg IV
* NS 0.9% IV 1000ml
* CT abdomen/pelvis without contrast
* CT chest without contrast

The CT scans of chest and abdomen were performed at 6:32 pm and read at 7:25 pm. The CT chest stated "dilatation of the ascending aorta and aortic arch measures 4/7 cm at the level of the main pulmonary artery (series 6 image 27) findings concerning for aneurysm." The CT abdomen/pelvis stated "Aneurysm of ascending aorta and proximal aortic arch measures 4.7 cm."

Patient #1 was transferred to from Exceptional ER to Covenant Medical Center at 10:19 pm via ambulance with a paramedic.


A review of the UMC Emergency Department Policy & Procedure Manual revealed the following policies:

"955.0 Patient Rounds" states, in part:

"All patients in an EC treatment area will have vital signs performed and documented every 2 hours or more often as clinical condition warrants.

A. All patients presenting with a diastolic blood pressure of 90 or greater will have a repeat manual blood pressure taken as appropriate (especially after antihypertensive medication administration) and prior to discharge."

"SPP #CO-41 EMTALA Guidelines for Emergency Center" states, in part:

"Statement of Purpose:

1.0 Purpose:

1.1 To require, in conjunction with state-specific policies, that UMC Emergency Center provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development, who comes to the Emergency Center and requests such examination, as required by the Emergency Medical Treatment and Labor Act ('EMTALA'), 42. U.S.C., Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder.

2.0 Definitions:
...
2.19 Medical Screening Examination ('MSE') is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or with respect to a woman who could be in labor, whether or not the woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. With respect to an individual with behavioral symptoms, an MSE consists of both a medical and behavioral health screening."

A review of the UMC Bylaws, Rules & Regulations for the Medical Staff revealed the following (page 30):
"V. Emergency Services
...
D. Patients treated in the Emergency Center must be seen by an attending physician or mid-level provider, to include Physician Assistants and Nurse Practitioners, prior to transfer, discharge, consult or referral to the patient's primary care physician or medical home. Attending physicians and mid-level providers are considered to be qualified medical providers and may perform medical screening exams.

E. No patients will be transferred or discharged from the Emergency Center without being attended by a member of the Professional and/or House Staff and until they are stabilized."

The Chief Medical Officer and other administrative staff were advised that the above would be referred to CMS for physician review.