HospitalInspections.org

Based on policy and procedure review, closed medical record review, and staff interview the hospital's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of Patients' Rights to ensure care in a safe setting; failed to have an organized Nursing Service; and failed to provide Emergency Services to meet the patients' needs.

The findings include:

1. The hospital failed to ensure care in a safe setting by failing to ensure the nursing staff supervised and evaluated patient by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient #2).

~cross refer to 482.13 Patient Rights Condition: Tag A0115

2. The hospital's nursing staff failed to have an effective nursing service providing oversight to ensure registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Condition: Tag A0385

3. The hospital failed to meet the emergency needs of 1 of 12 patients ( Patient #2) in accordance with the hospital's policy and procedures.


~cross refer to 482.55 Emergency Services Condition - Tag A1100

Based on policy and procedure review, closed medical record reviews, and staff interviews, the hospital failed to ensure care in a safe setting by failing to ensure the nursing staff supervised and evaluated patient by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient #2).

1. The hospital failed to ensure care in a safe setting by failing to ensure the nursing staff supervised and evaluated patient by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient #2).


~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

Based on policy and procedure review, closed medical record reviews, and staff interviews, the hospital failed to ensure care in a safe setting by failing to ensure the nursing staff supervised and evaluated patient care by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient #2).


The findings include:

Review of the hospital policy "Emergency Department Triage Policy", last reviewed 08/2014.. "I. PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam. Patients will be reassessed while awaiting the medical screening exam as the patient's condition dictates...IV. PROCEDURE A. Triage decisions are based on the 5 point Emergency Severity Index... V. REFERENCES Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook http://www.ahrq.gov/research/esi/esi1.htm. accessed 12/07/11."

Review of the Reference (referred to in the hospital's triage policy), Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook, published November 2011 revealed " ...Chapter 2, page 12..."When the patient is an ESI level 2, the triage nurse has determined that it would be unsafe for the patient to remain in the waiting room for any length of time. While ESI does not suggest specific time intervals, ESI level-2 patients remain a high priority, and generally placement and treatment should be initiated rapidly. ESI level-2 patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather than move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2..."

Closed medical record review of Patient # 2 revealed a 66 year old male who presented to the hospital's DED (Dedicated Emergency Department) on April 6, 2015 at 1634 with his spouse. Record review revealed the Point Nurse (first nurse who greets the patient) documented an arrival complaint of "ABD PAIN/N/V/D SENT TO R/O APPY" (abdominal pain, nausea, vomiting, diarrhea sent to rule out appendicitis) and assigned an ESI (Emergency Severity Index) acuity level 2 (Emergent). Record review revealed triage began at 1648 with a documented prehospital treatment: "pt seen at XXXX Internal Medicine" and chief complaint of "Abdominal Pain". Nursing narrative note at 1649 "patient reports to the ED with severe lower abdominal pain that radiates from RLQ (right lower quadrant) to mid abdomen. patient reports n/v (nausea and vomiting) since this am". Record review reveals patient's documented vital signs at 1649 BP (Blood Pressure) 130/78 (taken in left upper arm), Pulse 75, Respirations 19, Temperature 97.8 Oral. Oxygen Saturation (SPO2) 94%. Review revealed at 1652 a pain assessment pain score of "10-Worst pain ever, Pain type: acute, Pain location: Abdomen and Pain descriptors: Cramping". Review revealed the patient's mobility at arrival was wheelchair and at 1654 acuity remained at an ESI level 2 and triage was completed at 1655 and Patient #2 was placed in the waiting room for bed placement. Record review revealed no documentation of communication to the charge nurse of the acuity level of Patient #2 and bed placement needed for the patient. Review revealed at 1655 HEPATIC FUNCTION PANEL, LIPASE, CHEMISTRY PANEL, CBC (complete blood count) WITH DIFFERENTIAL, URINALYSIS and ECG 12 Lead ordered by the triage per protocol. Review revealed specimens were collected by a nursing assistant I with documented vital signs of BP 117/69, pulse 76, Temperature 98.3, respirations 18, SPO2 91% at 1718 then placed back in the waiting room for bed placement. Review revealed at 1800 CBC with differential resulted with abnormal result WBC (White blood cell) 23.9 (range 4.0-10.0k/ul). Record review revealed patient "roomed in ED (emergency department) at 1902 ( 2 hours and 28 minutes after presentation to the emergency department). Review of ED Notes at 1909 revealed " Approx 1909 pt answering assessment questions appropriately; AOX3; Monitor in place Describing abdominal pain to the left side radiating to the left groin and sharp intermittent pain to thigh hip x several day; Pt straightened right leg on stretcher and sat up; asked to reposition himself to be more comfortable; no verbal response received, glazed look in eyes and pallor with diaphoresis notes, pt attempting to speak without success; assisted pt to supine position and placed NRB (non-rebreather mask) on face @ 15LPM (liters per minute); ER MD #1 called to bedside; arriving to order NS(normal saline) bolus and stat CT scan of abdomen; assisted by ERT (emergency room tech)XXXX and ERT XXXX and RN (registered nurse) XXXX and RN, XXXX awaiting further orders. Record review revealed vital signs at 1910 BP 125/82, respirations 22, SPO2 98% and CT scan ordered at 1916. Review revealed at 1917 a peripheral IV was placed in the left antecubital (arm): size 18 gauge. Review revealed at 1944 General surgery consult was called, at 1945 Etomidate (sedation) 10mg (milligrams) was given intravenous, vital signs BP 70/52, heart rate 102, SPO2@ 88% and Type and Crossmatch for 2 unit of RBC (Red Blood Cells) was ordered. Review revealed at 1949 consult for vascular surgeon was called. Review revealed at 1951 succinycholine (paralytic medication) 100mg given intravenous and 1952 non surgical airway placed; Airway Device: ETT (Endotracheal tube) Size 8, and patient was placed on the ventilator. Review revealed at 1956 CT final result: PROBABLE HEMOPERITONEUM AND HEMO RETROPERITONEUM (blood in abdominal cavity) SECONDARY TO LEAKAGE FROM ABDOMINAL AORTIC ANEURYSM. BOTH KIDNEYS POORLY PERFUSED. REPORT DISCUSSED DIRECTLY TO DR XXXX BY DR XXXX AT 04/06/2015 AT 1942. Review revealed at 1953 DR XXXX paged out for MASS TRANSFUSION PROTOCOL and patient's Vital signs BP 103/57, heart rate 113, respirations 113 SPO2 100%. Review revealed at 1957 patient started on LEVOPHED (increase Blood pressure) infusion- Dose 0.2mcg (micrograms)/min (minute).Review revealed at 2020 patient placed on a propofol (sedation) infusion at a dose of 5mcg/kg/min. Record review revealed care handoff was given to the OR (operating room) at 2037 for repair of ruptured abdominal aortic aneurysm. Pt admitted to ICU (Intensive Care Unit ) after surgery. Review of Surgery note on 04/07/2015 at 1542 "Patient worsening condition s/p (status post) ongoing resuscitation and aggressive supportive measures. Profound acidosis and anemia and not responsive to aggressive replacements. Patient's condition discussed with Dr XXXX and with the patient's wife with agreement that the situation is now futile and the patient would not want to continue with aggressive measures. Life supporting measures are not planned to be continued at this time.." Record review revealed at 04/07/2015 at 1600 "supportive care was withdrawn and patient expired shortly after.. "

Interview on 09/29/2015 at 1130 with ED Department Manager revealed that triage reassessments are based on the "nurses" assessment and judgement based on the patient's condition".

Interview on 09/30/2015 at 1016 with RN #1 revealed that ESI level 2 patients are "Urgent- someone who needs to be seen quickly but not emergently". Interview revealed, "If I was concerned I would pick up the phone and call the charge nurse and note it in the chart"

Interview on 09/30/2015 at 1111 with RN #2 revealed that ESI level 2 patients are time dependent and need to be seen quickly as possible or they can deteriorate into level 1. Interview revealed, "It is a standard that nurses document communication with the charge nurse when needing patient placement in the patient chart".

Interview on 09/30/2015 at 1245 with ED MD #1 revealed it is not unusual for nurses to call or come get orders for CT scans for patients in triage if patients have to wait. Interview also revealed as to reference Patient #2, "Remembers nurses yelling they needed a Dr in room 12, he was diaphoretic, didn't look good, things went quickly from there".

Based on policy and procedure review, closed medical record review, and staff interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

1. The nursing staff failed to supervise and evaluate patient care by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient # 2).

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on policy and procedure review, closed medical record reviews, and staff interviews, the nursing staff failed to supervise and evaluate patient care by failing to reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient # 2).

The findings include:

Review of the hospital policy "Emergency Department Triage Policy", last reviewed 08/2014.. "I. PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam. Patients will be reassessed while awaiting the medical screening exam as the patient's condition dictates...IV. PROCEDURE A. Triage decisions are based on the 5 point Emergency Severity Index... V. REFERENCES Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook http://www.ahrq.gov/research/esi/esi1.htm. accessed 12/07/11."

Review of the Reference (referred to in the hospital's triage policy), Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook, published November 2011 revealed " ...Chapter 2, page 12..."When the patient is an ESI level 2, the triage nurse has determined that it would be unsafe for the patient to remain in the waiting room for any length of time. While ESI does not suggest specific time intervals, ESI level-2 patients remain a high priority, and generally placement and treatment should be initiated rapidly. ESI level-2 patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather than move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2..."

Closed medical record review of Patient # 2 revealed a 66 year old male who presented to the hospital's DED (Dedicated Emergency Department) on April 6, 2015 at 1634 with his spouse. Record review revealed the Point Nurse (first nurse who greets the patient) documented an arrival complaint of "ABD PAIN/N/V/D SENT TO R/O APPY" (abdominal pain, nausea, vomiting, diarrhea sent to rule out appendicitis) and assigned an ESI (Emergency Severity Index) acuity level 2 (Emergent). Record review revealed triage began at 1648 with a documented prehospital treatment: "pt seen at XXXX Internal Medicine" and chief complaint of "Abdominal Pain". Nursing narrative note at 1649 "patient reports to the ED with severe lower abdominal pain that radiates from RLQ (right lower quadrant) to mid abdomen. patient reports n/v (nausea and vomiting) since this am". Record review reveals patient's documented vital signs at 1649 BP (Blood Pressure) 130/78 (taken in left upper arm), Pulse 75, Respirations 19, Temperature 97.8 Oral. Oxygen Saturation (SPO2) 94%. Review revealed at 1652 a pain assessment pain score of "10-Worst pain ever, Pain type: acute, Pain location: Abdomen and Pain descriptors: Cramping". Review revealed the patient's mobility at arrival was wheelchair and at 1654 acuity remained at an ESI level 2 and triage was completed at 1655 and Patient #2 was placed in the waiting room for bed placement. Record review revealed no documentation of communication to the charge nurse of the acuity level of Patient #2 and bed placement needed for the patient. Review revealed at 1655 HEPATIC FUNCTION PANEL, LIPASE, CHEMISTRY PANEL, CBC (complete blood count) WITH DIFFERENTIAL, URINALYSIS and ECG 12 Lead ordered by the triage per protocol. Review revealed specimens were collected by a nursing assistant I with documented vital signs of BP 117/69, pulse 76, Temperature 98.3, respirations 18, SPO2 91% at 1718 then placed back in the waiting room for bed placement. Review revealed at 1800 CBC with differential resulted with abnormal result WBC (White blood cell) 23.9 (range 4.0-10.0k/ul). Record review revealed patient "roomed in ED (emergency department) at 1902 ( 2 hours and 28 minutes after presentation to the emergency department). Review of ED Notes at 1909 revealed " Approx 1909 pt answering assessment questions appropriately; AOX3; Monitor in place Describing abdominal pain to the left side radiating to the left groin and sharp intermittent pain to thigh hip x several day; Pt straightened right leg on stretcher and sat up; asked to reposition himself to be more comfortable; no verbal response received, glazed look in eyes and pallor with diaphoresis notes, pt attempting to speak without success; assisted pt to supine position and placed NRB (non-rebreather mask) on face @ 15LPM (liters per minute); ER MD #1 called to bedside; arriving to order NS(normal saline) bolus and stat CT scan of abdomen; assisted by ERT (emergency room tech)XXXX and ERT XXXX and RN (registered nurse) XXXX and RN, XXXX awaiting further orders. Record review revealed vital signs at 1910 BP 125/82, respirations 22, SPO2 98% and CT scan ordered at 1916. Review revealed at 1917 a peripheral IV was placed in the left antecubital (arm): size 18 gauge. Review revealed at 1944 General surgery consult was called, at 1945 Etomidate (sedation) 10mg (milligrams) was given intravenous, vital signs BP 70/52, heart rate 102, SPO2@ 88% and Type and Crossmatch for 2 unit of RBC (Red Blood Cells) was ordered. Review revealed at 1949 consult for vascular surgeon was called. Review revealed at 1951 succinycholine (paralytic medication) 100mg given intravenous and 1952 non surgical airway placed; Airway Device: ETT (Endotracheal tube) Size 8, and patient was placed on the ventilator. Review revealed at 1956 CT final result: PROBABLE HEMOPERITONEUM AND HEMO RETROPERITONEUM (blood in abdominal cavity) SECONDARY TO LEAKAGE FROM ABDOMINAL AORTIC ANEURYSM. BOTH KIDNEYS POORLY PERFUSED. REPORT DISCUSSED DIRECTLY TO DR XXXX BY DR XXXX AT 04/06/2015 AT 1942. Review revealed at 1953 DR XXXX paged out for MASS TRANSFUSION PROTOCOL and patient's Vital signs BP 103/57, heart rate 113, respirations 113 SPO2 100%. Review revealed at 1957 patient started on LEVOPHED (increase Blood pressure) infusion- Dose 0.2mcg (micrograms)/min (minute).Review revealed at 2020 patient placed on a propofol (sedation) infusion at a dose of 5mcg/kg/min. Record review revealed care handoff was given to the OR (operating room) at 2037 for repair of ruptured abdominal aortic aneurysm. Pt admitted to ICU (Intensive Care Unit ) after surgery. Review of Surgery note on 04/07/2015 at 1542 "Patient worsening condition s/p (status post) ongoing resuscitation and aggressive supportive measures. Profound acidosis and anemia and not responsive to aggressive replacements. Patient's condition discussed with Dr XXXX and with the patient's wife with agreement that the situation is now futile and the patient would not want to continue with aggressive measures. Life supporting measures are not planned to be continued at this time.." Record review revealed at 04/07/2015 at 1600 "supportive care was withdrawn and patient expired shortly after.. "

Interview on 09/29/2015 at 1130 with ED Department Manager revealed that triage reassessments are based on the "nurses' assessment and judgement based on the patient's condition".

Interview on 09/30/2015 at 1016 with RN #1 revealed that ESI level 2 patients are "Urgent- someone who needs to be seen quickly but not emergently". "If I was concerned I would pick up the phone and call the charge nurse and note it in the chart"

Interview on 09/30/2015 at 1111 with RN #2 revealed that ESI level 2 patients are time dependent and need to be seen quickly as possible or they can deteriorate into level 1. "It is a standard that nurses document communication with the charge nurse when needing patient placement in the patient chart".

Interview on 09/30/2015 at 1245 with ER MD #1 revealed it is not unusual for nurses to call or come get orders for CT scans for patients in triage if patients have to wait. Interview also revealed as to reference Patient #2 " Remembers nurses yelling they needed a Dr in room 12, he was diaphoretic, didn't look good, things went quickly from there". That was the first time he was aware of the patient.

Based on policy and procedure review, closed medical record review, and staff interviews, the hospital failed to meet the emergency needs of 1 of 12 patients ( Patient #2) in accordance with the hospital's policy and procedures.

The findings include:

1. The emergency department nursing staff failed to supervise and evaluate patient care by failing to monitor, reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient # 2).


~cross refer to 482.55(a)(3) Standard - Tag A1104.

Based on policy and procedure review, closed medical record reviews, and staff interviews, the emergency department nursing staff failed to supervise and evaluate patient care by failing to monitor, reassess and address a patient's complaint of pain which resulted in deterioration in the patient's condition and subsequent death in 1 of 12 patients in the emergency department (Patient # 2).

The findings include:

Review of the hospital policy "Emergency Department Triage Policy", last reviewed 08/2014.. "I. PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam. Patients will be reassessed while awaiting the medical screening exam as the patient's condition dictates...IV. PROCEDURE A. Triage decisions are based on the 5 point Emergency Severity Index... V. REFERENCES Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook http://www.ahrq.gov/research/esi/esi1.htm. accessed 12/07/11."

Review of the Reference (referred to in the hospital's triage policy), Agency for Healthcare Research and Quality, US Department of Health and Human Services, Emergency Severity Index Version 4 Implementation Handbook, published November 2011 revealed " ...Chapter 2, page 12..."When the patient is an ESI level 2, the triage nurse has determined that it would be unsafe for the patient to remain in the waiting room for any length of time. While ESI does not suggest specific time intervals, ESI level-2 patients remain a high priority, and generally placement and treatment should be initiated rapidly. ESI level-2 patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather than move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2..."

Closed medical record review of Patient # 2 revealed a 66 year old male who presented to the hospital's DED (Dedicated Emergency Department) on April 6, 2015 at 1634 with his spouse. Record review revealed the Point Nurse (first nurse who greets the patient) documented an arrival complaint of "ABD PAIN/N/V/D SENT TO R/O APPY" (abdominal pain, nausea, vomiting, diarrhea sent to rule out appendicitis) and assigned an ESI (Emergency Severity Index) acuity level 2 (Emergent). Record review revealed triage began at 1648 with a documented prehospital treatment: "pt seen at XXXX Internal Medicine" and chief complaint of "Abdominal Pain". Nursing narrative note at 1649 "patient reports to the ED with severe lower abdominal pain that radiates from RLQ (right lower quadrant) to mid abdomen. patient reports n/v (nausea and vomiting) since this am". Record review reveals patient's documented vital signs at 1649 BP (Blood Pressure) 130/78 (taken in left upper arm), Pulse 75, Respirations 19, Temperature 97.8 Oral. Oxygen Saturation (SPO2) 94%. Review revealed at 1652 a pain assessment pain score of "10-Worst pain ever, Pain type: acute, Pain location: Abdomen and Pain descriptors: Cramping". Review revealed the patient's mobility at arrival was wheelchair and at 1654 acuity remained at an ESI level 2 and triage was completed at 1655 and Patient #2 was placed in the waiting room for bed placement. Record review revealed no documentation of communication to the charge nurse of the acuity level of Patient #2 and bed placement needed for the patient. Review revealed at 1655 HEPATIC FUNCTION PANEL, LIPASE, CHEMISTRY PANEL, CBC (complete blood count) WITH DIFFERENTIAL, URINALYSIS and ECG 12 Lead ordered by the triage per protocol. Review revealed specimens were collected by a nursing assistant I with documented vital signs of BP 117/69, pulse 76, Temperature 98.3, respirations 18, SPO2 91% at 1718 then placed back in the waiting room for bed placement. Review revealed at 1800 CBC with differential resulted with abnormal result WBC (White blood cell) 23.9 (range 4.0-10.0k/ul). Record review revealed patient "roomed in ED (emergency department) at 1902 ( 2 hours and 28 minutes after presentation to the emergency department). Review of ED Notes at 1909 revealed " Approx 1909 pt answering assessment questions appropriately; AOX3; Monitor in place Describing abdominal pain to the left side radiating to the left groin and sharp intermittent pain to thigh hip x several day; Pt straightened right leg on stretcher and sat up; asked to reposition himself to be more comfortable; no verbal response received, glazed look in eyes and pallor with diaphoresis notes, pt attempting to speak without success; assisted pt to supine position and placed NRB (non-rebreather mask) on face @ 15LPM (liters per minute); ER MD #1 called to bedside; arriving to order NS(normal saline) bolus and stat CT scan of abdomen; assisted by ERT (emergency room tech)XXXX and ERT XXXX and RN (registered nurse) XXXX and RN, XXXX awaiting further orders. Record review revealed vital signs at 1910 BP 125/82, respirations 22, SPO2 98% and CT scan ordered at 1916. Review revealed at 1917 a peripheral IV was placed in the left antecubital (arm): size 18 gauge. Review revealed at 1944 General surgery consult was called, at 1945 Etomidate (sedation) 10mg (milligrams) was given intravenous, vital signs BP 70/52, heart rate 102, SPO2@ 88% and Type and Crossmatch for 2 unit of RBC (Red Blood Cells) was ordered. Review revealed at 1949 consult for vascular surgeon was called. Review revealed at 1951 succinycholine (paralytic medication) 100mg given intravenous and 1952 non surgical airway placed; Airway Device: ETT (Endotracheal tube) Size 8, and patient was placed on the ventilator. Review revealed at 1956 CT final result: PROBABLE HEMOPERITONEUM AND HEMO RETROPERITONEUM (blood in abdominal cavity) SECONDARY TO LEAKAGE FROM ABDOMINAL AORTIC ANEURYSM. BOTH KIDNEYS POORLY PERFUSED. REPORT DISCUSSED DIRECTLY TO DR XXXX BY DR XXXX AT 04/06/2015 AT 1942. Review revealed at 1953 DR XXXX paged out for MASS TRANSFUSION PROTOCOL and patient's Vital signs BP 103/57, heart rate 113, respirations 113 SPO2 100%. Review revealed at 1957 patient started on LEVOPHED (increase Blood pressure) infusion- Dose 0.2mcg (micrograms)/min (minute).Review revealed at 2020 patient placed on a propofol (sedation) infusion at a dose of 5mcg/kg/min. Record review revealed care handoff was given to the OR (operating room) at 2037 for repair of ruptured abdominal aortic aneurysm. Pt admitted to ICU (Intensive Care Unit ) after surgery. Review of Surgery note on 04/07/2015 at 1542 "Patient worsening condition s/p (status post) ongoing resuscitation and aggressive supportive measures. Profound acidosis and anemia and not responsive to aggressive replacements. Patient's condition discussed with Dr XXXX and with the patient's wife with agreement that the situation is now futile and the patient would not want to continue with aggressive measures. Life supporting measures are not planned to be continued at this time.." Record review revealed at 04/07/2015 at 1600 "supportive care was withdrawn and patient expired shortly after.. "

Interview on 09/29/2015 at 1130 with ED Department Manager revealed that triage reassessments are based on the "nurses' assessment and judgement based on the patient's condition".

Interview on 09/30/2015 at 1016 with RN #1 revealed that ESI level 2 patients are "Urgent- someone who needs to be seen quickly but not emergently. If I was concerned I would pick up the phone and call the charge nurse and note it in the chart"

Interview on 09/30/2015 at 1111 with RN #2 revealed that ESI level 2 patients are time dependent and need to be seen quickly as possible or they can deteriorate into level 1. Interview revealed, "It is a standard that nurses document communication with the charge nurse when needing patient placement in the patient chart".

Interview on 09/30/2015 at 1245 with ER MD #1 revealed it is not unusual for nurses to call or come get orders for CT scans for patients in triage if patients have to wait. Interview also revealed as to reference Patient #2 , "Remembers nurses yelling they needed a Dr in room 12, he was diaphoretic, didn't look good, things went quickly from there". Interview revealed that was the first time he was aware of the patient being in the ED.