HospitalInspections.org

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Based on medical record review, document review and interview, in three (3) of ten (10) medical records reviewed, the facility failed to:
(1) Implements its policy and procedure to ensure adequate monitoring of patients with elevated blood pressure;
(2) Provide timely intervention for patients with elevated blood pressure.

Findings include:

Patient # 1 was a 75-year-old male who presented to the Emergency Department on 7/24/2023 at 4:15 PM on the advice of his cardiologist for evaluation of his elevated blood pressure. The patient's past medical history was significant for multiple myeloma - stage 3, high blood pressure, Asthma, Atrial Fibrillation and Anxiety.
Triage assessment was completed at 5:26 PM. Vital signs were blood pressure (BP)- 204/96, Pulse (P)- 65, Oxygen level (O2)- 97% and temperature (T)- 97.4. The patient was assigned an ESI level of 2. (Acuity level of 1 - 5 with 1 - resuscitation, 2 - emergent, 3 - urgent, 4 - semi-urgent, 5 - non-urgent). The patient reported that he was having an infusion therapy at another facility when the nurse indicated that his blood pressure was elevated and was up to 210 over unknown. He also reported mild chest pain.

At 5:30 PM, Staff O, Physician Assistant (PA) evaluated the patient and ordered Electrocardiogram (EKG), Chest X-Ray, Complete metabolic panel (CMP), Complete blood count (CBC), Urinalysis and a troponin level (cardiac protein).

The EKG was completed at 5:32 PM and the report indicated that ST-Elevation Myocardial Infarction (STEMI) was negative. The chest X-ray performed at 6:15 PM showed no evidence of acute disease.

At 7:01 PM, the patient's blood pressure was rechecked, and it was 197/98 mmHg.

The patient was marked for elopement at 11:41 PM, four hours and forty minutes after the patient's last blood pressure was checked.

There was no evidence the patient's elevated blood pressure was managed prior to his departure and there was no reassessment of the patient's vital signs.

Review of the hospital's policy and procedure (P&P) titled "Vital Signs and Re-assessment," last reviewed 1/27/2023, indicated that "patients with significantly abnormal vital signs, or those who are potentially unstable, must have continuous and more frequent monitoring and be referred to the assigned attending immediately."

The facility's Vital Signs and Reassessment policy failed to provide guidance on the frequency of monitoring patients with significantly abnormal vital signs.

Patient #2 was a 56-year-old female who presented to the ED on 7/24/2023 at 11:00 AM and was triaged at 11:24 AM with complaints of tingling in her hands and feet with high blood pressure. The patient's vital signs were BP-209/100, P-55, O2- 100%, T- 98.1. The patient's past medical history included chronic kidney disease, hypertension, and Lupus. Per the providers note dated 7/24/2023 at 11: 24 AM by Staff O (Physician Assistant), the patient reported having a stroke in June 2023.

The Medical Screening Examination was completed at 11:24 AM. Staff O (PA) ordered electrocardiogram (EKG), Chest X-Ray, Complete metabolic panel (CMP), Complete blood count (CBC), Urinalysis and a troponin level (cardiac protein). The EKG showed ST-Elevation Myocardial Infarction (STEMI) was negative. The chest X-ray performed did not show evidence of acute disease.

The patient vitals were repeated at 8:48 PM; BP- 237/110, P-64, O2- 100%.
Repeat vital signs on 7/25/2023 at 3:45 AM noted a Blood Pressure of 237/104.

On 7/25/2023 at 4:10 AM, Blood pressure medications, clonidine, and amlodipine as well as other orders were placed and administered to the patient at 5:33 AM, at this time the patient had been in the ED for 18 hours and 30 minutes.

Patient # 3 was a 69-year-old female with a past medical history of hypertension and heart palpitations. The patient arrived in the ED on 07/24/2023 at 3:09 PM and was triaged immediately. Triage vital signs were 165/92, P-100.

At 3: 15 PM, Staff O, Physician Assistant documented patient had heart palpitations and hypertension while at work today. Patient denied any chest pain. Staff O ordered electrocardiogram (EKG), Chest X-Ray, Complete Metabolic Panel (CMP), Complete blood count (CBC), Urinalysis and a troponin level (cardiac protein).

The EKG was completed at 3:21 PM and the report indicated that ST-Elevation Myocardial Infarction (STEMI) was negative. The chest X-ray performed showed no evidence of acute disease.

At 8:52 PM, blood pressure increased to 166/104.

The patient was assigned a bed in the ED on 7/25/2023 at 4:45 AM.
The patient was discharged home on 7/25/2023 at 10:51 AM.

There was no documented evidence that patient's blood pressure was reassessed prior to her discharge home and there was no evidence of physician treatment of the patient's elevated blood pressure after 13 hours and 45 minutes of her stay in the ED.

On 09/28/2023, at 12:04 PM, during an interview with Staff K (Chief Nursing Officer), she attributed prolong ED wait time to a nursing shortage. She stated, "We all know, there is nationwide shortage of nurses. We have available a list of nurses who volunteer to work and there is a float pool from Medical- Surgical units."

During interview of Staff O (ED PA) on 10/2/2023 at 1:37 PM, Staff O stated that if blood pressure is greater than 200, they will look at other symptoms the patient may be presenting with. They will perform EKG and Chest X-Ray to rule out any cardiac involvement. Staff O confirmed that he does not remember specifics about these patients.

During interview with Staff E (ED Medical Director) on 10/02/2023, Staff E acknowledged these findings.