HospitalInspections.org

Based on interview and record review the facility Emergency Department staffs (Charge Nurse 1 [CN 1] failed to call a Code Fast (an emergency hospital announcement used to activate for all patients arriving in the Emergency Department [ED] who have onset of new stroke (a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off) symptoms (slurred speech, left facial droop, left arm and left leg weakness) within the last 24 hours) in accordance with the facility's policy and procedure for one (1) of thirty sampled patients (Patient 30). Patient 30 had symptoms of stroke on arrival, in the ED, on 6/29/2022 at 2:26 p.m.

The deficient practice resulted to Patient 30's delayed care by the stroke team members (a response team that is ready 24-hours-a-day to quickly evaluate patients and initiate interventions.) and had the potential for other patient having stroke not getting immediate care. The Code Fast was called, on 06/29/22 at 3:56 p.m. (1 hours and 30 minutes after arrival in the ED).

Findings:

A review of Patient 30's Emergency Patient Record, Undated, indicated, Patient 30 arrived at the facility, on6/29/22 at 2:23 p.m. The record indicated The record indicated, "Rapid Initial Assessment (initial admission assessment)," completed by Charge Nurse 1 (CN 1), on 6/29/22 at 2:26 p.m., indicated Patient 30 was brought into the ED by ambulance from home for onset of slurred speech, left facial droop, left arm, and left leg weakness. Patient's Last Known Well ([LKW] the date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at their baseline) time was on 06/28/2022 8:30 p.m. The record indicated that a Code Fast was called by Medical Doctor 2 (MD 2) on 06/29/2022 3:56 p.m.

During an interview, on 10/17/2023, at 3:31 p.m., the Charge Nurse 1 (CN 1) stated she (CN 1) and MD 3 saw and assessed Patient 30, on 06/29/22, at 2:26 p.m. CN 1 stated Patient 30 came in with stroke symptoms with LKW time under 24 hours. Patient 30 met criteria for a Code Fast.

During an interview, with the Emergency Department Director (EDD) on 10/17/2023, at 3:40 p.m., the Emergency Department Director (EDD)stated that Patient 30 emergency patient records noted that Patient 30 met criteria for a Code Fast. EDD stated ED Nurses must evaluate the care for each patient on admission and when appropriate, adhere to facility's policy. EDD stated ED staff (CN 1) should have activated code fast on Patient 30.

A review of the facility's policy and procedure (P&P), titled, "Code Fast/ Stroke Response", with last reviewed date of 2/2018, indicated that Code Fast (CF) will be activated for all patients arriving in the ED who have onset of new stroke symptoms within the last 24 hours. The CF will be activated by either and ED RN or ED Provider. Whomever assesses stroke symptoms first will call CF. When an RN or mid-level provider activates a CF, they are responsible for immediately notifying the MD.

Based on interview and record review the facility failed to ensure care in the Emergecny Department were according to facility's policy and procedure as evidence by for two (2) of 30 sampled patients (Patient 12 and Patient 30):

1. For Patient 12, the facility's physician (Medical Doctor 3, [MD 3]) and Registered Nurse 8 [RN 8] in the Emergency Department (ED) failed to provide pain assessment according to facility's policy and procedure for pain management. Patient 12 presented in the facility ED, on 9/27/23 with complaint of pain to the right big (great) toe and the right big toenail was partially off.

This deficient resulted to Patient 12 having not pain assessment for the right big toenail pain. This deficient practice has the potential for Patient 12 and other patients with complaint of pain in the ED not getting appropriate care for pain.

2. For Patient 30, a Code Fast (an emergency hospital announcement used to activate for all patients arriving in the Emergency Department [ED] who have onset of stroke [a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off] symptoms [slurred speech, left facial droop, left arm and left leg weakness] within the last 24 hours) was not activated in accordance with the facility's policy and procedure for stroke. Patient 30 had symptoms of stroke on arrival, in the ED, on 6/29/2022 at 2:26 p.m and code fast called at 3:56 p.m.

The deficient practice resulted to Patient 30's delayed care (1 hours and 30 minutes) by the stroke team members (a response team that is ready 24-hours-a-day to quickly evaluate patients and initiate interventions) and had the potential for other patient having stroke not getting immediate care.

Findings:

1. During a record review of Patient 12's, Emergency Patient Record, indicated Patient 12 came into the ED, on 9/27/2023 at 1:54 AM, presenting with pain to a big toe and the toenail partially off. The record indicated, "Initial Rapid Assessment (initial admission assessment)," in the ED)," was started at 1:58 AM that included documented vital signs (measurements of the body's most basic functions the includes: blood pressure, body temperature, heart pulse rate, and respiration), severe sepsis screening (signs and symptoms of sepsis, life threatening effect of infection, such as altered body temperature, slurred speech, accelerated heart rate), and wound evaluation. The record indicated Patient 12's wound (right big toe) was described as an avulsion (pulled or torn from the bed) of the right great toe. The record indicated no evaluation of Patient 12's right big toe.

During an interview with MD 1, and concurrent record review of Patient 12's Emergency Patient Record, on 10/17/2023 at 12:55 PM in the ED, MD 1 stated Patient 12 did not have a pain assessment. MD 1 stated that prior to treating patients for simple wounds, such lacerations and cuts, nurses and physicians should use a fresh bottle of normal saline to clean open wounds for each patient seen. MD 1 stated depending on the severity of the injury, pain management should be part of the treatment as well as the pain assessment during the patient's stay.

During a record review of the facility's policy and procedure for Pain Management, revised 10/220, indicated that the physicians and nurses have the responsibility to manage pain for patients in the facility. The policy and procedure indicated these practitioners (physician and nurses) have a duty to assess or evaluate patients' pain levels and apply appropriate interventions to reduce pain if present. Under the section, "Pain Assessment," Patients were assessed based on their clinical presentation, services sought and in accordance with the care, treatment and services provided. Pain was to be assessed during initial admission assessment and before, during, and after pain producing or pain-relieving interventions. The components of pain assessment included assessment of intensity, location, character, onset, and how it (pain) affects common daily activities.

2. A review of Patient 30 ' s Emergency Patient Record, undated, indicated, Patient 30 arrived at the facility, on 6/29/22 at 2:23 p.m. The record indicated, "Rapid Initial Assessment (initial admission assessment)," completed by Charge Nurse 1 (CN 1), on 6/29/22 at 2:26 p.m., indicated Patient 30 was brought into the ED by ambulance from home for onset of slurred speech, left facial droop, left arm and left leg weakness. Patient ' s Last Known Well ([LKW] the date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at their baseline) time was on 06/28/2022 8:30 p.m. The record indicated that a Code Fast was called by Medical Doctor 2 (MD 2) on 06/29/2022 at 3:56 p.m.

During an interview, on 10/17/2023, at 3:31 p.m., the Charge Nurse 1 (CN 1) stated she and MD 3 saw and assessed Patient 30, on 06/29/2022, at 2:26 p.m. CN 1 stated Patient 30 came in with stroke symptoms and Patient 30 ' s LKW time of under 24 hours indicated Patient 30 met criteria for a code fast.

During an interview, with the Emergency Department Director (EDD) on 10/17/2023, at 3:40 p.m., the Emergency Department Director (EDD) stated that Patient 30 emergency patient records noted that patient met criteria for a Code Fast. EDD stated it was the facility ' s expectation that staff adhere to hospital policy and initiate Code Fast. EDD stated ED staff should have activated Code Fast for Patient 30.

During an interview, on 10/18/2023, at 9:43 a.m., the Stroke Coordinator (SC) stated that Patient 30 met criteria for a code fast on initial assessment by CN 2 and MD 3, Patient 30 walked in the ED with stroke symptoms and Patient 30 ' s LKW time was under 24 hrs. SC stated CN 2 and MD 3 did not call a Code Fast.

A review of the facility's policy and procedure (P&P), titled, "Code Fast/ Stroke Response", with last reviewed date of 02/2018, indicated that Code Fast (CF) will be activated for all patients arriving in the ED who have onset of new stroke symptoms within the last 24 hours. The CF will be activated by either and ED RN or ED Provider. Whomever assesses stroke symptoms first will call CF. When an RN or mid-level provider activates a CF, they are responsible for immediately notifying the MD.