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Based on document review and interview, it was determined that the Hospital failed to adhere to acceptable standards of care for managing a patient with critical laboratory results in the emergency department (ED). This is likely to cause serious harm, injury, or death to any patient receiving care in the ED. As a result, the Condition of Participation, 42 CFR 482.55, Emergency Services, was not met.

Findings include:

1. The Hospital failed to appropriately intervene regarding the critical laboratory results, to ensure that actions taken were in accordance with the policies and procedure governing the medical care of patients in the emergency department (ED). See deficiency at 1104.

The immediate jeopardy (IJ) was identified on 4/8/2022 at 42 CFR 482.55, Emergency Services, due to the Hospital's failure to follow the processes for addressing critical laboratory values in the ED (emergency department). Subsequently, a patient died. The IJ was identified on 4/8/2022, and was announced on 4/8/2022 at 4:20 PM, during a meeting with the President of the Hospital, Executive Director of Quality, System, Chief Operating Officer, Chief Medical Officer, ED Medical Director, Vice President of Care Transformation, Regulatory Compliance and Patient Safety, Assistant Chief Nursing Officer, and Interim Chairman of Psychiatry, Behavioral Health. The IJ was removed by the exit date of 4/12/2022.

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) clinical records reviewed with critical laboratory values, the Hospital failed to appropriately intervene regarding the critical laboratory results, to ensure that actions taken were in accordance with the policies and procedure governing the medical care of patients in the emergency department (ED). This has the potential to cause serious injury or harm to any patient in the ED.

Findings include:

1. On 4/6/2022, Pt. #1's clinical record was reviewed. Pt. #1 was a 45-year-old female patient who presented to the ED on 12/28/2021. The clinical record included:

- The Chicago Fire Department run sheet on 12/28/2021 indicated, " ... (Pt. #1 alert and oriented) ... states that she has some sudden vomiting and possibly indigestion ... (Pt. #1) states that she was eating when this suddenly began. Crew pre-notified (the Hospital emergency room) and ... placed (Pt. #1) in the triage area ... with staff ..." (The ambulance crew arrived at the Hospital on 12/28/2021 at 8:16 PM).

- E #1's (ED registered nurse) progress notes on 12/28/2021 at 8:19 PM included, "(Pt. #1) ... Presents to ER with (complaint of) epigastric pain and vomiting ... (Blood pressure): 188/68 (normal value 120/80), pulse: 70, temperature: 97.5 ... ESI of 3 (Emergency severity index/five-level ED triage algorithm. Level 3 are stable patients and should be seen urgently by a physician) ..."

- The ED medical screening examination by MD #1(ED physician) and E #3 (Advanced Practice Nurse) on 12/28/2021 signed at 8:28 PM included, "(Pt. #1) brought to (the) ED via (emergency medical services) for new-onset vomiting and heartburn ... denies (shortness of breath) ..." E #3 ordered laboratory testing that included troponin at 8:22 PM.

- The troponin test results on 12/28/2021 included, "Troponin 18 ... (normal range 0-12) ... Critical Value: Called Results to: (Name of E #1) ... at 9:19 PM ... Notes ... High sensitivity troponin results exceed the 99th percentile upper reference limit, consistent with myocardial (heart muscle) injury ...Recommend additional and serial testing ... Rising and/or falling levels in the absence of ischemia, suggest acute myocardial injury. Rising and/or falling levels, in the presence of ischemia and the appropriate clinical setting are consistent with an acute myocardial infarction (heart attack)."

- Following (E #1's) receipt of the critical laboratory value on 12/28/2021 at 9:19 PM, the clinical record did not indicate that E #1 communicated to the ED provider regarding the troponin critical laboratory results. At 11:46 PM, an ED technician (E #2) obtained vital signs on Pt. #1 as follows: BP 188/69, Pulse: 80, Respiration 12, Oxygen level 98% (normal 92% and greater). At 3:44 AM, E #1 documented NAx3 (no answer when called three times). Since arrival at the Hospital, Pt. #1 had been in the ED waiting room and was not attached to a heart monitor.

- The clinical record indicated that since receipt of the critical laboratory results at 9:19 PM, E #1 had no nursing reassessment or interventions regarding the critical laboratory result. There was also no documentation that E #3 followed-up and intervene regarding the troponin critical value since 8:28 PM.

- E #2 (ED technician) performed vital signs on Pt. #1 on 12/28/2021 at 11:46 PM that included, "BP 188/69, Pulse 80, Respiration: 12, Oxygen level 98% (normal above 92%).

- E #5's (ED registered nurse) progress notes on 12/29/2021 at 3:53 AM included, "(Received Pt. #1) via cart to (treatment room) in cardiac arrest with CPR (cardiopulmonary resuscitation) in progress. (Pt. #1 was) found in (the) bathroom unresponsive and pulseless."

- The medical emergency code sheet indicated that on 12/29/2021 at 3:51 AM, Pt. #1 had no pulse and cardiac rhythm, and CPR was initiated. Pt. #1 was pronounced dead at 4:15 AM. The physician's primary impression was cardiac arrest.

2. On 4/6/2022, the Hospital's scope of services (dated 1/2019) was reviewed and included, " ... II. Important Aspects of Care: high risk, high volume, problem-prone processes. Nursing staff, medical staff, other healthcare professionals, and all members of the healthcare team function collaboratively as part of an interdisciplinary team to achieve quality patient outcomes ... Emergency Services aspects of care include ... Ongoing systematic assessment of the physical ... needs of the patients including accurate, complete documentation of care ... Communication of patient status and other pertinent data to other members of the healthcare team ..."

3. On 4/6/2022, the Hospital's job description for the ED nurses (dated 6/2019) was reviewed and included, " ... Communication and collaboration with ... physicians and other health care professionals ... Primary Responsibilities ... 22. Documents accurately, timely ... and appropriately: patient ... care ... interventions, evaluations ... and current status ..."

4. On 4/6/2022, the Hospital's policy and procedure in the ED titled, "Critical (Laboratory) Value Reporting" (reviewed by the Hospital on 1/2021) was reviewed and required, "Purpose: To establish a standardized process for immediate communication of critical laboratory results to the responsible practitioner who could act on the results ... II. This policy applies to all patient care areas ... V. Procedure. 1. Inpatient critical laboratory values are communicated by (laboratory) personnel to, and accepted by a Registered Nurse... 3. All critical (laboratory) values should be reported in a timely manner to the attending physician, resident physician, or allied health professional responsible for managing the patient's care ... 4. The goal time interval between receiving the critical value and reporting the critical value to the physician or allied health professional is 30 minutes."

5. On 4/6/2022, the Hospital's policy in the ED titled, "Nursing Assessment and Reassessment" (reviewed on 1/2022) was reviewed and included, " ... Reassessment ... Reassessment is based on the patient's diagnosis, need for care ... Frequency of reassessments ... 2. Critical care reassessments should be completed every 2-3 hours or more frequently depending on the changing condition of the patient ..."

6. On 4/7/2022 at approximately 9:10 AM, a telephone interview was conducted with E #2 (ED Technician). E #2 stated, "(Pt. #1) was in the waiting room ... I took her vital signs ... she has been waiting for three hours." E #2 stated that he told the charge nurse that Pt. #1 had been waiting for a long time.

7. On 4/7/2022 at approximately 9:20 AM, a telephone interview was conducted with E #5 (ED RN). E #5 stated that Pt. #1 had been in the ED waiting room since the time of arrival. E#5 said that Pt. #1 was later found unresponsive and with no pulse inside the restroom.

8. On 4/7/2022 at approximately 9:33 AM, a telephone interview was conducted with E #3 (Advanced Practice Nurse). E #3 stated that he was never notified of Pt. #1's troponin results. E #3 said that the nurse should have notified the provider of the troponin results to take the necessary interventions. E #3 verified that since arrival in the ED, Pt. #1 had been in the waiting room and was not connected to a heart monitor. Regarding Pt. #1's troponin, E #3 said, "The result is elevated. You would want to do further tests and evaluation to find out why is (the troponin) elevated. If not, anything could potentially happen; the worst outcome could be death."

9. On 4/7/2022 at approximately 11:20 AM, an interview was conducted with MD #4 (Medical Director). MD #4 stated that the ED provider is expected to be notified of critical laboratory values by the nurse to ensure that patients are safe and receive the appropriate medical care management.

10. On 4/8/2022 at approximately 11:30 AM, another interview was conducted with MD #4. MD #4 stated that when a patient has been triaged in the ED, the triage team (nurses, advanced practice nurse, and physicians) are expected to check on the patient's status, including tests that were ordered. MD #4 stated that critical laboratory results can also be viewed by the triage team from the ED tracking board. MD #4 added that the triage team is expected to check on the tracking board constantly, at least less than an hour. MD #4 could not provide documentation that the critical laboratory results were acknowledged or acted upon by the triage team.