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Based on record review and interview, the Hospital failed to establish policies and procedures governing the medical care provided in the Emergency Department (ED) regarding the ongoing assessment of Patient #4 who arrived at the ED complaining of respiratory illness including new cough and coughing while eating and drinking. Patient #4 was not evaluated for a pulse oximetry measurement at triage and was asked to wait in the waiting room for 6 hours with no ongoing assessment. Patient #4 was found unresponsive in the waiting room.

Refer to A1104

Based on record review and interviews, the Hospital failed to establish policies and procedures governing the medical care provided in the Emergency Department (ED). Specifically, for 1 Patient (#4) out of a total sample of 10 patients, the Hospital failed to obtain an oxygen saturation level (SPO2) at the time of triage, despite the Patient's complaints of respiratory illness including new cough and coughing while eating and drinking. Patient #4 was not reassessed after being triaged nor was an SPO2 ever obtained, and the Patient was found unresponsive in the waiting room while waiting for an extended period (6 hours) to be evaluated by a physician.

Findings include:

Medical Record review indicated that Patient #4 arrived to the ED on 11/28/22 at 8:25 P.M. complaining of a cough. RN #1 was working at triage and was unable to measure a oxygen saturation (SPO2) level during Patient #4's assessment. Further record review indicated that on 11/29/22 at 3:05 A.M., Patient #4 was found to be unresponsive while being brought back from the waiting room, subsequently a Code Blue was called, Patient #4 was resuscitated and ultimately his/her guardian authorized Comfort Measures Only and the Patient was pronounced dead at 5:25 A.M.

During an interview on 4/4/23 at 3:43 P.M., Physician #1 indicated that on the day Patient #4 arrived the hospital census was high and there was a full waiting room. The triage nurse assessed the patient and ordered lab work including an influenza test and chest x-rays. Physician #1 said that lab orders and imaging will have the results sent back to whomever ordered the test, and it could be the triage nurse, a midlevel provider, or a physician. Physician #1 said the lab will call with critical results to the charge nurse and that generally abnormal labs should be communicated by the nurse to the provider, however this was not done.

Physician #1 indicated that Patient #4 should have been reassessed after the initial triage in which the nurse was unable to obtain SPO2.

Physician #1 said his first interaction with Patient #4 was when the nurse was bringing him/her back from the waiting room and saying she wasn't sure if there was a pulse, a Code Blue was initiated, and he assumed care for Patient #4 at that time.

During an interview on 4/5/23 at 9:56 A.M., RN #1 said she triaged Patient #4 and after assessing Patient #4 she completed the lab orders and requested an X-ray. RN #1 said that her shift ended shortly after she triaged Patient #4 and doesn't remember seeing any results.

During an interview on 4/5/23 9:30 A.M., RN#2 said she was charge nurse the night Patient #4 came in. She said the triage nurse was running behind that night and there were too many people waiting to be triaged. RN #2 said a second triage station was set up to check vital signs and get information. RN#2 said Patient #4 was seen by RN#1, triaged as an ESI 3 because he/she needed multiple services, wasn't him/herself, had a cough and change in functional level reported by a family member. RN#2 said RN #1 was unable to obtain an SpO2 but said his/her other vital signs were stable. She said Patient #4 wasn't well looking but was seated upright and that labs and an X-ray were ordered.

RN#2 said when Patient #4 was being brought into the ED room, his/her family member said I don't think he/she looks okay. RN#2 said the nurse said she wasn't sure of a pulse and immediately brought Patient #4 back quickly and a Code Blue response was started. RN#2 said Patient #4 was in the waiting room for 5 or 6 hours and had not been reassessed. RN#2 said that generally reassessment of vital signs will occur for patients, however, there is no formal process for reassessing patients.

During an interview with the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) on 4/5/23 at 8:11 A.M., the CMO said Patient #4's case was discussed at Quality Safety Coordinating Group (QSCG) and that there was a new ED medical director. The CMO said that the ED medical director was implementing nurse driven protocols that all patients will be assigned to a provider.

During an interview with the Chief of Emergency Medicine and Associate Chief of Emergency Medicine on 4/5/23 at 9:06 A.M., the Chief of Emergency Medicine said after Patient #4's case a change being planned is that they are implementing a rotating provider in triage who will assess 3 or 4 patients and then assign themselves to the patient. He said another strategy is starting a new after-hours triage, trying to implement taking over the neighboring GI suite/ recovery area after they have finished their cases for the day and using it as ED expansion when waiting room is at capacity but that implementation of that takes collaboration and is reliant on enough staff. He said the last draft of that proposal was written last week and needs to be signed off by administration.

During an interview on 4/5/23 at 11:17 A.M., the ED Nursing Director said that as a result of this incident, the ED is now moving patients out quicker and they have changed the time of their daily throughput huddle (to facilitate patient movement throughout the hospital) to an earlier time in the day and there is now a throughput supervisor to oversee this. She further said the ED has increased the size of their charge nurse team and now has dedicated charge nurses that have received education about when to call a Code Help.

The Hospital has no policies governing ongoing/continuing assessments of patients in the triage area, and failed to address that Patient #4's pulse oximetry was not measured and was not reassessed after waiting for an extended period (6 hours) to be evaluated by a physician.