HospitalInspections.org

Based on review of the documents and interviews with the staff the facility failed to provide an appropriate and thorough medical screening examination (MSE) within the capability of the hospital's emergency department, including diagnostic testing for elevated blood pressure for patient # 1.

The findings were:
Patient # 1 medical chart dated 8/16/2023 was reviewed , it was noted:
Chief complaint was upper right leg pain.
Imaging Results- Spine Lumbar, 2-3 Views: Impression: Unremarkable lumbar spine radiograph

Blood Pressure on 08/16/2023
1:46 AM: (!) 189/84
2:42 AM: (!) 185/91
3:00 AM: (!) 195/92
4:00 AM: (!) 197/90
4:30 AM: (!) 203/86

Comment: Physician notified and OK with DC

Patient was prescribed Norvasc 10 mg tablet for the elevated blood pressure and advised to follow up with their Primary Care Physician (PCP). The patient was discharged at 4:32 AM. The last blood pressure for the patient was taken on 8/16/23 at 4:30 AM which noted 203/86.

Patient # 1 medical chart dated 8/18/2023 was reviewed , it was noted:
Patient arrived via EMS with cardiac arrest. The hospital timeline is as follows:
1008 Pulse check: No palpable pulses. No cardiac activity on bedside US. CPR continued via Lucas device.
1008 Patient with a gastric intubation by EMS. Reintubated using a 7.5 tube at teeth.
1010 Additional Bicarb dose and EPI dose given
1010 Pulse check, no cardiac movement on ultrasound, asystole, CPR restarted.
1011 Another round of Epi
1012 Pulse check: No palpable pulses. No cardiac activity on bedside US. CPR continued via Lucas device. Another round of epi given. Asystole on cardiac monitor.
1013 Pulse check, another round of Epi, asystole.
1016 Time of Death called

A review of the document titled "Current Summary Provision of Care Event, provided by Director of Quality on 11/09/2023 at 12:33 PM revealed in part the following:
Date of event: 08/18/2023 at 12:00 noon
The event was: Cardiopulmonary Arrest/Resuscitation. The patient died. A brief discussion revealed the patient was seen two days ago for low back pain and "bilateral" lower extremity pain. Patient was brought by to the facility by EMS for cardiac arrest and asystole, upon arrival no return of spontaneous circulation. Event is a Medical Examiner case. No cause of death determined as of this writing. No immediate actions taken.

Associate Medical Director spoke with the attending physician and stated that the chart was documented well and believes it's too early to if something as missed.

During an interview with staff # 10 Amanda Russell, RN Quality Coordinator on 11/09/2023 at approximately 2:20 PM revealed the following:
Surveyor: During the patient's visit on 8/16/2023, do you see an order for an EKG?
Staff # 10: I have looked through the chart and do not see an order for an EKG.