HospitalInspections.org

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined that UPMC Pinnacle Hospitals failed to provide emergency care in a timely manner to one of 10 medical records reviewd (MR1). The facility failed to reassess a reported change in condition and failed to monitor a patient in the waiting area which may have delayed interventions which could have possibly prevented the patient ' s death.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

Findings:

A review of facility policy "...Patients' Notice and Bill of Rights and Responsibilities DATE: January 4, 2021..." revealed "...Staff and Environment - You have a right to: 1. Receive respectful care given by competent personnel in a setting that:...a. is safe and promotes your dignity, positive self image and comfort;...Other Healthcare Services
You have a right to: 1. Emergency procedures to be implemented without unnecessary delay...Quality, Support, Advocacy. You have the right to:...2. Quality care and high professional standards that continually are maintained and reviewed..."

The review of MR1 revealed the following:

The review of the "Patient Care Timeline (6/26/2022 03:08 to 6/26/2022 08:58" revealed the following:

"...03:08 Patient arrived in ED...03:08:38 Chief Complaints Updated Chest Pain Vomiting...03:08:38 Acuity - 3...03:45 Vital Signs...Temp: 36.8 °C (98.2 °F); Heart Rate: 100; BP: 126/99;
BP Location: Left arm; BP Method: Automatic; Patient Position: Sitting; Resp: 20; Oxygen Therapy; SpO2: 100 %; Pulse Oximetry Type: Intermittent; Oxygen Therapy: None (Room air)...05:28 Code Start...05:46 Code Outcome, Outcome
Survival: No, Time of Death: 05:46..."


The review of the Nursing Documentation revealed the following:

"...ED Triage Notes...at 6/26/2022 3:08 AM...vomited at intake. Denies recent illness. Pain is non radiating..."

"...ED Nursing Notes...6/26/2022 4:17 AM...Patient to intake desk saying she can't breathe. 100%RA/99HR (pulse oxygen level and heart rate) at intake. Updated on wait. Patient able to speak in full sentences..."

"...ED Nursing Notes...6/26/2022 5:24 AM...While taking a patient to WR (waiting room) in W/C (wheelchair) noticed this patient in WR with head hyperextended over back of w/c. Attempted to arouse patient with no response. Checked patient for pulse, no pulse, yelled for help to take patient into bed 3. CPR started immediately..."

"...ED Nursing Notes... 6/26/2022 5:46 AM...Time of Death 0546 per Dr.______(name redacted)."

The review of the Emergency Department Waiting Area Security Video tapes revealed the following:

06-26-2022 04:15:31 PT1 appears on the screen at the register's window.

06-26-2022 04:16:06 Staff push PT1 in wheel chair into waiting area.

06-26-2022 04:20:37 PT1 moves wheelchair around and knocks on the triage room door.

06-26-2022 04:21:22 Staff opens door and another staff arrives in the hallway. The staff appear to talk with the PT1. Staff walk away. PT1 is in hallway in front of one of the triage room doors.

06-26-2022 04:24:58 PT1 in wheelchair with head extended over back of wheelchair and patient's left arm was out stretched over arm of wheelchair.

06-26-2022 04:27:12 Staff open triage room door that PT 1 was in front of. Staff look around the waiting area and another patient walks into triage room with staff.

06-26-2022 04:31:23 Staff member enters waiting area from behind PT1 in the wheelchair. Staff member walks beside PT1 in wheelchair, looking around the waiting area. Then staff member walks out of the waiting area, again walking past the PT1 in wheelchair.

06- 26-2022 04:39:41 Security is seen walking through the waiting area and walking past PT1 in the wheelchair.

06- 26- 2022 04:41:27 Staff enter waiting area walking past patient. Staff talk with another patient and leave the waiting area. Walking past PT1.

06-26-2022 04:57:57 Staff enter waiting area, walking past PT, looks around waiting area and walks out of the waiting area. Again, waking past PT1.

06-26- 2022 05:24;38 Staff enter waiting area with another patient in wheelchair. Staff walk past PT1 when entering and again when leaving waiting area.

06- 26- 2022 05:26:06 Staff attempt to enter the waiting area with another patient in wheelchair. PT1 is still in wheelchair in front of triage room. Staff attempt to move PT1, staff then went into triage room and returns with another staff member. PT1 is wheeled into the triage room.

Between 06-26-2022 04:24:58 and 06-26-2022 05:26:06, PT1 was in wheelchair with head extended over back of wheelchair and patient's left arm out stretched over arm of wheelchair. The review of the security tapes did not reveal PT1 moving during the time frame.

Interview conducted on June 30, 2022, with EMP1 confirmed that the patient went to the intake desk and did not have a complete assessment and that the policy did not address reassessment of a patient who has complaints of new or increased concerns after the initial assessment and ESI number was assigned outside of the required assessment related to the assigned ESI numbers.

Interview conducted on July 1, 2022, with EMP3 confirmed that 5 staff members entered and exited the waiting area during the hour that PT1 sat not moving in a wheelchair with head extended over the back of wheelchair and left arm extended out over the arm of the wheelchair. Further interview confirmed that the patient did not appear to move for approximately one hour.

Cross Reference:
§482.55(a)(3) Emergency Services Policies
§482.55(b)(2) Qualified Emergency Services Personnel

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to have a policy that addresses reassessment for patients that present after the initial assessment and triage with a new or change in condition for one of ten medical records reviewed (MR1).

Findings include:

A review of facility policy "Title: Unit Standard of Care for Emergency Dept Patients" did not reveal documentation of requirements for reassessment of patients with new or increased concerns after the initial assessment and Emergency Severity Index (ESI) number was assigned. The policy does not address patients with new or increased concerns outside of the required assessments related to the assigned ESI numbers.

PT1 presented to the Emergency Department and was assigned an ESI 3. The review of MR1 revealed the following:

"...ED Nursing Notes...6/26/2022 4:17 AM...Patient to intake desk saying she can't breathe. 100%RA/99HR (pulse oxygen level and heart rate) at intake. Updated on wait. Patient able to speak in full sentences..."

"...ED Nursing Notes...6/26/2022 5:24 AM...While taking a patient to WR (waiting room) in W/C (wheelchair) noticed this patient in WR with head hyperextended over back of w/c. Attempted to arouse patient with no response. Checked patient for pulse, no pulse, yelled for help to take patient into bed 3. CPR started immediately..."

Interview conducted on June 30, 2022, with EMP1 confirmed that the patient went to the intake desk and did not have a complete assessment and that the policy did not address reassessment of a patient who has complaints of new or increased concerns after the initial assessment and ESI number was assigned outside of the required assessment related to the assigned ESI numbers. Further interview confirmed the patient was found pulseless and Patient was pronounced expired at 05:46 AM.

Cross Reference:
§482.55 Emergency Services
§482.55(b)(2) Qualified Emergency Services Personnel

Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined the facility failed to monitor a patient in the waiting area of the Emergency Room for one of ten medical records reviewed (MR1).


Findings:

A review of facility policy "...Patients' Notice and Bill of Rights and Responsibilities DATE: January 4, 2021..." revealed "...Staff and Environment - You have a right to: 1. Receive respectful care given by competent personnel in a setting that:...a. is safe and promotes your dignity, positive self image and comfort;...Other Healthcare Services
You have a right to: 1. Emergency procedures to be implemented without unnecessary delay...Quality, Support, Advocacy. You have the right to:...2. Quality care and high professional standards that continually are maintained and reviewed..."

The review of MR1 revealed the following:

The review of the "Patient Care Timeline (6/26/2022 03:08 to 6/26/2022 08:58" revealed the following:

"...03:08 Patient arrived in ED...03:08:38 Chief Complaints Updated Chest Pain Vomiting...03:08:38 Acuity - 3...03:45 Vital Signs...Temp: 36.8 °C (98.2 °F); Heart Rate: 100; BP: 126/99;
BP Location: Left arm; BP Method: Automatic; Patient Position: Sitting; Resp: 20; Oxygen Therapy; SpO2: 100 %; Pulse Oximetry Type: Intermittent; Oxygen Therapy: None (Room air)...05:28 Code Start...05:46 Code Outcome, Outcome
Survival: No, Time of Death: 05:46..."


The review of the Nursing Documentation revealed the following:

"...ED Triage Notes...at 6/26/2022 3:08 AM...vomited at intake. Denies recent illness. Pain is non radiating..."

"...ED Nursing Notes...6/26/2022 4:17 AM...Patient to intake desk saying she can't breathe. 100%RA/99HR (pulse oxygen level and heart rate) at intake. Updated on wait. Patient able to speak in full sentences..."

"...ED Nursing Notes...6/26/2022 5:24 AM...While taking a patient to WR (waiting room) in W/C (wheelchair) noticed this patient in WR with head hyperextended over back of w/c. Attempted to arouse patient with no response. Checked patient for pulse, no pulse, yelled for help to take patient into bed 3. CPR started immediately..."

"...ED Nursing Notes... 6/26/2022 5:46 AM...Time of Death 0546 per Dr.______(name redacted)."

The review of the Emergency Department Waiting Area Security Video tapes revealed the following:

06-26-2022 04:15:31 PT1 appears on the screen at the register's window.

06-26-2022 04:16:06 Staff push PT1 in wheel chair into waiting area.

06-26-2022 04:20:37 PT1 moves wheelchair around and knocks on the triage room door.

06-26-2022 04:21:22 Staff opens door and another staff arrives in the hallway. The staff appear to talk with the PT1. Staff walk away. PT1 is in hallway in front of one of the triage room doors.

06-26-2022 04:24:58 PT1 in wheelchair with head extended over back of wheelchair and patient's left arm was out stretched over arm of wheelchair.

06-26-2022 04:27:12 Staff open triage room door that PT 1 was in front of. Staff look around the waiting area and another patient walks into triage room with staff.

06-26-2022 04:31:23 Staff member enters waiting area from behind PT1 in the wheelchair. Staff member walks beside PT1 in wheelchair, looking around the waiting area. Then staff member walks out of the waiting area, again walking past the PT1 in wheelchair.

06- 26-2022 04:39:41 Security is seen walking through the waiting area and walking past PT1 in the wheelchair.

06- 26- 2022 04:41:27 Staff enter waiting area walking past patient. Staff talk with another patient and leave the waiting area. Walking past PT1.

06-26-2022 04:57:57 Staff enter waiting area, walking past PT, looks around waiting area and walks out of the waiting area. Again, waking past PT1.

06-26- 2022 05:24;38 Staff enter waiting area with another patient in wheelchair. Staff walk past PT1 when entering and again when leaving waiting area.

06- 26- 2022 05:26:06 Staff attempt to enter the waiting area with another patient in wheelchair. PT1 is still in wheelchair in front of triage room. Staff attempt to move PT1, staff then went into triage room and returns with another staff member. PT1 is wheeled into the triage room.

Between 06-26-2022 04:24:58 and 06-26-2022 05:26:06, PT1 was in wheelchair with head extended over back of wheelchair and patient's left arm out stretched over arm of wheelchair. The review of the security tapes did not reveal PT1 moving during the time frame.

Interview conducted on June 30, 2022, with EMP1 confirmed that the patient went to the intake desk and did not have a complete assessment and that the policy did not address reassessment of a patient who has complaints of new or increased concerns after the initial assessment and ESI number was assigned outside of the required assessment related to the assigned ESI numbers.

Interview conducted on July 1, 2022, with EMP3 confirmed that 5 staff members entered and exited the waiting area during the hour that PT1 sat not moving in a wheelchair with head extended over the back of wheelchair and left arm extended out over the arm of the wheelchair. Further interview confirmed that the patient did not appear to move for approximately one hour.

Cross Reference:
§482.55 Emergency Services
§482.55(a)(3) Emergency Services Policies