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Based on staff interviews, review of patients' emergency room medical records and hospital policies, the hospital failed to stabilize an existing medical condition within the capabilities of the staff and services available at the hospital required to stabilize an existing medical condition prior to transfer to a higher level of care hospital to 1 of 20 sampled patients (#3). The hospital's failure to stabilize the patient by discontinuing a medication to stabilize the patient's blood pressure resulted in the patient's blood pressure to decelerate to the point that the patient required cardiopulmonary resuscitation.

Refer to findings in Tag A-2407.

Based on staff interviews, review of patients' emergency room medical records and hospital policies, the hospital failed to stabilize an existing medical condition within the capabilities of the staff and services available at the hospital required to stabilize an existing medical condition prior to transfer to a higher level of care hospital to 1 of 20 sampled patients (#3). The hospital's failure to stabilize the patient by discontinuing a medication to stabilize the patient's blood pressure resulted in the patient's blood pressure to decelerate to the point that the patient required cardiopulmonary resuscitation.

Findings:

EMERGENCY DEPARTMENT MEDICAL RECORD REVIEW AND STAFF INTERVIEWS

On 1/06/2022 at 10:44 p.m., patient #3 presented to the Emergency Department (ED) on with chief complaint of "Flu-like symptoms". Patient #3 was triaged by a nurse at 10:47 p.m. Vital signs at that time were noted to be Temperature 97.5, HR 90, Respirations 20, BP 103/73, and O2 saturation 98% on room air.

On 1/07/2022 at 1:28 a.m., physician (Dr.) H saw patient #3. The patient's ED record revealed a history of end- stage renal disease on dialysis, hypertension and presenting with flu-like symptoms and a low-grade temperature, Heart Rate (HR) was 90, Blood Pressure (BP) was 103/73, Oxygen (O2) saturation was 98% on room air, and Temperature of 97.5 at 10:47 p.m.

On 1/07/2022, Dr. H ordered a Chest X-Ray; results at 3:16 a.m. was a Possible Pericardial Effusion. Pericardial Effusion "refers to the accumulation of excess fluid in the pericardial sac surrounding the heart." (www.ncbi.nlm.nih.gov).

On 1/07/2022, results at 4:20 a.m. revealed a computerized tomography (CT) scan of the Chest report of a Large Pericardial Effusion.

On 1/07/2022 at 6:15 a.m., Dr. H planned to admit patient #3 and called Dr. I, the hospitalist, to see if he would admit the patient to his service. When Dr. I received the information on patient #3, he said Dr. H should discuss the case with Dr. J, a cardiologist, to get his recommendations and ensure the patient shouldn't be transferred rather than admitted. Upon contacting Dr. J, he stated to get an Echocardiogram (an imaging test that uses ultrasound to monitor the heart function) and transfer the patient to a Cardio-Thoracic Specialty Receiving Hospital for cardio-thoracic specialty services.

On 1/07/2022 at approximately 6:15 a.m., Dr. H ordered an Echocardiogram (ECHO) stat (immediately) at approximately 6:15 a.m., and after giving Dr. G a report, signed the case over to Dr. G, who was coming on shift. The ECHO technician was called to come in around 6:15 a.m. but asked the 8:00 a.m. technician to come in earlier.

On 1/07/2022 at approximately 6:47 a.m. and upon re-evaluation of the patient, Dr. G noted that patient #3's blood pressure started to decrease, and his breathing and respiratory rate were increasing. He placed a call to Dr. F, the cardiologist at the Cardio-Thoracic Specialty Receiving Hospital, informing him that he did not feel safe waiting for the echocardiogram to be done as the patient appeared to be decompensating. Dr. F instructed Dr. G to start peripheral Phenylephrine (a medication to increase blood pressure) and to slow intravenous (IV) fluids at this time to keep patient #3's blood pressure elevated, do the echocardiogram, and he would call the cardiothoracic surgeon to see if he can accept the patient for a pericardial window. "A pericardial window is a procedure done on the sac around the heart. Surgically removing a small part of the sac lets doctors drain excess fluid from the sac." (www.hopkinsmedicine.org). Dr. F called Dr. G back to let him know that patient had been accepted. Dr. G ordered IV Phenylephrine and IV fluids as instructed by Dr. F and then called the emergency medicine physician at the Cardio-Thoracic Specialty Receiving Hospital to let him know the patient would be coming through their ED and had been accepted by the cardio-thoracic surgeon and Dr. F as well as informing him of patient #3's medical history and current condition of a large pericardial effusion.

On 1/07/22 around 9:16 a.m., an ECHO report revealed an estimated Ejection Fraction rate of 15-20%, large free flowing pericardial effusion identified and features consistent with severe tamponade physiology. "Cardiac tamponade is a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This places extreme pressure on your heart. The pressure prevents the heart's ventricles from expanding fully and keeps your heart from functioning properly. Your heart can't pump enough blood to the rest of your body when this happens. This can lead to organ failure, shock, and even death." (www.healthline.com).

On 1/07/22 at approximately 9:30 a.m., Dr. G talked to the patient and noted the patient was comfortable and agreed to transfer to the receiving hospital. Patient #3's BP came up to 119/88 HR 87 on IV Phenylephrine and IV fluids, and the patient stated he felt improved. The plan was to transfer the patient to the Cardio-Thoracic Specialty Receiving Hospital for a pericardial window procedure.

On 1/07/22 at 10:04 a.m., patient #3's vital signs just prior to transfer to the Cardio-Thoracic Specialty Receiving Hospital were noted to be BP 119/88, HR 87, Respirations 31, and O2 Saturation 100% via nasal cannula on O2 at 3 liters per minute. Patient status was noted as "Stable for transfer".

Investigation by the Risk Manager and Quality Director found that upon getting the patient ready to transfer to the Cardio-Thoracic Specialty Receiving Hospital, registered nurse (RN) B discontinued IV Phenylephrine that Dr. G ordered without notifying Dr. G, and without an order to discontinue the medication.

On 6/15/2022 at 11:25 a.m., RN B confirmed that he did not remember if he notified Dr. G about discontinuing IV Phenylephrine. The ED record did not contain any information about IV Phenylephrine being discontinued.

On 6/15/2022 at 1:55 p.m., the Risk Manager noted when she asked RN B why he discontinued IV Phenylephrine, he stated it was because patient #3's BP was stable but admitted he did not have an order to discontinue the medication.

On 6/15/2022 at 2:48 p.m., Dr. G stated he was not notified IV Phenylephrine was discontinued by RN B and would not have discontinued the medication because it was ordered to keep the patient's BP up.


EMERGENCY MEDICAL SERVICE (EMS) RECORD

On 1/07/22, in the ambulance on the way to the Cardio-Thoracic Specialty Receiving Hospital, patient #3's BP dropped to 75/35, and 5 minutes later elevated again to 91/72. EMS staff stated in their report that they couldn't get a good Saturation of Peripheral Oxygen (SPO2) reading because the patient's fingers were cold. The patient was then placed on a non-Re-Breather mask and O2 at 15 liters per minute.


CARDIO-THORACIC RECEIVING HOSPITAL ED RECORD

On 1/07/22 at 10:25 a.m., patient #3 arrived at the Cardio-Thoracic Specialty Receiving Hospital, was noted to be alert and diaphoretic (perspiring profusely), and was transferred to a bed as soon as he arrived in the ED. The patient was placed on a BP monitor. His BP was 119/84 but the SPO2 was still undetectable.

Approximately 5 minutes later at 10:30 a.m., the patient was unresponsive, did not have a palpable pulse, and cardiopulmonary resuscitation (CPR) was started. Pericardiocentesis (aspiration of fluid from the pericardial space that surrounds the heart) was attempted during CPR. Blood was obtained but despite efforts, the patient's pulse never returned, and he was pronounced expired at 11:09 a.m. on 1/07/22.

The ED medical record at the Cardio-Thoracic Specialty Receiving Hospital revealed ED physician Dr. E's progress note of 1/07/2022 at 11:16 a.m. noted patient #3 was started on IV Phenylephrine at the sending hospital which improved his blood pressure. However, IV Phenylephrine was stopped before EMS transport for an unknown reason. Patient #3 arrived to the receiving facility in respiratory distress, decreased level of consciousness, and went into cardiac arrest within minutes of arriving in the receiving hospital's ED.


POLICIES AND PROCEDURES

On 6/17/2022 at 10:30 AM, a review of policies and procedures and interview with Director of Quality revealed the policies and procedures governing who can order and discontinue medications are part of their "Medication Administration Privileges". PolicyStat ID 11028703, approved on 1/14/2022, read, "The privilege of administration of medication to patients is governed at the highest level by Federal and Florida laws and rules promulgated by their agencies. Florida defines medication administration as "the obtaining and giving of a single dose of medicinal drugs by a legally authorized person to a patient for his consumption." (FS 465.003). ALL medication must be properly ordered/prescribed according to Medical Staff Bylaws and PolicyStatID 11906556 "Medication order Writing", approved 06/15/2022, noting, "The authority for medication ordering is in accordance with the Medical Staff Bylaws and Rules and Regulations of the Medical Staff." The Quality Director stated the hospital staff abides by Chapter 464 Part 1 Nurse Practice Act (ss.464.003(b) which reflects the administration of medications and treatments as prescribed by a "duly licensed practitioner authorized by the laws of this state . . . ." The Quality Director acknowledged RN B would not be authorized to order and/or discontinue medications independently.



The facility's Policy titled, "Florida EMTALA Medical Screening Examination and Stabilization, 004. Policy ID stat 294830, Effective 4/1/2018 was reviewed." The Policy revealed in part, "Stabilizing Treatment within Hospital Capability. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the ED has determined within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility." Patient # 3 was not stabilized prior to transfer on 1/7/2022. The ED nurse discontinued the phenylephrine drip without a physician's order at the time of transfer.