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Based on observation, interview and record reviews conducted on days of survey, the Condition of Participation: Patient Rights was not met as evidenced by the hospital's failure to protect and promote the rights of each patient to assure that safe care was provided. Based on information obtained the following findings reflect an Immediate Jeopardy situation was determined to exist as the result of actual harm to a patient who sought treatment in the Emergency Department.


Refer to tags: A-0131, 0144, 0145, 0147

Based on interview and record review, the nursing staff in the Emergency Department failed to follow hospital policy during the process of obtaining consent for treatment for one applicable patient. (Patient #1) Findings include:

On 9/24/13 Patient #1 was transported to the ED via ambulance with complaints of pain and other symptoms. Once in the ED it is responsibility of staff to obtain consent for treatment. Per hospital policy Informed Consent last revised 6/18/13 states " Valid informed consent must be obtained from each patient prior to any medical procedure or treatment ......". For the Emergency Department the policy titled Consent, last revised 8/27/13 states regarding the purpose for consent " To obtain written permission on all Emergency Department patients unless unable to sign due to unconscious state or life threatening emergency when not accompanied by a party responsible for signing permission" .

After Patient #1 was placed in bay #11 on 9/24/13 and the Triage process was completed, Registrar #1 from Access Services approached the patient to obtain his/her signature for treatment and to review insurance information and demographics. When Patient #1 was not responding to Registrar #1, the Registrar spoke to Nurse #1 informing her that s/he thought Patient #1 was dead and no signature for treatment was obtained. Nurse #1 took the consent form and signed for treatment. Per interview on 10/8/13 at 1:58 PM, Nurse #1 confirmed s/he had signed the consent form for Patient #1 to receive treatment in the ED, informing the Registrar Patient #1 was not answering any questions. However, per interview on 10/8/13 at 9:08 AM the Clinical Nurse Specialist for the ED stated "We sign that the patient is unable to sign and the reason why they can't sign". Per review of Patient #1's "Uniform Consent and Authorization to Release Information" form noted the signature of Nurse #1 is noted and dated on the designated line which read: " If Person Representative, describe relationship".

Based on observation, interviews and record review, the hospital failed to assure immediate interventions were implemented for a patient who demonstrated a reported change in condition shortly after arrival to the Emergency Department and nursing staff failed to follow hospital policy and standards of practice to assure care and services were delivered in a safe setting for 1 applicable patient. (Patient #1) Findings include:

Per record review, Patient #1 arrived via ambulance to the Emergency Department (ED) on 9/24/13 at 23:07. Patient #1's medical history contained multiple co-morbidities to include: Type 2 Diabetes mellitus; Epilepsy with severe seizure disorder; End Stage Renal Disease (ESRD) requiring dialysis treatments 3 x per wk; sleep apnea; asthma, obesity, hypothyroidism and Bipolar disorder. Per Emergency Medical Services (EMS)/Rescue Squad "Prehospital Care Report" for 9/24/13 at 22:30, Patient #1 was complaining of severe back pain, relating it to a fall which occurred on 9/14/13 and a recent cortisone injection. The report also noted Patient #1 was observed to have "...dry heaves...complained of stomach pain....s/he is short of breath...starting to breath rapidly...Also having some chest pain...Pt put on 3 lit (liters) of 02 (oxygen) nasal canula pt noting that O2 did help with breathing". Per interview on 10/8/13 at 11:40 AM, a Advanced EMT #1 (Emergency Medical Technician) who was part of Patient #1's transport team to the ED on 9/24/13 confirmed the patient was anxious. EMT #1 stated because of Patient #1's presenting symptoms to include continuous low blood pressure readings ( 85/60, 84/54. & 76/56 ) and the inability to establish an IV, the Paramedic was requested to arrive at the scene for assistance. EMT #1 also stated Patient #1 was placed on a 4 lead cardiac monitor but frequent artifact was noted due to the patient's restless movement, discomfort and anxiety.

Upon arrival EMS staff were directed to place Patient #1 in bay #11, a large 2 bed area often used for trauma cases. Nurse #1, assigned to Triage, began the initial Triage process by entering demographic information into the Electronic Medical Record (EMR) but had not assisted with the patient's transfer. Report was provided by EMS staff to Nurse #1 and with the assistance of an ED Technician, Patient #1 was transferred to the ED stretcher by EMS staff. Per EMT #1 , Patient #1 was removed from the Rescue Squad Cardiac monitor and oxygen and assistance was provided to the ED Technician to obtain a blood pressure, which process was difficult due to patient's restlessness and EMT #1 stated s/he provided Patient #1 reassurance due to the patient's continued anxiety.

Per interview on 10/7/13 at 1:58 PM, Nurse #1 confirmed she had obtained a report from EMS regarding Patient #1 to include back pain, shortness of breath and stomach pain. "S/he was yelling...appeared to be in quite a bit of pain". Nurse #1 further stated s/he had cared for Patient #1 in the past during previous ED visits. Nurse #1 rated the patient's pain to be a "10" (on a 1-10 pain scale/10 being the worse level of pain) but noted Patient #1 did not answer Nurse #1's questions during the Triage process stating the patient was yelling in pain. At the completion of the Triage process that was conducted on the opposite side of the large trauma bay, Nurse #1 left the area. No direction was provided by Nurse #1 to other ED staff to place Patient #1 on a cardiac monitor or apply oxygen. The only vital signs recorded, taken by the ED technician, included: B/P 130/96, pulse 88 and oxygen level via pulse ox meter was reported at 96 on room air.

Nurse #2, who was assigned to Patient #1, sat at the nurses station located opposite the trauma bay #11 and observed Patient #1's arrival by EMS. Per interview on 10/7/13 at 12:01 PM, Nurse #2 stated s/he was on the computer and did not get up to assist staff and EMS with the patient's transfer or assess the patient's physical status once the ED technician had completed vital signs. Nurse #2 stated " ...the patient was crying out in pain...I continued my charting". Nurse #1 stated staff had dimmed the lights in bay #11 to "...make the patient more comfortable...I would glance over to see her/him move their arm or leg".

Per ED Triage Protocol: Chest Pain, last reviewed 02/13 states "Triage protocols are an effective way to provide timely diagnostics and gain efficiencies for provision of services to select patients based on presenting signs and symptoms. The use of standardized approach to triage to facilitate medical decision making by the provider." Nursing orders for ED Triage for chest pain includes : "Vital signs; 02 per titration guidelines; saline well (IV) and cardiac monitor". Neither Triage Nurse #1 or Nurse #2 made any effort to follow hospital protocol.

At approximately 10 minutes after admission to the ED between 2220-2224 on 9/24/13 Access Services Registrar #1 entered bay #11 to complete the registration process, verify information and obtain a signature for treatment from Patient #1. Per telephone interview on 10/7/13 at 4:00 PM. Registrar #1 stated "I spoke to her/him a couple of times (Patient #1)...her/his head was to the side and her/his mouth was open. There was no response from her/his eyes. I was quite close to her/him. I was up by her/his head. I looked at her/his chest area to see if there was any movement." Registrar #1 reported s/he quickly went to the end of the trauma bay area and "I said to the nurses who were nearby. I said s/he (Patient #1) is dead. One of the nurses said 'oh s/he's playing possum'.....'I'll sign your papers for her/him'....She signed my paper and at that point I left the emergency room....I did not know if s/he was actually dead when I left the emergency department".

Despite the comments made by Registrar #1, neither Nurse #1 or Nurse #2 went to assess Patient #1. Nurse #2 confirmed s/he saw Registrar #1 enter bay #11 and described Registrar #1 as s/he was walking out from bay #11 as ".... nervous" and "...said I think s/he's dead". Nurse #2 stated at the time of interview that " I said s/he was moving. She was sleeping. I did not go up to look at her/him....I know I should have but I didn't".

Within 1-2 minutes after the Registrar's reported observations of Patient #1, Nurse #3, who was unaware of comments and concerns raised by Registrar #1, walked by bay #11 and glanced at Patient #1. Per interview on 10/7/13 at 3:15 PM, Nurse #3 stated "...s/he did not look well at all...s/he was not on a heart monitor, checked for a pulse...". Nurse described the pulse as "faint" and waved for Nurse #2, who was sitting at the nurses station, to come to bay #11. Per nursing note written by Nurse #1 at 2327, "...RN walked by Pts. room, noted Pt. to appear cyanotic, Pt. found to be pulseless and apnic (not breathing), CPR initiated". Resuscitation for cardiac arrest continued for 20 minutes. Patient's condition did not improve, the code was ended and time of death was noted to be 2351.

Per interview on 10/8/13 at 10:18 AM, the Supervisor for Access Services, who oversees registration of patients receiving treatment in the ED, stated s/he was informed by a member in the Access Services that Registrar #1 was upset after reporting to a nurse on the night of 9/24/13 that upon entering bay #11 s/he noted the patient appeared dead, but the nurse "blew her off". When the Supervisor for Access Services was asked about the relationship between Access Service staff and ED nursing staff, s/he reported there have been past issues between departments when staff conducting ED registration have alerted nursing of a immediate concern related to a patient seeking ED services and the response from nursing was the Registrars were "..over reacting...".

Based on staff interview and record review, the hospital failed to assure all patients seeking treatment are free from neglect for 1 applicable patient. (Patient #1) The facility failed to report within 48 hours allegations of abuse to Adult Protective Services in accordance with Vermont State Statute Title 33 Chapter 69 "Reports of abuse, Neglect and Exploitation of Vulnerable Adults". Findings include:

On the night of 9/24/13 2 nurses assigned to work in the ED demonstrated indifference and neglect when notified by a hospital employee that a newly admitted patient to the ED demonstrated a change in condition. Both nurses failed to respond when alerted the patient appeared dead and demonstrated disregard for the patient's emergent needs and condition by describing the patient as" playing possum".

Patient #1 arrived via ambulance to the Emergency Department (ED) on 9/24/13 at 23:07. Patient #1 had multiple co-morbidities to include: Type 2 Diabetes mellitus; Epilepsy with severe seizure disorder; End Stage Renal Disease (ESRD) requiring dialysis treatments 3 x per wk; sleep apnea; asthma, obesity, hypothyroidism and Bipolar disorder. Per Emergency Medical Services (EMS)/Rescue Squad "Prehospital Care Report" for 9/24/13 at 22:30, Patient #1 was complaining of severe back pain, relating it to a fall which occurred on 9/14/13 and a recent cortisone injection. The report also noted Patient #1 was observed to have "...dry heaves...complained of stomach pain....s/he is short of breath...starting to breath rapidly...Also having some chest pain...Pt put on 3 lit (liters) of 02 (oxygen) nasal canula pt noting that O2 did help with breathing". Per interview on 10/8/13 at 11:40 AM, a Advanced EMT #1 (Emergency Medical Technician) who was part of Patient #1's transport team to the ED on 9/24/13 confirmed the patient was anxious. EMT #1 stated because of Patient #1's presenting symptoms to include continuous low blood pressure readings ( 85/60, 84/54. & 76/56 ) and the inability to establish an IV, the Paramedic was requested to arrive at the scene for assistance. EMT #1 also stated Patient #1 was placed on a 4 lead cardiac monitor but frequent artifact was noted due to the patient's restless movement, discomfort and anxiety. Upon arrival to the ED, EMS removed the monitor and discontunued the oxygen.

Per interview on 10/7/13 at 1:58 PM, Nurse #1 confirmed she had obtained a report from EMS regarding Patient #1 to include back pain, shortness of breath and stomach pain. "She was yelling...appeared to be in quite a bit of pain". Nurse #1 rated the patient's pain to be a "10" (on a 1-10 pain scale/10 being the worse level of pain) but noted Patient #1 did not answer Nurse #1's questions during the Triage process stating the patient was yelling in pain. At the completion of the Triage process that was conducted on the opposite side of the large trauma bay, Nurse #1 left the area. No direction was provided by Nurse #1 to other ED staff to place Patient #1 on a cardiac monitor or apply oxygen. The only vital signs recorded, taken by the ED technician, included: B/P 130/96, pulse 88 and oxygen level via pulse oximeter was reported at 96 on room air. Nurse #1 acknowledged s/he was aware of Patient #1 from past ED visits and acknowldeged "..s/he often needs everything....and it takes extra time..." during the provision of care. In addition, Nurse #1 confirmed Patient #1 should have been placed on a cardiac monitor upon admission to bay #11.

Nurse #2, who was assigned to Patient #1, sat at the nurses station located opposite trauma bay #11 and observed Patient #1's arrival by EMS. Per interview on 10/7/13 at 12:01 PM, Nurse #2 stated s/he was on the computer and did not get up to assist staff and EMS with the patient's transfer or assess the patient's physical status once the ED technician had completed vital signs. Nurse #2 stated " ...the patient was crying out in pain...I continued my charting". Nurse #1 stated staff had dimmed the lights in bay #11 to "...make the patient more comfortable...I would glance over to see her/him move their arm or leg". Nurse #2 did not direct ED technician to place the patient on a cardiac monitor, nor was an attempt made to achieve IV access or to address and reassess the patient's complaints of pain. Patient #1 was left alone.

At approximately 10 minutes after admission to the ED between 2220-2224 on 9/24/13 Access Services Registrar #1 entered bay #11 to complete the registration process, verify information and obtain a signature for treatment from Patient #1. Per telephone interview on 10/7/13 at 4:00 PM. Registrar #1 stated "I spoke to her/him a couple of times (Patient #1)...her/his head was to the side and her/his mouth was open. There was no response from her/his eyes. I was quite close to her/him. I was up by her/his head. I looked at her/his chest area to see if there was any movement." Registrar #1 reported s/he quickly went to the end of the trauma bay area and "I said to the nurses who were nearby. I said she/he (Patient #1) is dead. One of the nurses said 'oh s/he's playing possum'.....'I'll sign your papers for her/him'....She signed my paper and at that point I left the emergency room....I did not know if s/he was actually dead when I left the emergency department". The nurse who described Patient #1 as "playing possum" was later identified by Registrar #1 as Nurse #1.

Despite the comments made by Registrar #1, neither Nurse #1 or Nurse #2 went to assess Patient #1. Nurse #2 confirmed s/he saw Registrar #1 enter bay #11 and described Registrar #1 as s/he was walking out from bay #11 as ".... nervous" and "...said I think s/he's dead". Nurse #2 stated at the time of interview " I said s/he was moving. She was sleeping. I did not go up to look at her/him....I know I should have but I didn't". Verification of comments made by Nurse #1 to Registrar #1 were denied, and at the time of interview, Nurse #1 stated Nurse #2 made the sarcastic comment. However within 1-2 minutes after the Registrar's reported observations of Patient #1, Nurse #3, who was unaware of comments and concerns raised by Registrar #1, walked by bay #11 and glanced at Patient #1. Per interview on 10/7/13 at 3:15 PM, Nurse #3 stated "...s/he did not look well at all...s/he was not on a heart monitor, checked for a pulse...". Nurse #3 described the pulse as "faint" and waved for Nurse #2, who continued sitting at the nurses station, to come to bay #11. Per nursing note written by Nurse #1 at 2327, "...RN walked by Pts. room, noted Pt. to appear cyanotic, Pt. found to be pulseless and apnic (not breathing), CPR initiated ". Resuscitation for cardiac arrest continued for 20 minutes. Patient's condition did not improve, the code was ended and time of death was noted to be 2351.

In addition, the hospital failed to report the adverse event involving ED nursing staff and Patient #1 within the required 48 hours per Vermont State Statute Title 33 Chapter 69 "Reports of Abuse, Neglect and Exploitation of Vulnerable Adults. Although individual hospital staff, who are mandated reporters, were intially informed beginning on 9/26/13 of events surrounding the unexpected death of Patient #1 on 9/24/13, and Administrative staff to include Risk Mangement and Patient Safety and Quality were fully informed of the adverse event on 10/1/13, voice mail notification to the State Agency/Adult Protective Services did not occurr until 10/3/13 at 5:41 PM (after hours) stating only there had been a complaint related to ED services made by an employee.

Based on interview and record review, the hospital failed to assure the patient's right to the confidentiality of his or her clinical records were maintained for 1 applicable patient. ( Patient #1) Findings include:

During the course of the investigation regarding care and services not provided to Patient #1 on the evening of 9/24/13 it was reported a call had been made to EMS shortly after the patient's expired to report the death to EMS personnel. Per interview on 10/8/13 at 11:40 AM, EMT #1 stated "The hospital called the rescue squad, said that s/he had passed". Per interview on 10/8/13 at 12:59 PM ED Technician #1 stated s/he had overheard a discussion by EMS staff regarding Patient #1's presenting symptoms and whether the symptoms were cardiac related. S/he also confirmed shortly after Patient #1 expired a nurse made a call to EMS/Rescue Squad office to notify them the patient had expired. When asked if this is routine ED policy and procedure to make such a phone call, the ED Technician stated it was not.

Based on interview and record review, the Condition of Participation for Quality Assessment and Performance Improvement (QA/PI) was not met due to the hospital's failure to initiate immediate interventions to ensure patient safety. Based on information obtained the following findings reflect an Immediate Jeopardy situation was determined to exist as the result of actual harm to a patient who sought treatment in the Emergency Department.


Refer to Tags: A-286

Based on staff interview and record review, the hospital QA/PI program failed to implement timely preventative actions to assure patient safety throughout the hospital after an adverse patient event had occurred involving 1 applicable patient. (Patient #1) Findings include:

Per interview on 10/7/13 at 9:55 AM, the Administrative Director for Patient Safety and Quality confirmed the Administrative staff was made aware on 10/1/13 of an adverse patient event which occurred on the night of 9/24/13 when 2 RN's employed in the ED demonstrated indifference and neglect when notified by a hospital employee that a newly admitted patient to the ED demonstrated a change in condition. Both nurses failed to respond when alerted the patient appeared dead and demonstrated disregard for the patient's emergent needs and condition by describing the patient as" playing possum". Upon learning of the adverse event, which included the death of the patient, the hospital administrative staff placed 2 nurses on suspension. An investigation of the event was initiated with interviews conducted of staff working on the night of 9/24/13. Per interview on 10/7/13 at 10:50 AM the Administrative Director for Inpatient Services confirmed the ED Nurse Manager had not begun any general discussions with staff regarding the incident or expectations regarding patient safety, care and services or patient rights. When the surveyor sought assurance that the hospital has implemented preventive actions and mechanisms that include feedback and learning throughout the hospital in order to prevent a similar incident from occurring, the Clinical Nurse Specialist for the ED stated on 10/7/13 at 10:56 AM since the adverse event "We have not done anything different. We provide quality care in the ED on a daily basis....if there are issues they are addressed, as this will be". However, the Clinical Nurse Specialist, who was also acting as ED Nurse Manager due to illness of the designated Nurse Manager, had not reviewed Patient #1's ED record to identify any QA/PI concerns.

Additional concerns regarding implementing expedient action in response to the adverse patient event was also reviewed by the surveyor on 10/8/13. Per interview on 10/8/13 at 9:08 AM the Administrative Director - Compliance Officer, Administrative Director Inpatient Services and ED Clinical Nurse Specialist, confirmed nursing staff had still not been "spoken to" nor preventive actions identified and implemented. The internal investigation was continuing, however a Root Cause Analysis had been postponed due to the surveyors arrival and a review of the code in the ED on 9/24/13 had not been reviewed by the Code Committee.

Per interview on 10/8/13 at 4:30 PM, the Administrative Director- Compliance Officer subsequently reported that as of the afternoon of 10/7/13, 7 days since being made aware of the adverse patient event and after the arrival of surveyors, communication had now begun with nursing staff. The Administrative Director of Outpatient Services had initiated individual counseling, increasing staff awareness regarding the "Culture of Safety" and ensuring accountability. A nursing leadership meeting had transpired and mechanisms were being put in place and "action plans" formulated.

Based on staff interview and record review the Condition of Participation: Nursing was not met as evidenced by the failure of Nursing staff to maintain standards of nursing practice during the provision of care and failed to respond when notified of a change in a patient's condition. Based on information obtained the following findings reflect an Immediate Jeopardy situation was determined to exist as the result of actual harm to a patient who sought treatment in the Emergency Department.

A RN must supervise the nursing care for each patient. A RN must evaluate the care for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. Evaluation would include assessing the patient's care needs, patient's health status/conditioning, as well as the patient's response to interventions.

Refer to A-0115, 0131; 0144; 0145; 0147; 0395

Based on staff interview and record review, nursing staff failed to evaluate the care for each patient upon admission to the Emergency Department and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for 1 applicable patient . (Patient #1) Findings include:

On the night of 9/24/13 2 nurses assigned to work in the ED demonstrated indifference and neglect when notified by a hospital employee that a newly admitted patient to the ED demonstrated a change in condition. Both nurses failed to respond when alerted the patient appeared dead and demonstrated disregard for the patient's emergent needs and condition by describing the patient as" playing possum".

Per hospital policy Nursing Responsibilities revised 01/10 which pertains to the ED nursing staff states : "The scope of emergency nursing practice involves the assessment, analysis, nursing diagnosis, outcome identification, planning, implementation of interventions, and evaluation of human responses to perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute, and which occur in a variety of settings. These may require minimal care to life-support measures; patient, family, and significant other education; appropriate referral and discharge planning; and knowledge of legal implications" Emergency Nurses Association Scope of Emergency Nursing practice. (July, 1999)

Per Vermont Title 26: Professions and Occupations, Chapter 28: Nursing "Registered nursing" means the practice of nursing which includes: (A) Assessing the health status of individuals and groups; (H) Maintaining safe and effective nursing care rendered directly or indirectly (I) Evaluating responses to interventions; (L) Collaborating with other health professionals in the management of health care and (M) Addressing patient pain.

However, per record review, Patient #1 arrived via ambulance to the Emergency Department (ED) on 9/24/13 at 23:07. Patient #1 had multiple co-morbidities to include: Type 2 Diabetes mellitus; Epilepsy with severe seizure disorder; End Stage Renal Disease (ESRD) requiring dialysis treatments 3 x per wk; sleep apnea; asthma, obesity, hypothyroidism and Bipolar disorder. Per Emergency Medical Services (EMS)/Rescue Squad "Prehospital Care Report" for 9/24/13 at 22:30, Patient #1 was complaining of severe back pain, relating it to a fall which occurred on 9/14/13 and a recent cortisone injection. The report also noted Patient #1 was observed to have "...dry heaves...complained of stomach pain....s/he is short of breath...starting to breath rapidly...Also having some chest pain...Pt put on 3 lit (liters) of 02 (oxygen) nasal canula pt noting that O2 did help with breathing". Per interview on 10/8/13 at 11:40 AM, a Advanced EMT #1 (Emergency Medical Technician) who was part of Patient #1's transport team to the ED on 9/24/13 confirmed the patient was anxious. EMT #1 stated because of Patient #1's presenting symptoms to include continuous low blood pressure readings ( 85/60, 84/54. & 76/56 ) and the inability to establish an IV, the Paramedic was requested to arrive at the scene for assistance. EMT #1 also stated Patient #1 was placed on a 4 lead cardiac monitor but frequent artifact was noted due to the patient's restless movement, discomfort and anxiety.

Per interview on 10/7/13 at 1:58 PM, Nurse #1, who was assigned to Triage on the evening of 9/24/13, confirmed upon Patient #1's arrival to the ED, s/he had obtained a report from EMS regarding Patient #1 to include back pain, shortness of breath and stomach pain. "S/he was yelling...appeared to be in quite a bit of pain". Nurse #1 further stated s/he had cared for Patient #1 in the past during previous ED visits. Nurse #1 rated the patient's pain to be a "10" (on a 1-10 pain scale/10 being the worse level of pain) but noted Patient #1 did not answer Nurse #1's questions during the Triage process stating the patient was yelling in pain. At the completion of the Triage process that was conducted on the opposite side of the large trauma bay, Nurse #1 left the area. No direction was provided by Nurse #1 to other ED staff to place Patient #1 on a cardiac monitor or apply oxygen. The only vital signs recorded, taken by the ED technician, included: B/P 130/96, pulse 88 and oxygen level via pulse oximeter was recorded as 96 on room air. At the time of interview, Nurse #1 stated s/he should have placed the patient on the monitor and paid more attention at the time of triage.

Nurse #2, who was assigned to Patient #1, sat at the nurses station located opposite the trauma bay #11 and observed Patient #1's arrival by EMS. Per interview on 10/7/13 at 12:01 PM, Nurse #2 stated s/he was on the computer and did not get up to assist staff and EMS with the patient's transfer or assess the patient's physical status once the ED technician had completed vital signs. Nurse #2 stated " ...the patient was crying out in pain...I continued my charting". Nurse #1 stated staff had dimmed the lights in bay #11 to "...make the patient more comfortable...I would glance over to see her/him move their arm or leg".

At approximately 10 minutes after admission to the ED between 2220-2224 on 9/24/13 Access Services Registrar #1 entered bay #11 to complete the registration process, verify information and obtain a signature for treatment from Patient #1. Per telephone interview on 10/7/13 at 4:00 PM. Registrar #1 stated "I spoke to her/him a couple of times (Patient #1)...her/his head was to the side and her/his mouth was open. There was no response from her/his eyes. I was quite close to her/him. I was up by her/his head. I looked at her/his chest area to see if there was any movement." Registrar #1 reported s/he quickly went to the end of the trauma bay area and "I said to the nurses who were nearby. I said she/he (Patient #1) is dead. One of the nurses said 'oh s/he's playing possum'.....'I'll sign your papers for her/him'....She signed my paper and at that point I left the emergency room....I did not know if s/he was actually dead when I left the emergency department".

Despite the comments made by Registrar #1, both Nurse #1 or Nurse #2 failed to assess the health status of Patient #1. Nurse #2 confirmed s/he saw Registrar #1 enter bay #11 and described Registrar #1 as s/he was walking out from bay #11 as ".... nervous" and "...said I think s/he's dead". Nurse #2 stated at the time of interview that " I said s/he was moving. She was sleeping. I did not go up to look at her/him....I know I should have but I didn't".

Within 1-2 minutes after the Registrar's reported observations of Patient #1, Nurse #3, who was unaware of comments and concerns raised by Registrar #1, walked by bay #11 and glanced at Patient #1. Per interview on 10/7/13 at 3:15 PM, Nurse #3 stated "...s/he did not look well at all...s/he was not on a heart monitor, checked for a pulse...". Nurse described the pulse as "faint" and waved for Nurse #2, who was sitting at the nurses station, to come to bay #11. Per nursing note written by Nurse #1 at 2327, "...RN walked by Pts. room, noted Pt. to appear cyanotic, Pt. found to be pulseless and apnic (not breathing), CPR initiated". Resuscitation for cardiac arrest continued for 20 minutes. Patient's condition did not improve, the code was ended and time of death was noted to be 2351.

Per interview on 10/8/13 at 12:32 PM, the Medical Director for the ED stated s/he was made aware of the adverse patient event 1 week ago and remarked "a nurse making incredible poor judgement which may have delayed this patient having a chance of recovery.....". S/he further stated it was "...impossible to believe.....". The Medical Director further stated if it was known a patient had chest pain or shortness of breath "......absolutely the expectation would be putting patient on the monitor, EKG within 10 minutes, even more so with atypical pain, abdominal pain."

Per interview on 10/8/13 at 11:00 AM, the Administrative Director of Outpatient Services stated the Nurse Manager for the ED has firm expectations if someone was not making the bar s/he would talk to the person and say you have to step it up or out. This is very unfortunate".

Based on staff interview and record review the Condition of Participation: Emergency Services was not met as evidenced by the hospital's failure to meet the needs of patients in accordance with acceptable standards of practice for 1 applicable patient. Based on information obtained the following findings reflect an Immediate Jeopardy situation was determined to exist as the result of actual harm to a patient who sought treatment in the Emergency Department. (Patient #1) Findings include:

Per Vermont Title 26: Professions and Occupations, Chapter 28: Nursing "Registered nursing" means the practice of nursing which includes: (A) Assessing the health status of individuals and groups; (H) Maintaining safe and effective nursing care rendered directly or indirectly (I) Evaluating responses to interventions; (L) Collaborating with other health professionals in the management of health care and (M) Addressing patient pain.
Nursing staff on 9/24/13 to failed to maintain standards of nursing practice in the ED to include assessing the health status of Patient #1, whose medical history included multiple comorbitities. Upon arrival to the ED via ambulance at 23:07, EMS team had initially assessed the patient at his/her home where s/he complained of acute back pain, shortness of breath, abdominal pain, non radiating chest pain and nausea. Although the patient had been on a cardiac monitor and provided oxygen during transport to the hospital ED, upon transfer to an ED stretcher the cardiac monitor and oxygen was removed by EMS staff.

ED nursing staff failed to provide safe and effective nursing care to Patient #1. Per interview on 10/7/13 at 1:58 PM, Nurse #1 confirmed s/he had obtained a report from EMS regarding Patient #1 to include back pain, shortness of breath and stomach pain. "She was yelling...appeared to be in quite a bit of pain". Nurse #1 further stated s/he had cared for Patient #1 in the past during previous ED visits. Nurse #1 rated the patient's pain to be a "10" (on a 1-10 pain scale/10 being the worse level of pain) but noted Patient #1 did not answer Nurse #1's questions during the Triage process stating the patient was yelling in pain. At the completion of the Triage process that was conducted on the opposite side of the large trauma bay, Nurse #1 left the area. No direction was provided by Nurse #1 to other ED staff to place Patient #1 on a cardiac monitor or apply oxygen. The only vital signs recorded, taken by the ED technician, included: B/P 130/96, pulse 88 and oxygen level via pulse ox meter was reported at 96 on room air.

Nurse #2, who was assigned to Patient #1, sat at the nurses station located opposite the trauma bay #11 and observed Patient #1's arrival by EMS. Per interview on 10/7/13 at 12:01 PM, Nurse #2 stated s/he was on the computer and did not get up to assist staff and EMS with the patient's transfer or assess the patient's physical status once the ED technician had completed vital signs. Nurse #2 stated " ...the patient was crying out in pain...I continued my charting" and failed to address and assess the patient's obvious pain. Nurse #1 stated staff had dimmed the lights in bay #11 to "...make the patient more comfortable...I would glance over to see her/him move their arm or leg".

At approximately 10 minutes after admission to the ED between 2220-2224 on 9/24/13 Access Services Registrar #1 entered bay #11 to complete the registration process, verify information and obtain a signature for treatment from Patient #1. Per telephone interview on 10/7/13 at 4:00 PM. Registrar #1 stated "I spoke to her/him a couple of times (Patient #1)...her/his head was to the side and her/his mouth was open. There was no response from her/his eyes. I was quite close to her/him. I was up by her/his head. I looked at her/his chest area to see if there was any movement." Registrar #1 reported s/he quickly went to the end of the trauma bay area and "I said to the nurses who were nearby. I said she/he (Patient #1) is dead. One of the nurses said 'oh s/he's playing possum'.....'I'll sign your papers for her/him'....S/he signed my paper and at that point I left the emergency room....I did not know if s/he was actually dead when I left the emergency department".

Despite the comments made by Registrar #1, neither Nurse #1 or Nurse #2 went to assess Patient #1. Nurse #2 confirmed s/he saw Registrar #1 enter bay #11 and described Registrar #1 as s/he was walking out from bay #11 as ".... nervous" and "...said I think s/he's dead". Nurse #2 stated at the time of interview that " I said s/he was moving. She was sleeping. I did not go up to look at her/him....I know I should have but I didn't".

Within 1-2 minutes after the Registrar's reported observations of Patient #1, Nurse #3, who was unaware of comments and concerns raised by Registrar #1, walked by bay #11 and glanced at Patient #1. Per interview on 10/7/13 at 3:15 PM, Nurse #3 stated "...s/he did not look well at all...s/he was not on a heart monitor, checked for a pulse...". Nurse described the pulse as "faint" and waved for Nurse #2, who was sitting at the nurses station, to come to bay #11. Per nursing note written by Nurse #1 at 2327, "...RN walked by Pts. room, noted Pt. to appear cyanotic, Pt. found to be pulseless and apnic (not breathing), CPR initiated". Resuscitation for cardiac arrest continued for 20 minutes. Patient's condition did not improve, the code was ended and time of death was noted to be 2351.

Per ED Triage Protocol: Chest Pain, last reviewed 02/13 states "Triage protocols are an effective way to provide timely diagnostics and gain efficiencies for provision of services to select patients based on presenting signs and symptoms. The use of standardized approach to triage to facilitate medical decision making by the provider." Nursing orders for ED Triage for chest pain includes : "Vital signs; 02 per titration guidelines; saline well (IV) and cardiac monitor".

Per interview on 10/8/13 at 12:32 PM, the Medical Director for the ED stated s/he was made aware of the adverse patient event 1 week ago and remarked "a nurse making incredible poor judgement which may have delayed this patient having a chance of recovery.....". S/he further stated it was "...impossible to believe.....". The Medical Director further stated if it was known a patient had chest pain or shortness of breath "......absolutely the expectation would be putting patient on the monitor, EKG within 10 minutes, even more so with atypical pain, abdominal pain."