The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| TMC- BONHAM HOSPITAL | 504 LIPSCOMB STREET BONHAM, TX 75418 | Sept. 8, 2014 |
| VIOLATION: MEDICAL SCREENING EXAM | Tag No: C2406 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 20 patients presenting to the ED received a medical screening that was ongoing and appropriate for their condition resulting in the patient returning to the hospital with declining in health (Patient #6) and subsequent death. The facility also failed to ensure physician's documented and performed medical screenings timely in 2 of 20 patients reviewed. (Patient #23 and 24) It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and had the likelihood to cause serious harm, injury, impairment or death for all patients presenting to the ED of this hospital. Findings include: Review of an ED visit record dated 08/20/2014 revealed that Patient #6 was a [AGE] year old female who presented to the ED at 12:29 p.m. At 12:37 p.m., Staff nurse #8 documented Patient #6 had a chief complaint of respiratory problem and the triage level was classified as urgent (meaning she should be placed in to an appropriate ED treatment room so that emergency measures can be initiated immediately). The following vital signs were documented: 103 (heart rate), 117/93 (blood pressure), 97.5 (temperature), 22 (respirations), and oxygen saturation was 92 percent on oxygen at 2 liters per nasal cannula. There was no documentation of an assessment of what the oxygen saturation was prior to oxygen administration. According to the ED record, the provider (physician) arrival time was 12:37 p.m. Review of a "ED Respiratory" assessment completed by Staff nurse #8 at 12:42 p.m. revealed that Patient #6 breathing was labored, tachnypenic (more than 20 per minute), dyspneic (difficulty breathing) with activity, had clear lung sounds that were diminished in the upper and lower lobes, and with a non-productive cough. Review of the emergency notes revealed that at 1:01 p.m., Physician #13 documented Patient #6 had an emergency medical condition. The patient's condition was such that the patient had a medical condition requiring further emergency medical evaluation, treatment, and/or stabilization. Review of an "ED DOC Respiratory" assessment completed by Physician #13 at 1:01 p.m. revealed that he had reviewed the nursing assessment and agreed. His respiratory assessment revealed breath sounds were normal. Physician #13 documented that Patient #6 was in respiratory distress, splinting and using accessory muscle. Underneath the progress notes section, Physician #13 documented no wheezing heard, duoneb given and feels better, though breath sounds are unchanged, pulse oximetry in low 90/s with or w/o (without) oxygen or duoneb. The clinical impression was COPD (chronic obstructive pulmonary disease) and anxiety. The plan was to discharge patient home with prescriptions of Z-pak (antibiotic), Ativan (anti- anxiety agent) and Albuterol (bronchial dilator). Review of vital signs dated 08/20/2014 at 1:26 p.m., revealed Patient #6 had an elevated heart rate of 108, blood pressure 112/83, temperature 97.9, respiration rate 20, and oxygen saturation of 96 percent on oxygen 2 liters per nasal cannula. Review of a hospital note revealed Patient #6 was discharged home at 2:00 p.m. There was no documentation of an assessment of the patient's respiratory status at the time of discharge. There was no documentation of staff obtaining lab on Patient #6 during the ED visit. There was no documentation of the patient's oxygen saturation being stable on room air prior to discharge. Discharge records revealed no documentation of the Patient #6 being discharged on oxygen or if the patient understood discharge instructions. During an interview on 09/08/2014 at 1:26 p.m., Staff #2 confirmed the missing assessments and there being no documentation of the patient being sent home on oxygen. During an interview on 09/08/2014 at 8:23 p.m., Physician #13 reported on admit of a patient, with respiratory problems/distress who did not have a pulse oximetry of 100 percent on room air would receive a triage first. Then a chest x-ray and possibly laboratory tests done. Patients being discharge without oxygen would be expected to have an oxygen saturation of 90-92 percent, preferably 95 percent on room air. Review of an ED record dated 08/23/2014 (3 days later) revealed that Patient #6 returned to the hospital at 11:17 a.m., At 11:19 a.m., Patient #6 was documented as having respiratory problems and was assessed during nursing triage to be at a level of non-urgent (meaning no resources required or lowest priority to be seen). Patient #6 had a heart rate of 89, blood pressure of 86/69, temperature of 97.5, respirations of 26, and an oxygen saturation of 92 percent on 3 liters of oxygen. Review of a physician assessment dated [DATE] at 11:21 a.m., Physician #14 deemed the patient to have an Emergency medical condition. At 11:22 a.m., Physician #14 documented that Patient #6 was seen here 2 days ago, given Z-pak (antibiotic) and Ativan(anti-anxiety), presents today by ambulance, tachypenic at 30, sats 98 % RA. No respiratory distress, regular rate and rhythm, and breath sounds normal. Review of an ED nursing note dated 08/23/2014 at 11:50 a.m., revealed Patient #6 presented to the ED via EMS with SOB and hypoxemia (low blood oxygen). Patients oxygen saturation was 84 (percent) on room air upon admittance to ED. Patient was placed on a non-rebreather mask at 15 Liters and maintained oxygen saturation at 99 percent. Patient was seen in this ED on Wednesday and given a Z-pak. Patient stated that she "believes the Z-pak is causing her breathing issues and anxiety." EMS stated they had attempted IV access 3 times prior to arrival without success. Patient placed in bed #2. Review of nurses notes revealed on 08/23/2014 at 12:13 p.m., Patient #6 had intravenous fluids infusing at 75 cc per hour. Review of laboratory results completed on 08/23/2014 at 12:10 pm. revealed the following: White blood count elevated at 25.0 with reference ranges being 4.4-11.0; Red blood count elevated at 6.36 with reference ranges being 4.20-5.40; Platelet count elevated at 799 with reference ranges being 150-400. According to <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm>, a platelet count is a test to measure how many platelets you have in your blood. Platelets are parts of the blood that help the blood clot. They are smaller than red or white blood cells. Some of the reasons listed as causes for increased platelet count were after certain infections, major surgery or trauma, allergic reactions and recent spleen removal. According to the website some people with high platelet counts may be at risk of forming blood clots. Blood clots can lead to serious medical problems. At 12:26 p.m. Glucose was elevated at 177 with reference ranges being 74-106; Blood urea nitrogen was elevated at 39 with reference ranges being 7-18; Creatinine elevated at 1.3 with reference ranges being 0.6-1.3; At 1:37 p.m. Chest x-ray showed cardiac silhouette is mildly enlarged, stable from prior study. No gross consolidation or effusion. No pneumothorax. No grossly acute findings. At 4:08 p.m., The Computed tomography scan of the abdomen and pelvis revealed small to moderate amount of ascites in the abdomen or pelvis. There is cholethiasis with wall thickening of the gallbladder appeared this may be reactive secondary to ascites. Primary inflammation of the gallbladder cannot be excluded. Prior splenectomy. Large and small bowel loops are normal in caliber. Normal appendix. Review of nurses notes dated 08/23/2014 revealed at 3:12 p.m., Patient #6's IV infiltrated. The IV was not restarted until 2 hours later at 5:04 p.m. Review of nurse's notes at 6:37 p.m., revealed Physician #15 was paged at this time for possible admission and he did not return the call until 8:10 p.m. (over 1.5 hours later). Patient #6 was to be admitted to observation/telemetry. Review of ED vital sign sheet revealed the last documented set of vital signs taken were at 8:53 p.m before leaving the ED. Patient #6 had a 110 heart rate, 97/69 blood pressure, 98.6 temperature, 30 respiratory rate, and oxygen saturation of 92 percent on 2 liters of oxygen. Review of a nursing assessment (at admission on the Medical-surgical unit) at 9:25 p.m., revealed the primary diagnosis was tachypnea and the secondary diagnosis was dehydration. Patient #6 vital signs were 98.0 temperature, 99 heart rate, 30 respirations, 83/44 blood pressure and oxygen saturation of 91 percent on 3 liters of oxygen (a decline in status). The patient's skin was documented as being pale, cyanotic and cool. She was on a telemetry and had a regular rhythm. Patient #6 had pain underneath the right underarm and rib area at a pain level of 2 on a scale of 10. Review of nurses notes timed 9:30 p.m., revealed the following documentation: "informed doctor that patient, upon transfer upstairs to her room 200, was weighed and was assisted into bed on room air, patient appeared to be struggling to breath, reapplied oxygen and patient oxygen saturation was at 91%. Stated patient appeared to be cyanotic until we reapplied oxygen. Physician #14 (ED doctor) in turn ordered a d-dimer, pt/inr and a ptt." Review of lab results dated 08/23/2014 revealed Patient #6 had a final elevated D-Dimer result at 10:30 p.m. of 1880 with reference range being 0-500. The PTT was 35.3 (Reference range 20.6-38.6), PT 14.4 (Reference range 8.0-14.0) and INR 1.4 (Reference range 0.8-1.4). The D-dimer blood test is a very useful laboratory test that helps doctors rule out pulmonary embolism or deep vein thrombosis (DVT) in a patient. This is not a routine blood test and is performed only during emergencies or in cases where the patient is in pain. Review of a medication administration record revealed Patient #6 was started on Normal saline 0.9 percent intravenous fluids at 40 cc per hour at 11:27 p.m. and was given 2 Tylenol with Codeine at 11:33 p.m. (2 hours after first complaining of pain). Review of a vital sign sheet and medication flow sheets revealed Patient #6 had the following: At 11:41 p.m., the vital signs were 99.5 temperature, 105 heart rate, 30 respiratory rate, 89/67 blood pressure and pain level of 5 and oxygen saturation of 90 percent on 3 liters of oxygen. There was no documentation of what was done about the dropping oxygen saturation. Review of an anticoagulant flow sheet dated 08/24/2014 at 12:40 a.m., revealed Patient #6 was given a 4000 unit bolus of the anti-coagulant Heparin and started on a Heparin drip at 9 milliliters per hour for a PTT result of 35.3. This intervention was provided 3 hours after the documented change in condition and 2 hours after receipt of the lab results. At 3:58 a.m., the monitor tech documented Patient #6 was in "sinus rhythm with decreased ST at 100" At 4:23 a.m. (over 4 hours later after the change in condition) there was nursing documentation of a 96.0 temperature, 108 heart rate, 30 respiratory rate, 90/64 blood pressure and the oxygen saturation had dropped to 80 percent on 3 liters of oxygen. There was no documentation of what intervention was taken after this further decline in the patient's status. Over an hour later the following was documented: At 5:29 a.m., the monitor tech documented Patient #6 had a rhythm change: sinus rhythm with BBB (bundle branch block), primary atrioventricular block (nurse was notified). At 5:31 a.m., the monitor tech documented Patient #6 was in BBB to V-tach ([DIAGNOSES REDACTED]). The tech made another entry that the nurse was called and informed patient was in V-tach and dying. At 5:31 a.m., Physician #15 was called by the nurse and informed patient vital signs were "95.8, 108, 40, 11/49, 83 to 85 percent on 3L/m via n/c. Patient is mouth breathing, encouraged to breath through her nose and slow her resp. Dr. (Physician #15) said he would be here shortly." At 5:33 a.m., the monitor tech documented calling an ER nurse to tell him the patient was dying. Review of a "Code Blue Record" at 5:40 a.m. revealed Physician #14 (ER) doctor initiated the code and was in charge. Review of attached notes revealed Physician #14 documented at 6:00 a.m. he was called to see patient in acute cardiopulmonary arrest, by report, sudden onset. Upon arrival patient was not responsive, no pulse, no spontaneous responsive effort. CPR was initiated immediately. Patient was intubated and oxygenation/chest compressions and CPR meds were administered per CPR protocol. After 35 minutes, with no response, CPR was stopped, no pulse, no spontaneous respiratory effort.. Documentation on the "Code Blue Record" revealed Patient #6's time of death was 6:07a.m. During an interview on 09/08/2014 after 12:55 p.m., Staff #2 revealed Patient #6's chart was under extra security because of issues with the family. Staff #2 confirmed Physician #15's delay in return call to nursing staff and nursing staff delay in treatment after Patient #6 had a change in condition at 4:23 a.m.. Staff #2 confirmed she could not find documentation of the nurse's response in the record. During an interview on 09/08/2014 after 1:10 p.m., Staff #1 and #2 was asked questions about Patient #6's care and what happened on the floor. Staff #1 and #2 reported the chart was going through internal and external review. They had not completed their investigation yet. Because of the clinical nature they could not comment. No specific information could be shared with the surveyor. During an interview on 09/11/2014 at 11:50 a.m., Physician #14 reported Patient #6 was kept in the ED a long time because it took a while to get the computed tomography results. Physician #14 reported he went to the floor to check the patient because Physician #15 called him. Physician #15 told him the nurse from the floor (medical surgical unit) had called him and said Patient #6 was hypoxic and tachycardic. Physician #14 confirmed when he got to the floor Patient #6 had already passed and he assisted with the code. Physician #14 reported a lot of the documentation he made on Patient #6 during her stay in the electronic record was missing. Physician #14 reported the information he was provided by the medical director was that Patient #6 died as a result of a pulmonary embolism. Review of an ED visit record revealed Patient #24 was a [AGE] year old male who (MDS) dated [DATE] at 10:06 p.m. with extremity pain/trauma. A triage assessment was performed at 10:21 p.m. and Patient #24 was classified as being semi-urgent (meaning the patient should be placed into an appropriate ED treatment room so that emergency measures could be initiated immediately). At 10:35 p.m. the physician arrived to the bedside according to nursing documentation. At 10:36 p.m. nursing documented Patient #24 had a large hematoma to the left leg, the temperature of the limb was warm and there was a pain level of 8. At 10:47 p.m. nursing documented after discussing plan of care, patient stated he didn't want x-ray or pain medication, patient states he will check out AMA. There was no documentation on the record the physician provided a medical screening on Patient #24 when he arrived at 10:35 p.m. Review of an ED record revealed Patient #23 was an [AGE] year old female who (MDS) dated [DATE] at 10:26 a.m., with medical problems undefined. A triage assessment was performed at 10:47 a.m. and nursing classified the patient as being Urgent (meaning the patient should be placed intointo an appropriate ED treatment room so that emergency measures could be initiated immediately). According to the ED record the physician arrived at the bedside at 10:47 a.m. The physician documented at 12:17 p.m. (over an hour later) a medical screening was performed and Patient #23 was considered to have an emergency medical condition. The physician assessment was documented at 12:19 p.m. According to a clinical impression on the physician assessment Patient #23 had a dorsal/limb pain/muscle strain, early pneumonia. There was documentation underneath the plan which read follow-up condition improved, no physician consult, and discharge home. Prescription was Valium 5 milligrams, to 1 tab po (by mouth) every HS (night) #8, Z pak. This documentation was on the same assessment timed for 12:19 p.m. There was no indication as to what time the physician wrote the plan. Review of the ED disposition revealed Patient #23 was discharged home or self-care (routine discharge) at 5:00 p.m. There was no nursing assessment prior to discharge, nor an explanation of medications to be taken at home. There was no documentation of discharge instructions explained and patient acknowledgement of understanding the instructions. The last documented set of vital signs from nursing was at 4:40 p.m. Review of an undated "Emergency Department Protocol" revealed the following were to be used when the ED physician was expected to take more than 20 minutes to get the patient. SOB Asthma/Wheezing & Pulse Ox>93 % Oxygen NC @ 2-4 LPM Pulse Oximetry & Monitor Pedi or Adult RT Protocol, or Albuterol UD with Atrovent 500 mcg Neb. With Pulse Ox <94 or distress, CBC, CMP, BNP P. (portable) CXR, EKG, Saline lock D-Dimer if Well's criteria>2.5 points With Fever & Cough, Possible Pneumonia add: Blood Culture X 2, Sputum C & S Review of policy named "EMTALA Medical Screening Exam and Stabilizing Treatment" dated 08/2014 revealed the following: An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred. Review of an emergency department policy named "Discharge Assessment/Teaching dated 11/2007 revealed the following: 3.1 Each patient will be assessed by the physician provider for readiness to discharge. 3.4 discharged patients will receive written discharge instructions, in a form the individual can understand, which will include at least the following: 3.4.1 Assessment of learning needs concerning discharge medications. 3.4.4 Specific treatment procedures 3.5 Nursing staff will complete a brief discharge assessment including a note on patient status and discharge vital signs. 3.6 The nurse will record the patient's understanding of instructions on the ER record. |
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| VIOLATION: STABILIZING TREATMENT | Tag No: C2407 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 1 of 20 patients presenting to the ED with respiratory complications received stabilizing treatment for an emergency medical condition (Patient #6). This failure resulted in a return visit to the emergency room with decline in condition and resulted in the patient's death. It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and had the likelihood to cause serious harm, injury, impairment, or death to all patients presenting to the ED of this hospital. Findings include: Review of an ED visit record dated 08/20/2014 revealed Patient #6 was a [AGE] year old female who presented to the ED at 12:29 p.m. At 12:37 p.m., Staff nurse #8 documented Patient #6 had a chief complaint of respiratory problem and the triage level was classified as urgent (meaning she should be placed in to an appropriate ED treatment room so that emergency measures can be initiated immediately). The following vital signs were documented: 103 (heart rate), 117/93 (blood pressure), 97.5 (temperature), 22 (respirations), and oxygen saturation was 92 percent on oxygen at 2 liters per nasal cannula. There was no documentation of an assessment of what the oxygen saturation was prior to oxygen administration. According to the notes the provider (meaning physician) arrival time was 12:37 p.m. Review of a "ED Respiratory" assessment completed by Staff nurse #8 at 12:42 p.m. revealed Patient #6 breathing was labored, tachnypenic (more than 20 per minute), dyspneic (difficulty breathing) with activity, had clear lung sounds that were diminished in the upper and lower lobes, and with a non-productive cough. Review of the emergency notes revealed at 1:01 p.m., Physician #13 documented Patient #6 had an emergency medical condition. The patient's condition was such that the patient had an emergency medical condition requiring further emergency medical evaluation, treatment, and/or stabilization. Review of an "ED DOC Respiratory" assessment completed by Physician #13 at 1:01 p.m. revealed he had reviewed the nursing assessment and agreed. His respiratory assessment revealed breath sounds were normal. Physician #13 documented that Patient #6 was in respiratory distress, splinting and using accessory muscle. Underneath the progress notes section Physician #13 documented no wheezing heard, duoneb given and feels better, though breath sounds are unchanged, pulse ox in low 90/s with or w/o (without) oxygen or duoneb. The clinical impression was copd (chronic obstructive pulmonary disease) and anxiety. The plan was to discharge patient home with prescriptions of Z-pak (antibiotic), Ativan (anti- anxiety agent) and Albuterol (bronchial dilator). Review of vital signs dated 08/20/2014 at 1:26 p.m., revealed Patient #6 had an elevated heart rate of 108, blood pressure 112/83, temperature 97.9, respiration rate 20 and oxygen saturation of 96 percent on oxygen 2 liters per nasal cannula. Review of a hospital note revealed Patient #6 was discharged home at 2:00 p.m. There was no documentation of an assessment of the patient's respiratory status at the time of discharge. There was no documentation of staff obtaining lab on Patient #6 during the ED visit. There was no documentation of the patient's oxygen saturation being stable on room air prior to discharge. Discharge records revealed no documentation of the Patient #6 being discharged on oxygen or if the patient understood discharge instructions. During an interview on 09/08/2014 at 1:26 p.m., Staff #2 confirmed the missing assessments and there being no documentation of the patient being sent home on oxygen. During an interview on 09/08/2014 at 8:23 p.m., Physician #13 confirmed on admit patients with respiratory problems/distress who did not have a pulse oximetry of 100 percent on room air would receive a triage first. Then a chest x-ray and possibly lab done. Patients being discharge without oxygen would be expected to have an oxygen saturation of 90-92 percent, preferably 95 percent on room air. Review of an ED vital record dated 08/23/2014 (3 days later) revealed Patient #6 returned to the hospital at 11:17 a.m., At 11:19 a.m. , Patient #6 was documented as having respiratory problems and was assessed during nursing triage to be at a level of non-urgent ( meaning no resources required or lowest priority to be seen). Patient #6 had a heart rate of 89, blood pressure of 86/69, temperature of 97.5, respirations of 26, and an oxygen saturation of 92 percent on 3 liters of oxygen. Review of a physician assessment dated [DATE] at 11:21 a.m. Physician #14 deemed the patient to have an Emergency medical condition. At 11:22 a.m., Physician #14 documented that Patient #6 was seen here 2 days ago, given z-pak and ativan, presents today by ambulance, tachypenic at 30, sats 98 % RA. No respiratory distress, regular rate and rhythm, and breath sounds normal. Review of an ED nursing note dated 08/23/2014 at 11:50 a.m., revealed Patient #6 presented to the ED via EMS with SOB and hypoxemia. Patients oxygen saturation was 84 (percent) on RA upon admittance to ED. Patient was placed on a non-rebreather at 15 Liters and maintained oxygen saturation at 99 percent. Patient was seen in this ED on Wednesday and given a Z-pak. Patient stated that she "believes the z-pak is causing her breathing issues and anxiety." EMS stated they had attempted IV access 3 times prior to arrival without success. Patient placed in bed #2. Review of nurses notes revealed on 08/23/2014 at 12:13 p.m., Patient #6 had intravenous fluids infusing at 75 cc per hour. Review of lab results completed on 08/23/2014 revealed some of the following: At 12:10 p.m.: White blood count elevated at 25.0 with reference ranges being 4.4-11.0; Red blood count elevated at 6.36 with reference ranges being 4.20-5.40; Platelet count elevated at 799 with reference ranges being 150-400 According to <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm>, a platelet count is a test to measure how many platelets you have in your blood. Platelets are parts of the blood that help the blood clot. They are smaller than red or white blood cells. Some of the reasons listed as causes for increased platelet count were after certain infections, major surgery or trauma, allergic reactions and recent spleen removal. According to the website some people with high platelet counts may be at risk of forming blood clots. Blood clots can lead to serious medical problems. At 12:26 p.m.: Glucose was elevated at 177 with reference ranges being 74-106; Blood urea nitrogen was elevated at 39 with reference ranges being 7-18; Creatinine elevated at 1.3 with reference ranges being 0.6-1.3; At 1:37 p.m.: Chest x-ray showed cardiac silhouette is mildly enlarged, stable from prior study. No gross consolidation or effusion. No pneumothorax. No grossly acute findings. At 4:08 p.m.: The Computed tomography scan of the abdomen and pelvis revealed small to moderate amount of ascites in the abdomen or pelvis. There is cholethiasis with wall thickening of the gallbladder appeared this may be reactive secondary to ascites. Primary inflammation of the gallbladder cannot be excluded. Prior splenectomy. Large and small bowel loops are normal in caliber. Normal appendix. Review of nurses notes dated 08/23/2014 revealed at 3:12 p.m., Patient #6's IV infiltrated. The IV was not restarted until 2 hours later at 5:04 p.m. Review of nurse's notes at 6:37 p.m., revealed Physician #15 was paged at this time for possible admission and he did not return the call until 8:10 p.m. (over 1.5 hours later). Patient #6 was to be admitted to observation/telemetry. Review of ED vital sign sheet revealed the last documented set of vital signs taken were at 8:53 p.m before leaving the ED. Patient #6 had a 110 heart rate, 97/69 blood pressure, 98.6 temperature, 30 respiratory rate, and oxygen saturation of 92 percent on 2 liters of oxygen. Review of a nursing assessment (at admission on the Medical-surgical unit)at 9:25 p.m., revealed the primary diagnosis was tachypnea and the secondary diagnosis was dehydration. Patient #6 vital signs were 98.0 temperature, 99 heart rate, 30 respirations, 83/44 blood pressure and oxygen saturation of 91 percent on 3 liters of oxygen (a decline in status). The patient's skin was documented as being pale, cyanotic and cool. She was on a telemetry and had a reugal rhythm. Patient #6 had pain underneath the right underarm and rib area at a level of 2. Review of nurses notes timed 9:30 p.m., revealed the following documentation; "informed doctor that patient upon transfer upstairs to her room 200, was weighed and was assisted into bed on room air, patient appeared to be struggling to breath, reapplied oxygen and patient oxygen saturation was at 91 %. Stated patient appeared to be cyanotic until we reapplied oxygen. Physician #14 (ED doctor) in turn ordered a d-dimer, pt/inr and a ptt." Review of lab results dated 08/23/2014 revealed Patient #6 had a final elevated D-Dimer result at 10:30 p.m. of 1880 with reference range being 0-500. The PTT was 35.3 (Reference range 20.6-38.6), PT 14.4 (Reference range 8.0-14.0) and INR 1.4 (Reference range 0.8-1.4). The D-dimer blood test is a very useful laboratory test that helps doctors rule out pulmonary embolism or deep vein thrombosis (DVT) in a patient. This is not a routine blood test and is performed only during emergencies or in cases where the patient is in pain. Review of a medication administration record revealed Patient #6 was started on Normal saline 0.9 percent intravenous fluids at 40 cc per hour at 11:27 p.m. and was given 2 Tylenol with Codeine at 11:33 p.m. (2 hours after first complaining of pain). Review of a vital sign sheet and medication flow sheets revealed Patient #6 had the following: At 11:41 p.m. the vital signs were 99.5 temperature, 105 heart rate, 30 respiratory rate, 89/67 blood pressure and pain level of 5 and oxygen saturation of 90 percent on 3 liters of oxygen. There was no documentation of what was done about the dropping oxygen saturation. Review of an anticoagulant flow sheet dated 08/24/2014 at 12:40 a.m., revealed Patient #6 was given a 4000 unit bolus of the anti-coagulant Heparin and started on a Heparin drip at 9 milliliters per hour for a PTT result of 35.3. This intervention was provided 3 hours after the documented change in condition and 2 hours after receipt of the lab results. At 3:58 a.m., the monitor tech documented Patient #6 was in "sinus rhythm with decreased ST at 100" At 4:23 a.m. (over 4 hours later after the change in condition) there was nursing documentation of a 96.0 temperature, 108 heart rate, 30 respiratory rate, 90/64 blood pressure and the oxygen saturation had dropped to 80 percent on 3 liters of oxygen. There was no documentation of what intervention was taken after this further decline in the patient's status. Over an hour later the following was documented: At 5:29 a.m., the monitor tech documented Patient #6 had a rhythm change: sinus rhythm with BBB (bundle branch block), primary atrioventricular block (nurse was notified). At 5:31 a.m., the monitor tech documented Patient #6 was in BBB to V-tach ([DIAGNOSES REDACTED]). The tech made another entry that the nurse was called and informed Patient #6 was in V-tach and dying. At 5:31 a.m., Physician #15 was called by the nurse and informed Patient #6 vital signs were "95.8, 108, 40, 11/49, 83 to 85 percent on 3L/m via n/c. Patient is mouth breathing, encouraged to breath through her nose and slow her resp. Dr. (Physician #15) said he would be here shortly." At 5:33 a.m., the monitor tech documented calling an ER nurse to tell him the patient was dying. Review of a "Code Blue Record" at 5:40 a.m. revealed Physician #14 (ER) doctor initiated the code and was in charge. Review of attached notes revealed Physician #14 documented at 6:00 a.m. he was called to see patient in acute cardiopulmonary arrest, by report, sudden onset. Upon arrival patient was not responsive, no pulse, no spontaneous responsive effort. CPR was initiated immediately. Patient was intubated and oxygenation/chest compressions and CPR meds were administered per CPR protocol. After 35 minutes, with no response, CPR was stopped, no pulse, no spontaneous respiratory effort.. Documentation on the "Code Blue Record" revealed Patient #6's time of death was 6:07a.m. During an interview on 09/08/2014 after 12:55 p.m., Staff #2 revealed Patient #6's chart was under extra security because of issues with the family. Staff #2 confirmed Physician 15's delay in return call to nursing staff and nursing staff delay in treatment after Patient #6 had a change in condition at 4:23 a.m.. Staff #2 confirmed she could not find documentation of the nurse's response in the record. During an interview on 09/08/2014 after 1:10 p.m., Staff #1 and #2 was asked questions about Patient #6's care and what happened on the floor. Staff #1 and #2 reported the chart was going through internal and external review. They had not completed their investigation yet. Because of the clinical nature they could not comment. No specific information could be shared with the surveyor. During an interview on 09/11/2014 at 11:50 a.m., Physician #14 reported Patient #6 was kept in the ED a long time because it took a while to get the computed tomography results. Physician #14 reported he went to the floor to check the patient because Physician #15 called him. Physician #15 told him the nurse from the floor (medical surgical unit) had called him and said Patient #6 was hypoxic and tachycardic. Physician #14 confirmed when he got to the floor Patient #6 had already passed and he assisted with the code. Physician #14 reported a lot of the documentation he made on Patient #6 during her stay in the electronic record was missing. Physician #14 reported the information he was provided by the medical director was that Patient #6 died as a result of a pulmonary embolism. Review of an undated "Emergency Department Protocol" revealed the following were to be used when the ED physician was expected to take more than 20 minutes to get the patient. SOB Asthma/Wheezing & Pulse Ox>93 % Oxygen NC @ 2-4 LPM Pulse Oximetry & Monitor Pedi or Adult RT Protocol, or Albuterol UD with Atrovent 500 mcg Neb. With Pulse Ox <94 or distress, CBC, CMP, BNP P. (portable) CXR, EKG, Saline lock D-Dimer if Well's criteria>2.5 points With Fever & Cough, Possible Pneumonia add: Blood Culture X 2, Sputum C & S Review of policy named "EMTALA Medical Screening Exam and Stabilizing Treatment" dated 08/2014 revealed the following: An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred. Review of an emergency department policy named "Discharge Assessment/Teaching dated 11/2007 revealed the following: 3.1 Each patient will be assessed by the physician provider for readiness to discharge. 3.4 discharged patients will receive written discharge instructions, in a form the individual can understand, which will include at least the following: 3.4.1 Assessment of learning needs concerning discharge medications. 3.4.4 Specific treatment procedures 3.5 Nursing staff will complete a brief discharge assessment including a note on patient status and discharge vital signs. 3.6 The nurse will record the patient's understanding of instructions on the ER record. |
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| VIOLATION: APPROPRIATE TRANSFER | Tag No: C2409 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 1 of 20 patients presenting to the ED with respiratory complications was stable and appropriate for discharge for an emergency medical condition (Patient #6). This failure resulted in a return visit to the emergency room with decline in condition and subsequent death. It was determined this deficient practice created an Immediate Jeopardy situation resulting in the death of patient #6 and had the likelihood to cause serious harm, injury, impairment, or death to all patients presenting to the ED of this hospital. Findings include: Review of an ED visit record dated 08/20/2014 revealed Patient #6 was a [AGE] year old female who presented to the ED at 12:29 p.m. At 12:37 p.m., Staff nurse #8 documented Patient #6 had a chief complaint of respiratory problem and the triage level was classified as urgent (meaning she should be placed in to an appropriate ED treatment room so that emergency measures can be initiated immediately). The following vital signs were documented: 103 (heart rate), 117/93 (blood pressure), 97.5 (temperature), 22 (respirations), and oxygen saturation was 92 percent on oxygen at 2 liters per nasal cannula. There was no documentation of an assessment of what the oxygen saturation was prior to oxygen administration. According to the notes the provider (meaning physician) arrival time was 12:37 p.m. Review of a "ED Respiratory" assessment completed by Staff nurse #8 at 12:42 p.m. revealed Patient #6 breathing was labored, tachnypenic (more than 20 per minute), dyspneic (difficulty breathing) with activity, had clear lung sounds that were diminished in the upper and lower lobes, and with a non-productive cough. Review of the emergency notes revealed at 1:01 p.m., Physician #13 documented Patient #6 had an emergency medical condition. The patient's condition was such that the patient had an emergency medical condition requiring further emergency medical evaluation, treatment, and/or stabilization. Review of an "ED DOC Respiratory" assessment completed by Physician #13 at 1:01 p.m. revealed he had reviewed the nursing assessment and agreed. His respiratory assessment revealed breath sounds were normal. Physician #13 documented that Patient #6 was in respiratory distress, splinting and using accessory muscle. Underneath the progress notes section Physician #13 documented no wheezing heard, duoneb given and feels better, though breath sounds are unchanged, pulse ox in low 90/s with or w/o (without) oxygen or duoneb. The clinical impression was copd (chronic obstructive pulmonary disease) and anxiety. The plan was to discharge patient home with prescriptions of Z-pak (antibiotic), Ativan (anti- anxiety agent) and Albuterol (bronchial dilator). Review of vital signs dated 08/20/2014 at 1:26 p.m., revealed Patient #6 had an elevated heart rate of 108, blood pressure 112/83, temperature 97.9, respiration rate 20 and oxygen saturation of 96 percent on oxygen 2 liters per nasal cannula. Review of a hospital note revealed Patient #6 was discharged home at 2:00 p.m. During an interview on 09/08/2014 at 8:23 p.m., Physician #13 confirmed that patients being discharged without oxygen would be expected to have an oxygen saturation of 90-92 percent, preferably 95 percent on room air. There was no documentation of an assessment of the patient's respiratory status at the time of discharge. There was no documentation of staff obtaining lab on Patient #6 during the ED visit. There was no documentation of the patient's oxygen saturation being stable on room air prior to discharge. Discharge records revealed no documentation of the Patient #6 being discharged on oxygen or if the patient understood discharge instructions. During an interview on 09/08/2014 at 1:26 p.m., Staff #2 confirmed the missing assessments and there being no documentation of the patient being sent home on oxygen. Review of an ED vital record dated 08/23/2014 (3 days later) revealed Patient #6 returned to the hospital at 11:17 a.m., At 11:19 a.m. , Patient #6 was documented as having respiratory problems and was assessed during nursing triage to be at a level of non-urgent ( meaning no resources required or lowest priority to be seen). Patient #6 had a heart rate of 89, blood pressure of 86/69, temperature of 97.5, respirations of 26, and an oxygen saturation of 92 percent on 3 liters of oxygen. Review of a physician assessment dated [DATE] at 11:21 a.m. Physician #14 deemed the patient to have an Emergency medical condition. At 11:22 a.m., Physician #14 documented that Patient #6 was seen here 2 days ago, given z-pak and ativan, presents today by ambulance, tachypenic at 30, sats 98 % RA. No respiratory distress, regular rate and rhythm, and breath sounds normal. Patient #6 was admitted to the hospital and subsequently died . Based on interview and record review, the facility failed to ensure physician certifications were complete and accurate in 20 of 20 patients prior to transfers (Patient #s' 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, and 45). This deficient practice had the likelihood to cause harm in all patients presenting to the emergency department of this hospital. Findings include: Review of "Memorandum of Transfer" (MOTs) from March 2014 -September 2014 revealed the following information listed on them: "Physician certification: Based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of the transfer to the patient and, in the case of labor, the unborn child. Summary of Risks and Benefits_____________________" Review of MOTs on Patient #s' 26, 27, 28,29,30,31,32,33,35,36,37,38,39,41,42,43,44, and 45 revealed the physicians left the area blank. Review of the MOT on Patient #28 revealed a date of service of 09/04/2014. Patient #28 was transferred to another hospital, but there was no documentation of where. Review of the MOT on Patient #27 who had a date of service of 09/03/2014 revealed the initial contact with receiving hospital, transferring physician secured receiving physician, and transferring physician's signature or signature of hospital staff acting under the physician's order was left blank. Patient #27 was transferred to another hospital and the physician certification was not signed off by a physician or any hospital personnel. Review of the MOT on Patient #34 revealed a date of service of 07/01/2014. Patient #34 was transferred to another hospital and the facility failed to document the time the transferring hospital administration contacted the receiving hospital. Review of the MOT on Patient #41 revealed a date of service of 05/01/2014. Patient #41 was transferred to another hospital and the facility failed to document the time the patient initially arrived at their facility. Review of the MOT on Patient #43 revealed a date of service of 04/11/2014. Patient #43 was transferred to another hospital, but there was no documentation of where. Review of the MOT on Patient #44 revealed a date of service of 03/03/2014. Patient #44 was transferred to another hospital and the facility failed to document the time the patient initially arrived at their facility. During an interview on 09/08/2014 after 3:00 p.m., Staff #2 confirmed the missing information. Review of a policy named "Transfer /Discharge of Patients from RRRH" dated 01/2013 revealed the following: "a. The physician/Nurse Practitioner will speak with the physician at the receiving facility to secure acceptance of the patient's care and sign the Memorandum of Transfer. (Memorandum of Transfer forms are filed separately from the medical record and are maintained for at least 5 years.) b. The Emergency Department will speak with the hospital representative at the receiving facility to secure acceptance of the patient and complete the Memorandum of Transfer. c. The physician/Nurse Practitioner will complete and sign the Physician's Certification of Transfer inlcuding documentation of the risks and benefits of this transfer. If the physician is not readying available at the time of transfer, the qualified medical person (Nurse Practitioner) may sign this form. the physician will also sign within a reasonable period of time." |
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