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ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 Feb. 22, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of videos, medical records, emergency department logs, policies and procedures and staff interviews, the facility failed to ensure that an individual who presents to the Emergency Department with complaints of shortness of breath was provided an appropriate medical screening examination that was within the capability of the hospital's Emergency department to determine that an emergency medical condition existed for 1( patient #1) of 16 sampled patients reviewed. The facility also failed to ensure that policies and procedures regarding triage for chest pain/shortness of breath protocols were followed for Patient #1. Refer to findings in tag A-2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of videos medical records, emergency department logs, policies and procedures and staff interviews, the facility failed to follow their own policies/procedures for performing a medical screening exam on 1(patient #1) of 16 sampled patient, to determine if an emergency medical condition existed. This failure presents a substantial probability to adversely affect all patient ' s health and safety.

Findings:

Review of video # 1 shows that on 04/08/15 at 4:13:13 PM ( 4:00 PM, 23 minutes and 13 seconds) patient # 1 and a man entering the emergency Department ( ED).
Review of the video shows that patient # 1 was in the waiting room and started having distress at:
4:18:16 Women identified as patient # 1, sitting in wheelchair grabbed man ' s arm, it is noted that patient # 1 having problem breathing.
4:19:12 Patient ' s hand goes to chest.
4:19:51 Patient ' s hand on face and having hard time breathing.
4:20:45 Looks at desk (Not able to see who the man is talking to) and points to patient # 1 needs help.
4:23:51 Patient # 1 slumped on couch.
4:23:53 Man walks out of video view. Visitor at patient ' s # 1 side.
4:24:56 ED Staff ( Unable to see staff's badges for identification) at patient"s # 1 side.
4:25:34 Two ED staff members and man (That was with patient # 1) tried to transfer the patient onto the stretcher times 2 tries.
4:25:48 The two ED staff and the man still trying to transfer patient # 1 on to the stretcher.
4:26:23 Patient # 1 on stretcher, on her side.
4:26:48 Patient # 1 on stretcher and out of sight of video.
A total of 13 minutes and 33 seconds till patient # 1 out of view of video.
Review of the video # 1 shows that there was no triage, no medical screening evaluation of patient #1 (Who was unresponsive) while she was in the ED waiting area, until the man with the patient walked out of view of video. The video did not reveal any resuscitative measures initiated by the ED staff, when patient was found non- responsive in the waiting room. Review of the video shows that there was no rise/fall of patient ' s #1 chest.
Medical Record and Emergency Department(ED) Log review:
Review of the ED registration log provided by the Charge nurse on 02/10/16 at 12:10 PM revealed Patient # 1 was logged in on 04/08/15 at 4:17 PM. This time did not match the time on the Video.
Review of the Medical Record for patient #1:
Review of the ED sign in sheet provided by risk manager for Patient # 1 medical records on 02/02/16 at 3:33 PM revealed a completed sheet that was clocked as received on 04/08/15 at 4:17 PM. The sheet included the patient's name, address,phone number, social security number, date of birth and a " primary Complaint: Difficulty Breathing.

Review of the ED nurses notes dated 4/08/2015 reads, transferred from ambulance stretcher to bed # 4 on 04/08/15 at 4:17 PM. Called to waiting room by spouse who states his wife is having a seizure and having trouble breathing. Patient in waiting room, slumped on couch and non-responsive. There was no pulse or spontaneous breathing noted. Unit coordinator brought out gurney, patient placed on stretcher and taken back to room 4. Cardiopulmonary Resuscitation (CPR) initiated and Physician Assistant (PA) at bedside. Cardiac monitor applied and shows asystole (No heart beat) and non-spontaneous respiration noted. Staff assisted patient with breathing. The patient's time of death was documented at 4:47 PM.
Review of ED Physician clinical history notes of present illness dated 04/08/15 at 4:17 PM, Examination started at 4:17 PM, and history was discussed with patient # 1 husband. The physician reviewed and agreed with the RN note. Presenting problem started minutes ago and was a witnessed arrest. Estimated down time was 3 minutes before resuscitative measures were began. No known precipitating cause and the patient was not viable on initial exam and there is no significant history available. Presenting cardiac rhythm - Asystole and had complained of chest pain prior to this event.
Review of the CPR log dated 04/08/15 revealed that CPR was initiated at 4:20 PM. Review of the video # 1 shows that patient was still in the waiting room at that time. Patient # 1 time of death was 4:47 PM.
Review of policies and Procedures:
Review of facility ' s policy titled " Emergency Services Policy " effective date of 12/30/14 states all patients presenting to the ED will receive an initial triage and classification by a Registered Nurse(RN) using the emergency severity index. All patients will then receive an initial focused nursing assessment, and a full body assessment if admitted to the facility.
Review of policy/procedure titled "ED- triage: initial Laboratory, X-ray and Medication order Protocols" Last review date of 4/3/13 reads: Only an RN on duty in the ED, who has been educated in basic triage guidelines and patients assessment including recognizing signs, symptoms and risk factors for acute coronary symptoms (ACS), may initiate the following triage orders before a physician or mid-level practitioner evaluates the patient in order to expedite care and treatment.

Further review of the facility's policy titled "Emergency Department (ED) Triage: Initial Laboratory, X-ray and medication" dated 04/03/13, revealed that ED registration staff and ED EMT( Emergency Medical Technician) / Paramedic/Greeter/ PCT( Patient Care Technician) receive focused training and education on recognition of symptoms of Acute Coronary Symptoms (ACS) in ED patient. Procedure: Following is a list of procedures or treatments that may be initiated, based on the chief complaint, history, and nursing assessment. The Nurse triaging the patient initiates an electronic order sheet set based on patient chief complaint such as " ED Triage Chest pain. "

Review of the facility ' s policy titled " The ESI Project " revised 2012 shows the triage process involves using the Emergency Severity Index(ESI) classification system. Appropriate assigning of the ESI level at time of triage is essential to safe and timely patient care resulting in more positive patient outcomes as well as a more positive patient experience. The ESI starts with triage, the process involves categorizing patients into different triage acuity levels based on preliminary assessment done by the triage RN. A ESI level 1 shows that resuscitation/life saving measures are needed.
The facility failed to ensure that patient # 1 was triaged by a Registered Nurse(RN) on duty in the ED as stated in the facilities policy when patient # 1 presented with a complaint of difficulty breathing.
Review of the facility ' s policy titled " Complaints such as ED chest pain " . Patient ' s entering the ED with a chief complaint that includes Chest Pain and or Shortness of Breath. Patient may present with syncope, nausea, vomiting, and shortness of breath. Other symptoms can be epigastric pain, shoulder, back and neck pain. Orders to be initiated include:
1. Transport to a monitored bed if available.
2. Undress patient, attach cardiac monitor, put oxygen on and a blood pressure cuff.
3. Oxygen at 2 liters by nasal cannula, keep oxygen over 92 %.
4. Obtain a 12 lead electrocardiogram within 10 minutes of arrival.
Review of the facility ' s policy titled " Volunteer Services Policies and Procedures " dated 05/20/14 states that a volunteer is assigned to assist the facility ' s ED staff by visiting patients and families for reassurance and helping with non-medical needs. In addition to assist by performing tasks which do not require a medical/non-license and does not require actual patient treatment.
Review of the facility ' s policy titled " Emergency Center Information Desk Volunteer " dated 05/20/14 shows that the volunteer makes copies of patient ' s paperwork/orders to give this information to the admission clerk. The volunteer notes date of birth on paperwork. If patient new to the ED, the volunteer will ask for photo identification and insurance cards to be copied. The volunteer puts the information in a folder in the order it was received.
Interviews:
During an interview on 02/10/16 at 4:03 PM, the volunteer in the ED stated that she was the volunteer in question when patient # 1 came into the ED. When asked what are her responsibilities as a volunteer in the ED. The volunteer stated that " I work the front desk. I am first person to meet the people when they came into the ED. I make them complete a sign in sheet. I then stamp the form. I give a copy to the charge nurse and one to the financial staff. I get it stamped within 30 seconds. " The volunteer was asked what the volunteer ' s limitation and if ask for patient ' s ability to pay. " I cannot do any medical things and I do not ask them about payment. " When asked what she can recall the day patient # 1 came to the ED. The volunteer stated that she did remember the incident, husband came into the waiting area with his wife. They both sat on a love seat. There were no other patients/family in the waiting area. The husband went to the vending machine to get some snacks. I asked the husband to fill out the sign in sheet. The volunteer was asked if she remembered the husband telling her his wife was having chest pains or shortness of breath. " No, he did not say a word to me at all. I did see her standing up from the wheelchair and then sitting in the love seat. The husband did not say anything to me about his wife ' s complaints. I stamped the sheet as soon as it was completed. I gave a copy to the RN and financial. "
During an interview on 02/10/16 at 12:10 PM, paramedic stated he has worked in the ED and usually works the desk area of the waiting area. We do have volunteers at the front desk area of the waiting room. If a patient comes in with chest pains, the patient is then assessed by an RN immediately. The volunteers are to tell the RN ' s if a patient has chest pains. If with family, I have the family sign them in.
During an interview on 02/10/16 at 2:10 PM, clinical manager stated when asked about the discrepancy with the documentation indicating the patient was transferred from ambulance stretcher. (Patient # 1 walked into waiting area of the ED with a man according to Video # 1). The clinical manager stated there are glitches in the computer soft wear that when you click " Stretcher " for some reason the word ambulance pre-populates in the notes. The clinical manager and Risk manager confirmed that patient # 1 was came into the waiting area of the ED by wheelchair.
During an interview on 02/22/16 at 9:15 AM, RN Manager stated that the expectations is that within 10 minutes of arrival of any patient stating that they have either chest pain or shortness of breath that the patient is to brought back to a room and electrocardiogram is to be done. The volunteer will tell the RN if there is a patient having chest pain or shortness of breath. The RN manager stated she felt that staff did what was needed. The RN Manager also stated that at no time did family member of Patient #1 say that wife was having either chest pain or shortness of breath. The videos verified that on 04/08/15 that between 4:18:16 and 4:19:51 patient # 1 was in distress in the ED waiting area. Patient's # 1 ED sign in sheet was stamped by the volunteer at 4:17 PM. with chief complaint listed as " Difficulty Breathing."
Review of the hospitals ED video # 1 dated 04/08/15 and the sign in sheet verified that on 04/08/15 while patient # 1 was in the waiting area of the ED that the patient was experiencing severe shortness of breath/Cardiac distress while in the waiting room. During an interview on 02/22/16 at 11:34 AM, Staff RN B stated when a patient comes into the waiting area, the volunteer signs them in. The registration will pop up on a screen in the ED or can view the monitors in the waiting area. Volunteers will tell staff if the patient has chest pain or shortness of breath. The volunteer can bring the patient to a room if available. The RN stated that the staff receive training each year on chest pain protocol.
During an interview on 02/22/16 at 11:59 AM, the Medical Director stated that due to the proximity of the rooms to the waiting rooms, expectation is that staff can get the patient into the treatment rooms if something happens in the waiting rooms. The patient would be brought back to a room and cardiac workup would then be done. The Medical Director stated that this might help.
During an interview on 02/22/16 at 12:27 PM, the registration clerk states that when a patient signs in on the triage sheet, the volunteer makes a copy and gives it to the triage RN. The volunteer also will make a copy of identification and gives it to the registration staff. If there is a problem in the waiting area the volunteer/registration staff will call for the RN to check the patient. As a registration clerk, I can go get a wheelchair if needed.
During an interview on 02/22/16 at 12:39 PM, Volunteer in the waiting room at this time states that if a patient states having either chest pain/shortness of breath will go get the RN to check the patient in the waiting area. There is a room off the waiting area that can be used by the RN to triage the patient.
During an interview on 02/22/16 at 1:30 PM, Clinical RN Manager of the ED states that there are cameras in the waiting area and that these cameras can be viewed in the main ED. The clinical RN manager was asked if someone ' s watches them at all times, was told " No " . Inquired on 04/08/15 what had happened and no answer was given.
Further review of patient ' s # 1 medical chart, video ' s, policy/procedures and interviews the facility failed properly triage and initiate a medical screening examination. Review of the video # 1 shows that there was no triage, initiated and that 13 minutes went by before patient # 1 had been seen by staff. The facility failed to ensure that their policy and procedure regarding Chest pain and Shortness of Breath was followed as evidenced by when patient # 1 (MDS) dated [DATE] with a complaint of shortness of breath, failed to administer oxygen, failed to complete an EKG( Electrocardiogram) within 10 minutes; and failed to transport the patient to a monitored bed. The facility also failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that trained ( RN, PCT, Greeter, EMT and PMG) medical staff were in the ED waiting area to recognize acute coronary symptoms, when patient # 1 (MDS) dated [DATE].