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FLAGLER HOSPITAL 400 HEALTH PARK BLVD SAINT AUGUSTINE, FL 32086 June 23, 2014
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on medical and facility record reviews, staff interviews, and a review of the hospital's Policy and Procedures, the facility failed to govern and evaluate the emergency medical care provided in the triage area of the Emergency Department (ED) and enforce that care and services rendered are according to the hospital's written Policies and Procedures for 1 (#17) of 17 patients.

The findings include:

1). A medical record review for Patient #17 reveals she was triaged into the ED on 6/20/14 at 9:38 pm with complaints of shortness of breath and chest pain. She received an electrocardiogram (EKG) on 6/20/14 at 9:38 pm. Patient #17 was assigned an Emergency Severity Index (ESI) of 2. A review of the EKG revealed it was determined as abnormal. There is no evidence to reveal any other care or treatment was provided to Patient #17. Patient #17 Left Without Being Seen on 6/21/2014 at 12:23 am. A further review of the medical record with the Assistant Director of the ED reveals there are no physicians' notes and no laboratory results for Patient #17.

An interview with the Assistant Director of the ED on 6/23/14 at 12:51 pm reveals Patient #17 was given a follow-up call the next day (6/21/14). Patient #17 verbalized that she was feeling better and would follow-up with her primary care physician. The Assistant Director of the ED stated the facility has a 'pull until full' policy at triage. When patients come in for chest pain and the treatment rooms are full, an EKG is to be done at triage and taken to one of the main ED physicians. The ED physicians will stamp the EKG with "ST Segment Elevation Myocardial Infarction (STEMI) yes or no." The physician will check the box appropriately and initial the EKG.

An interview with ED Employee A on 6/23/2014 at 1:13 pm reveals when patients check-in to triage and all the treatment rooms are full, the ED Technician assigned to triage will bring the EKG and give the physician a brief clinical picture of the patient, to include the complaint and medical history. Based on the information given, it is determined by the physician if the patient needs to be immediately seen; if the patient needs to be evaluated by the MD at triage to gather more information; or if the history and EKG does not present evidence of a significant event that requires an immediate intervention. While reviewing the EKG and medical history for Patient #17, ED Employee A verbalized they would have either gone up to triage and examined the patient or if there was a room available, they would have requested Patient #17 be brought back immediately to a treatment room.

An interview with the Triage Nurse on 6/23/2014 at 1:24 pm reveals that when patients come into the ED with complaints of chest pain, shortness of breath, nausea, dizziness, syncope, high Blood Pressure, jaw pain, or arm pain, this will fall under the Chest Pain Protocol. After the EKG is complete, it will be taken back to the MD to get signed. If the MD states the EKG is OK, then we (the triage nurse) will finish the triage, and the patient will go into the waiting room if there is a wait. I will then put in a Chest Pain Protocol that has basic labs (to include a Point of Care Troponin) and a chest x-ray to be completed while the patient is waiting. Patients who are assigned ESI of 2 are not to wait over 10 minutes.

A review of the Chest Pain Protocol Order set in Allscripts confirmed the Triage Nurse's statements regarding the Chest Pain Protocol, and what should be done for patients presenting into the ED with chest pain while waiting for bed placement in triage.

An interview with the Director of the ED on 6/23/14 at 5:33 pm reveals the facility is aware that there are problems with the facility's night shift regarding following the protocols. The facility's expectation is that patients receive the same high quality care both day and night. The Director of the ED acknowledged and confirmed that the Chest Pain Protocol was not followed. She stated the Point of Care Troponin is completed and yields a more rapid result, which could have alerted the ED staff of Patient #17's status and a need for immediate care, if indicated. Simply, the protocol was not followed and the facility is unaware the patient's outcome could have been changed.