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.

Based on record reviews, observations, and interviews, the hospital failed to ensure a Clinical Professional triaged (assessed) a patient to determine his/her immediate needs when he/she presented to the Emergency Department (ED) for 1 of 10 patients reviewed (Patient #1). This failure resulted in a delay of treatment for a patient, who was found not breathing and without a pulse in the waiting area, 25 minutes after arriving in the ED and prior to being triaged by a Clinical Professional. It was also determined that the hospital's current registration and triage process created a potential negative outcome for any patient presenting to this ED with an emergent need; thus, a determination of immediate jeopardy was made.


Patient #1's clinical record was reviewed and indicated the following:

- Documentation on the consent to treat form, that patients normally sign, indicated "patient gave verbally due to medical condition."

- Documentation on the ED triage form, part 1, dated 12/15/17 at 12:38 PM, indicated the patient's chief complaint was "cardiac arrest from WR [waiting room], grey, not breathing".

- A nursing note, dated 12/15/17 at 2:45 PM, indicated the "Pt [patient] was ambulatory into ED and registration completed. Triage nurse out to bring pt into triage room and pt noted to be slumped down in WC [wheelchair]. No pulse noted. Pt brought directly into CC4 [cardiac care room #4] and placed on stretcher and CPR initiated ...".

- Once in the ED room, resuscitation interventions were provided and the patient responded to these interventions. The patient was then transferred to the intensive care unit at 1:52 PM.

- On 12/18/17, a neurology consult was obtained and the reported stated the patient ".. does have severe neurological injury, and based on this, the likelihood of functional independent recovery is less than 1%. [He/She] is at high risk for progressing to a persistent vegetative state."

- On 12/20/17 at 1:08 PM, the patient expired. Documentation indicated the cause of death was identified as "Patient had workup after [he/she] had a cardiac arrest and [he/she] was found to have severe extensive anoxic [lack of oxygen] brain injury."

On 12/27/17, the hospital's "Incident Management Report", regarding the event involving Patient #1, was reviewed. The report, written by the ED Nurse Manager, indicated the following: the patient was in obvious respiratory distress on camera [security video] at 12:15 PM, and again at 12:22 PM.; both triage nurses were busy seeing other patients and that the patient had been left in front of triage room 2 by patient registration; at one point [triage nurse] left Triage Room #2 and grabbed the patient's wrist to check the wristband and then moved on to another patient; the Patient was found unresponsive approximately 13 minutes later by a nursing technician and the patient was brought into the treatment area; and CPR was performed for approximately 25 minutes before a pulse was obtained. The report also indicated "Pt will be admitted to CCU I Am, unsure on severity level at this time, depending on outcome. Nor am I sure if this would have been prevented even if [he/she] was brought to a room immediately."

A patient registration document titled "ED Greet" was reviewed. This document indicated upon registration "If the patient states that he/she is having a Stroke or Chest Pain please alert the Triage Nurse right away, do not send the patient to the waiting room. If the patient is sweating, shaking, or looks bad excuse yourself and ask a co-worker to get the nurse or Voicera [a communication device] the Triage nurse to come look at the patient ..."

On 12/27/17 at 11:30 AM, a surveyor observed, with the Chief of Security, the video recordings of the hospital's Emergency Department (ED) area for 12/15/17. The following was noted on the video recordings:

- At 12:14 PM, Patient #1 arrived at the ED entrance, via personal vehicle, which he/she drove. Security personnel approached the vehicle within 15 seconds of arrival.

- At 12:15 PM, a wheelchair was brought to the patient's vehicle; security personnel assisted the patient into the wheelchair; the patient entered the ED; and he/she was wheeled to the registration area. When the patient arrived at registration, there were two other patients at the registration desk.

- At 12:17 PM, the patient remained in line at registration and one of the patients at the registration desk was escorted by a registration staff member to the triage area.

- At 12:18 PM, the patient was moved to the registration desk. The patient appeared to be having difficulty breathing.

- At 12:23 PM, the patient was wheeled to the area in front of the window of Triage Room #2.

- At 12:24 PM, the patient remained in the area and was rocking in the wheelchair. A Registered Nurse (RN) left Triage Room #1 and then returned to Triage Room #1.

- At 12:24:55 PM, a RN left Triage Room #2, walked by Patient #1 who continued to rock in the wheelchair; and returned to Triage Room #2 at 12:25:20 PM.

- At 12:25:43 PM, the RN, from Triage Room #2, made contact with the patient by checking his/her wristband.

- Between 12:27 PM and 12:30 PM, the patient was slumped in the wheelchair moving his/her head and moving his/her legs.

- At 12:30:20 PM, the patient, who had been in Triage Room #2, left the room and another patient entered Triage Room #2.

- At 12:31 PM, Patient #1 continued to be slumped in the wheelchair.

- At 12:39 PM, an ED Technician was at Patient #1's chairside and 20 seconds later a RN was at the patient's chairside. Twenty-one seconds after the RN arrived, Patient #1 was moved to a treatment area.

On 12/27/17 at approximately 9:30 AM, the Associate Vice President Critical Care/Emergency Department, conducted a tour of the ED with a surveyor. The patient flow process in place on 12/15/17 was reviewed. He stated that patients entered the ED either through the walk-in entrance or the ambulance entrance. Walk-in patients were screened by security and then escorted to patient registration. Patients arriving by ambulance may be immediately placed in a bed, or if determined, by the ambulance staff to be stable for triage, the patient would be dropped off at security by the ambulance and follow the same process as walk-in patients. After registration, the patients then goes to the waiting room to await triage. He stated he identified a need for a nurse or other clinically trained individual at the point of entrance to direct patients to immediate care or to triage when he was hired in November 2017. He shared plans were developed to create these changes, but admitted that the hospital had not implemented any of the changes even after Patient #1's visit to the ED.

On 12/28/17 at 9:20 AM, the ED Nurse Manager and the Associate Vice President of Critical Care/ED were interviewed. They reported the hospital had created plans, prior to this incident, to change the patient intake (triage) process including adding a RN at the ED entrance. However, they confirmed that no substantial process changes had been made or put in place following the incident and prior to this onsite complaint investigation. Additionally, they reported an internal investigation was completed and no specific changes had been made after their investigation.

On 12/28/17 at 11:55 AM, the Co-Medical Director of the ED was interviewed. He shared a memo, dated 12/20/17, that explained changes that were going to be made to the patient flow process. These changes included adding a "Pivot Nurse" at the ED entrance; adding additional providers in triage; and patient registration would be conducted after the patient was seen by a clinical person and if necessary after treatment initiated. When the surveyor asked why this had not been implemented, he replied, "We don't have a real good interim plan". On 12/28/17 at 12:10 PM, he called the surveyor to state that he had spoken with Associate Vice President Critical Care/Emergency Department who was delegated to implement an immediate action plan as of 12/28/17.

On 1/5/18 at 9:28 AM, Employee #16, who was the patient registration clerk on duty on 12/15/17. was interviewed. She indicated that Patient #1 appeared very ill, she was not familiar with the patient, and she had difficulty obtaining information from the patient due to the patient's difficulty breathing. She indicated she wheeled the patient and left him/her in front of the triage room as both triage nurses were busy with patients and she wanted to make sure Patient #1 was seen as soon as possible. She indicated she sent another employee to find a nurse. When asked if a nurse was informed of this patient, she replied, "not by me." When asked if she had a Voicera device to call a nurse, she replied that she did not as she was only covering someone else's break.

On 1/15/18 at 1:07 PM, Employee #17, who was also working patient registration, was interviewed. She indicated that Employee #16 asked her to tell the triage nurse about Patient #1 and the patient's difficulty breathing. She stated that both triage nurses were occupied with other patients and that in the past registration staff have been told by the Charge Nurse to "go to the triage nurse". She reported that she was unable to connect with a Nurse as the department was "crazy busy", so she returned to patient registration and informed Employee #16 that she could not find a nurse.

Immediate Jeopardy is defined as "a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." This investigation determined the hospital failed to ensure a Clinical Professional triaged a patient to determine his/her immediate needs when he/she presented to the Emergency Department (ED) and this failure resulted in the delay of treatment for a patient. The ED Nurse Manager, the Associate Vice President of Critical Care/ED, and the ED Medical Director, indicated the hospital had identified a need to change the triage process, prior to this event on 12/25/17, and they had created long term plans to change the process. However, as of 12/28/17, 13 days after this event, there was no evidence that indicated the hospital had taken any action to change their triage process even after their internal investigation into this event. The hospital's current triage process continued to create a potential negative outcome for any patient presenting to this ED; thus, a determination of immediate jeopardy was made.

On 12/28/17, after consultation with a representative from the Boston Regional Office of the Centers of Medicare and Medicaid Services, a determination of immediate jeopardy was made.

On 12/28/17 at 3:30 PM, the hospital was made aware of the determination of immediate jeopardy and an immediate action plan was requested.

On 12/28/17, the hospital submitted an immediate action plan. This plan indicated the hospital would place a Registered Nurse at the patient registration area to act as the initial patient contact for all patients entering the ED; if a patient required immediate care, the patient would be moved immediately to an ED bed and registration would occur after stabilization; patients presenting with less severe complaints would be directed to patient registration and then be triaged for a more comprehensive assessment; and training would be conducted to advise all staff of the changes in the ED triage process.

On 12/29/17 at 8:20 AM, surveyors verified that the facility implemented their immediate action plan, thus removing the immediate jeopardy situation. Surveyors observed, at the ED entrance, a construction barrier was erected at Patient Registration and a worker was removing the first registration counter; this area was now designated as the temporary location for the Triage Nurse; and a Registered Nurse (RN) and an ED Technician were stationed at the patient registration area to greet patients entering the ED. An interview with a RN was conducted and she stated she had been assigned to screen all patients coming into the ED, both ambulatory and ambulance patients; patients were brought directly to a room in the ED and someone from Registration would go to the cubical and register the patient; and if the rooms were filled, the patient would be assessed until a bed could be found. The RN stated that she had been there since 7:00 AM and would be screening all new ED patients until 7:00 PM. Additional observations for one hour were made and the action plan was being followed. The surveyors also reviewed the acknowledgement forms, signed by ED staff, beginning on 12/28/17 at 7:00 PM.