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NORTHWEST HOSPITAL CENTER 5401 OLD COURT ROAD RANDALLSTOWN, MD 21133 Jan. 20, 2016
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on an onsite EMTALA survey that included observations, interviews and medical record reviews, it was determined that a patient who had been triaged as Level 2 (urgent) was monitored by two Basic Life Support (BLS) Emergency Medical Technicians (EMT's) and not hospital staff for approximately 70 minutes while waiting for a bed and received no medical screening exam for almost 2 hours after he had arrived in the Emergency Department (ED). Further, it was observed that the nurse relied on the EMT and not hospital staff to provide vital signs for a patient who had arrived to the ED by ambulance on 1/20/2016 during the survey rather than performing her own assessment.


Patient #1 was a male in his 70's who (MDS) dated [DATE] due to a change in mental status. The patient was brought to the ED by two BLS (Basic Life support) Emergency Medical Technicians (EMT's) and one Advanced Life Support (ALS) Paramedic. Though patient #1 did not have a history of diabetes, he had become hypoglycemic at home with a blood sugar of 49 mg/dl (norm 70-99 mg/dl), and had an oxygen saturation of 89% where norms are greater than 90%. While enroute to the ED the ALS paramedic gave the patient Dextrose 50% intravenously at 1845 and placed him on a cardiac monitor. Patient #1 had an extensive cardiac history and chronic low blood counts.


On presentation to the hospital at 1910, patient #1 had a blood glucose of 294 mg/dl, a blood pressure (BP) of 114/54, a pulse (P) of 77, respirations (R) of 16, an oxygen saturation (O2 sat.) of 99 on room air, a 0 pain score, and a 15 on the Glasgow Coma Scale (scale of 3-15 where 15 is the best response). This data was collected by the transporting EMT's.


Triage vitals done at 1916 by the RN revealed a BP of 122/62, P of 78, R of 16, O2 sat of 100, temperature of 36.5 C (97.7 F) and a complaint of back pain. There was no documentation that the patient's pain level was assessed by the RN despite his complaint of back pain. The RN documented in the patient's record under the Chief Complaint Description "more alert now. c/o (complains of back pain)." There was no documentation of any assessments, treatments or interventions being performed after and before 2026. At that time the patient was placed on a cardiac monitor according to the patient's record.


A review of the Emergency Medical Services report revealed that upon arrival at 1910 the patient was triaged and then assigned to wait in the hallway until a room became available. The EMS crew waited with the patient until an available room was ready. It was further revealed that at some point during patient #1's wait for a bed, the ALS provider left the hospital leaving the two BLS providers to wait with patient #1. There was no documented evidence that patient #1 remained on a cardiac monitor, and there was no documentation of treatment to the patient during the more than one hour of waiting in the hall. At 2015 patient #1 was moved to an ED bed , 59 minutes after triage. Between triage at 1916 and 2026 there was no evidence that the hospital staff provided assessment or treatment to Patient #1.


At 2040 the RN documented "Ambo PT (patient) to ram (room) 9 from home, c/o change in mental status, PT AxOx1 (alert and oriented x 1), family at bedside, will continue to monitor." Vitals performed by the RN at 2044 revealed a heart rate of 72, a high respiratory rate of 26, an O2 sat of 98, and a falling BP of 92/51. Patient #1 was placed on oxygen with an O2 flow of 3 Liters. The RN documented that patient #1 was having difficulty breathing at rest. Based on the medical record the patient had deteriorated from 1916 when he was triaged as a level 2 (urgent) to 2015 after he had waited in the hallway for an available bed.


Review of the patient's medical record revealed verbal orders at 2046 from an ED physician who did not come to patient #1's bedside. The orders included an EKG and bloodwork. At 2055 the RN documented that patient #1 was not oriented to person. At 2107, the RN documented that a finger stick for blood sugar was 71 mg/dl and that the physician was notified.


Not until 2113, approximately two hours from the time of his ED presentation, did a physician see patient #1 and perform a medical screening examination (MSE). As a result of the MSE Patient #1 was determined to have an emergency medical condition.


At 2230 Patient #1 went into cardiac arrest, and was able to be resuscitated. The patient went into cardiac arrest again at 2308 and was resuscitated again. The patient was then admitted to the intensive care unit and suffered two more cardiac arrests the following morning at 0425 and 0517. The patient expired during the last cardiac arrest.


During the 1/20/2016 onsite survey the ED Manager was interviewed at approximately 0930. The interview revealed that it had been the expectation of the ED staff that when a patient must wait for a bed, that the accompanying EMT's continue to monitor the patient. However, the EMTs are not hospital employees and are not credentialed by the hospital.


This was further reinforced by surveyor observations of the ED during the onsite survey on 1/20/2016. At 0933 the ED Charge RN was observed performing a triage for Patient #2 who had presented to the ED via ambulance. The RN stood in the triage podium area 4 - 5 feet from the patient gurney. One of the two EMT's who had accompanied the patient took a set of vitals while the RN gave an ID bracelet to the other EMT to apply to the patient's wrist. The EMT then gave his report to the RN. The RN was observed asking the patient how she was feeling but never approaching the patient during the triage process. An interview with the same Charge RN at approximately 0945 revealed that there was an expectation that EMT's would monitor patients until the patients were off-loaded onto an ED bed.


The ED Director was interviewed on 2/3/2016 at approximately 1300. The ED Director indicated that there was an agreement between EMS and the ED that for patients started in the field on cardiac monitoring, medics were to continue monitoring the patient when they arrive. No written agreement was provided to the surveyor.. In contrast to this, the ED Director also indicated that the ED has portable cardiac monitors. In the case of Patient #1 the ALS provider was certified to use and read a cardiac monitor, but the BLS providers who actually stayed with Patient #1 were not certified.


Based on all documentation and observations, it was determined that the facility failed to provide a timely stabilizing treatment for Patient #1 while allowing EMS to monitor the patient until a bed was available, and that the observed practices of RN at triage may impact patient triage scores and thus the timeliness of the MSE.