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HEALTHALLIANCE HOSPITALS, INC 60 HOSPITAL ROAD LEOMINSTER, MA 01453 May 9, 2014
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on interviews and a review of 1 (Patient #1) of 6 Emergency Department (ED) Records related to patients presenting to the ED with chest pain, in a total sample of 33 patients, the medical staff failed to ensure compliance with Emergency Services policies/procedures related to triage, vital sign monitoring and reassessment that resulted in a potentially serious delay in medical care.

Findings include:

An ED Patient Identification Form, dated 4/6/14, indicated Patient #1 presented to the ED with complaint of chest pain and numbness at 1:30 P.M.

An Electrocardiogram (EKG, a record of the electrical activity of the heart) Report, dated 4/6/14, indicted an EKG was performed on Patient #1 at 1:41 P.M.

A Triage Assessment, dated 4/6/14, at 1:53 P.M., indicated Patient #1 had 6/10 chest pain and numbness in both arms. The Triage Assessment indicated Patient #1 had been having chest pain for 2 months and had an episode of sweating with numbness in both arms the day before. The Triage Assessment indicated Patient #1's vital signs were within normal limits except for an elevated blood pressure of 191/123 (normal is 100-120/60-80).

The Emergency Services Policy/Procedure HA-43-04 titled, "Triage of Patients in the Emergency Department", indicated ED triage (the screening and classification of patients to determine priority of treatment), is done using the Emergency Severity Index (ESI) 5-level triage system. The Triage Policy/Procedure indicated patients without life-threatening or high risk medical situations are triaged as ESI level 3, 4 or 5 depending upon the number of resources their ED care will likely require. The Triage Policy/Procedure indicated that if ESI level 3, 4 or 5 patients have vital signs outside of specific limits, uptriaging to ESI level 2 is to be considered. The Triage Policy/Procedure indicated the high blood pressure limit is 200/110. The Triage Policy/Procedure indicated vital sign documentation and reassessment of patients is to occur in accordance with the ED Vital Signs Policy.

The 4/6/14 Triage Assessment indicated Patient #1 was triaged as a ESI level 3.

The Surveyor interviewed the Triage Nurse on 5/6/14, at 12:20 P.M. The Triage Nurse said there was no space available inside the ED and Patient #1's EKG was OK, so he/she was triaged to the Waiting Room. The Triage Nurse said Patient #1 sat in a chair and she could see him/her from the Triage Room. The Triage Nurse said Patient #1 was accompanied by Family Member #1.

The Emergency Services Policy/Procedure HA-43-53 titled, "Vital Signs and Reassessment", indicated patient vital signs are to be reassessed as dictated by the patient's ongoing evaluation and management. The Vital Signs and Reassessment Policy/Procedure indicated occurrences such as a change in condition, an adverse reaction or abnormal vital signs during a previous assessment require vital sign reassessment. The Vital Signs and Reassessment Policy/Procedure indicated patient's responses to interventions and changes in patient condition are to be documented. The Vital Signs and Reassessment Policy/Procedure indicated abnormal vital signs and changes in patient's conditions are to be reported to the ED provider and documented in the patient's record.

The Triage Nurse said shortly after the Triage Assessment, she was alerted that Patient #1 was having trouble breathing. The Triage Nurse said Patient #1 was anxious and hyperventilating (breathing too quickly). The Triage Nurse said she put one of her hands on Patient #1's shoulder and calmly coached Patient #1's breathing. The Triage Nurse said she retrieved a mask for Patient #1 to use, but Patient #1 did not like using the mask. The Triage Nurse said she went into the ED and told the Charge Nurse that Patient #1 had been hyperventilating and needed to be brought into the ED.

Patient #1's hyperventilation episode was not documented in the 4/6/14 ED Record. The ED Record did not indicate that Patient #1's vital signs were evaluated during or immediately following the hyperventilation episode or that Patient #1's hyperventilation episode or triage assessment blood pressure were reported to an ED Provider.

The Surveyor interviewed the Charge Nurse on 5/7/14, at 11:55 A.M. The Charge Nurse said the Triage Nurse told her she had a patient in the Waiting Room with chest pain, who had hyperventilated, and needed to be in the ED. The Charge Nurse said the Triage Nurse indicated the patient had already had an EKG and the EKG was not abnormal. The Charge Nurse said she cleared a bed and assigned the bed and a nurse to Patient #1.

Review of Patient #1's 4/6/14 ED Record indicated he/she was brought into the ED at 2:59 P.M. The ED Record indicated Patient #1's vital signs were taken at 4:42 P.M. and his/her blood pressure remained elevated at 182/124. The ED Record indicated Patient #1 was evaluated by ED Physician #3 shortly before 4:48 P.M.

The Surveyor interviewed the ED Registered Nurse (RN) assigned to Patient #1 (ED RN #2) on 5/6/14, at 11:20 A.M. ED RN #2 could not recall Patient #1.

The Surveyor interviewed ED Physician #3 on 5/7/14, at 9:20 A.M. ED Physician #3 said she got a sign-out report from ED Physician #2. ED Physician #3 said ED Physician #2 had seen Patient #1's EKG and indicated the EKG did not indicate a ST-segment-elevation myocardial infarction (a type of heart attack that requires immediate invasive emergency intervention). ED Physician #2 said Patient #1 was still having chest pain when she evaluated him/her and she ordered another EKG, bloodwork, aspirin and intravenous medication for high blood pressure). ED Physician #3 said she was not aware Patient #1 had a hyperventilation episode in the Waiting Room or that his/her triage assessment blood pressure was 191/123. ED Physician #3 said that had she been aware of Patient #1's elevated blood pressure and hyperventilation episode, she would have evaluated him/her sooner.

The Surveyor interviewed ED Physician #2 on 5/8/14, at 12:55 P.M. ED Physician #2 said he signed-up (on the Patient Tracking Board) to evaluate Patient #1, but he got tied up with admission and transfer patients and did not see Patient #1. ED Physician #2 said he was not aware Patient #1 had a hyperventilation episode in the Waiting Room or that his/her blood pressure was 191/123. ED Physician #2 said he told ED Physician #3 he had not evaluated Patient #1. ED Physician #2 said he then noticed Patient #1's documented elevated blood pressure and told ED Physician #3 about it. ED Physician #2 said ED Physician #3 evaluated Patient #1 a few minutes later.

ED Physician #3 said Patient #1's repeat EKG and blood testing indicated findings suggestive of a non-ST-segment-elevation heart attack.

Review of Patient #1's 4/6/14 ED Record indicated additional treatment interventions were provided and he/she was transferred to a tertiary care hospital (Hospital #2) for further evaluation and care. The ED Record indicated Patient #1 was transferred to Hospital #2 in stable condition.

Patient #1's Hospital #2 medical record indicated he/she arrived at the hospital in stable condition. The Hospital #2 medical record indicated additional diagnostic and treatment interventions including a cardiac catheterization (an invasive heart procedure) with stent (devices that are placed in heart blood vessel to keep them open) placement were provided to Patient #1. The Hospital #2 medical record indicated Patient #1 was discharged home in good condition on 4/9/14.