Bridgeport Hospital

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 50095 Based on observations during tour, a review of clinical records, hospital documentation, and interviews with hospital staff, for 6 of 12 patients (Patient #1, #2, #8, #12, #14, #15) reviewed for pain, the hospital failed to ensure staff followed their pain policy, for 1 of 16 patients (Patient #16) reviewed for medication administration, the hospital failed to ensure the timely ordering and provision of the patient ’ s home medication and for 1 out of 3 patients (Patient #12) reviewed for a change in condition, the hospital failed to ensure the provider was notified when Patient #12’s blood pressure markedly increased. Additionally, the hospital failed to ensure sharps were secured away from patient access and protected health information was safeguarded from unintended access, in accordance with hospital policy. The findings include: 1a. Patient #1 presented to the emergency department (ED) with a chief complaint of left elbow pain. The History of Present Illness (HPI) dated 07/14/2025 at 6:35 PM indicated Patient #1 presented to the emergency department (ED)with left elbow pain, associated swelling, redness, and warmth for two weeks, and no associated trauma. A review of the ED timeline dated 07/14/2025 at 12:14 PM indicated Patient #1 was assigned an acuity level of 3 (with level 1 being emergent and level 5 being non-urgent). Additionally, the patient reported a pain score of 7 out of 10 (with 10 being the most severe pain). Further review of the ED timeline failed to identify documentation indicating that Patient #1 was offered an intervention to relieve their pain, or that his/her pain was reassessed during the visit. The patient was discharged from the ED six and a half hours later at 6:44 PM. 1b. A review of Patient #2’s clinical record identified the HPI dated 07/14/2025 at 7:24 PM indicated the patient presented to the ED after a motor vehicle collision without airbag deployment. Patient #2 reported mild neck pain immediately after the collision, which was worsening. A review of the ED timeline dated 07/14/2025 at 4:57 PM indicated Patient #2 was assigned an acuity level of 4. Additionally, the patient reported a pain score of 5 out of 10. Further review of the ED timeline failed to identify documentation indicating that Patient #2 was offered an intervention to relieve their pain while in the ED. 1c. A review of Patient #8’s clinical record identified the patient had previous diagnoses that included high blood pressure during pregnancy. The HPI dated 07/14/2025 at 6:34 PM indicated Patient #8 presented to the ED by ambulance after experiencing a sudden onset of facial droop, burning pain behind the left eye, difficulty speaking, and left-sided paralysis. Upon arrival, the treatment team suspected a stroke, and the patient was sent for brain imaging. The imaging revealed a brain mass and no indication of a stroke. A review of the ED timeline dated 07/14/2025 at 4:53 PM indicated Patient #8 was assigned an acuity level of 2. Further review of the ED timeline failed to identify documentation indicating that Patient #8’s pain was assessed until the patient was seen by physical therapy the next morning (07/15/2025) at 8:33 AM, 15 hours and 40 minutes later. Although the patient’s vital signs were regularly reassessed, the documentation did not indicate that pain was also assessed at those times. 1d. A review of Patient #12’s clinical record identified an HPI dated 07/16/2025 at 5:20 PM indicated the patient presented to the ED after experiencing abdominal pain and persistent vomiting for two days. The patient reported weakness and a recent, black-colored bowel movement. A review of the ED timeline dated 07/16/2025 at 9:24 AM revealed Patient #12 reported a pain score of 9 out of 10 and was assigned an acuity level of 3. Further review of the ED timeline failed to identify documentation indicating that Patient #12 was offered an intervention to relieve their pain, or that his/her pain was reassessed during the visit. Although the patient’s vital signs were regularly reassessed, the documentation did not indicate that pain was also assessed at those times. The patient was discharged from the ED 13 hours and 7 minutes later at 10:31 PM. 1e. A review of Patient #14’s clinical record identified the HPI dated 07/17/2025 at 5:28 PM revealed the patient presented to the ED after five days of abdominal pain, nausea, and diarrhea. The patient reportedly received a semaglutide injection (an anti-diabetic and anti-obesity medication) the morning before symptoms began. Patient #14 stated they had not experienced previous adverse effects from the medication and was unsure if their symptoms were related to it. A review of the ED timeline dated 07/17/2025 at 12:09 PM revealed Patient #14 reported a pain score of 9 out of 10. At 12:22 PM, the patient was assigned an acuity level of 3. Although the patient received 4 milligrams (mg) of morphine (an opioid pain medication) at 12:57 PM, the ED timeline indicated that the patient’s pain was not reassessed until 5:27 PM, 4 hours and 30 minutes after the administration of pain medication. 1f. A review of Patient #15’s clinical record identified the HPI dated 7/14/2025 at 3:40 PM revealed the patient presented to the ED after an insect bite to the thigh three days earlier. The bite was followed by localized swelling, pain, drainage from the site, and a low-grade fever. A review of the ED timeline dated 07/14/2025 at 3:13 PM revealed Patient #15 reported a pain score of 5 out of 10 and the patient was assigned an acuity level of 5. At 4:53 PM. Patient #15 received 400 mg of ibuprofen (pain medication). Further review of the emergency department timeline did not identify documentation indicating that Patient #15’s pain was reassessed after receiving the pain medication. Patient #15 was discharged from the emergency department 1 hour and 25 minutes after receiving the ibuprofen. During an interview and clinical record review with Director #1 (ED Nursing Director) on 07/22/2025 at 11:54 AM, the Director stated that a pain score greater than 4 out of 10 required an intervention to be documented in the medical record. She also reported that it was best practice to reassess and document the patient’s pain within an hour of the pain intervention. She indicated that ED nursing staff are taught to reassess a patient’s vital signs and pain in accordance with the patient’s acuity level score. However, she could not explain why the clinical records lacked documentation of pain assessments, reassessments, and/or pain interventions. The hospital’s “Adult Emergency Department Competency Based Orientation Tool” identified that assessing a patient’s pain was part of their vital signs. The tool indicated that, in addition to the initial vital signs, subsequent vital signs were to be obtained based on the patient’s acuity and condition. For a level 1 patient, vital signs were to be reassessed at least every hour; for a level 2 patient, minimally every two hours; and for a level 3 patient, at least every three hours. Level 4 and level 5 patients’ vital signs were to be obtained per the provider’s discretion. Additionally, the tool indicated that vital signs were to be obtained within 30 minutes of transfer or discharge, or if the initial set of vital signs were abnormal. The hospital’s “ED Triage: Acetaminophen and Ibuprofen as an Analgesic/Antipyretic (Adult, Pediatrics) Standing Order” protocol (09/2024) indicated that the ED nurse may initiate standing orders for patients experiencing pain greater than 4 out of 10, or those with a temperature greater than or equal to 100.4 degrees Fahrenheit or 38 degrees Celsius. The protocol specified that 650 milligrams of acetaminophen by mouth is the first-line treatment for adults, provided the patient does not meet any exclusion criteria. If acetaminophen is excluded, 600 milligrams of ibuprofen is to be used for adults, as long as they do not meet the ibuprofen exclusion criteria. directed that the assessment for the standing order must be documented in the patient’s clinical record and authenticated by a provider involved in the patient’s care. The hospital’s “Pain Assessment and Management” policy (09/2024) directed, in part, for Emergency Department staff to assess and document a patient’s pain upon their arrival. Pain is reevaluated and the findings are documented when a patient’s condition changes, if it is clinically relevant, and following any treatment for pain. The policy further stated that pain management should involve an individualized, team-based approach using multiple methods, including both medications and non-medication strategies. Additionally, clinicians were directed to inform patients that effective pain relief is part of their care, that communicating unrelieved pain is important, and that healthcare professionals would respond appropriately. 2. A review of Patient #16’s clinical record identified the patient had previous diagnoses that included anxiety, depression, and bipolar disorder. A review of the emergency department (ED) timeline dated 07/16/2025 at 5:29 PM revealed Patient #16 presented to the ED after falling out of bed. According to the ED timeline, Patient #16 reported pain in the right axilla with a history of cysts in this area requiring drainage. Patient #16 also reported diarrhea and nausea. Subsequent imaging of the axilla identified an abscess that required surgery. A review of Patient #16’s clinical record identified home medications including 1000 micrograms of vitamin B12 daily, 1000 milligrams (mg) of divalproex (mood stabilizer) nightly, 500 mg of metformin (anti-diabetic medication) each morning, 5 mg prazosin (blood pressure medication) nightly, 200 mg of quetiapine (antipsychotic medication) nightly, 100 mg of sertraline (antidepressant medication) each morning, 100 mg of trazodone (an antidepressant that helps with sleep) nightly, and 90 micrograms (2 puffs) of albuterol sulfate (asthma inhaler) every 6 hours as needed for shortness of breath. During a clinical record review and an interview with Manager #1 (ED assistant nurse manager) and the Clinical Coordinator on 07/23/2025 at 2:00 PM, the clinical record revealed Patient #16 was assigned to the acute care surgical team on 07/17/2025 at 2:49 AM when it was identified that Patient #16’s abscess required surgical intervention. A review of the clinical record revealed that Patient #16’s home medications were not ordered until 26 hours and 7 minutes later, on 07/18/2025 at 4:56 AM. The Clinical Coordinator stated that the surgical team should have ordered Patient #16’s home medications when they accepted Patient #16 to their service on 07/17/2025 at 2:49 AM. However, neither she nor Manager #1 could explain the 26 hour and 7-minute delay in ordering Patient #16’s medications. A hospital policy regarding the ordering of patients’ home medications was requested but not provided. 4. A review of Patient #12’s clinical record identified the HPI dated 07/16/2025 at 5:20 PM indicated Patient #12 presented to the emergency department (ED) after experiencing abdominal pain and persistent vomiting for two days. The patient reported weakness and a recent, black-colored bowel movement. A review of the ED timeline dated 07/16/2025 at 9:19 AM revealed Patient #12’s blood pressure was 168/103 millimeters of mercury (mmHg). At 9:24 AM, the patient was assigned an acuity level of 3. The patient’s vital signs were reassessed at 12:16 PM, and the patient’s blood pressure was 185/113 mmHg. Review of the ED timeline failed to identify documentation that the provider was made aware of the increasing blood pressure. According to the ED timeline, the provider evaluated Patient #12 at 4:57 PM. During a clinical record and interview with the Clinical Coordinator and Manager #1 (ED assistant nurse manager) on 07/23/2025 at 11:54 AM, the Clinical Coordinator explained that a systolic blood pressure (the number on top in the blood pressure reading- indicates the pressure in the arteries when the heart beats and pumps blood out) at or above 180 mmHg would make the patient an acuity level of 2 (vital signs were to be reassessed at least every hour). She explained that upon obtaining the blood pressure of 185/113, the nurse should have spoken with the clinical coordinator, notified the provider of the blood pressure, or changed the patient’s acuity level so that the provider would have seen Patient #12 sooner. Neither the Clinical Coordinator nor Manager #1 could explain why none of these actions occurred. The hospital’s “Patient Assessment, Reassessment, and Plan of Care” policy (01/2023) directed, in part, for patients to be reassessed as necessary based on their changes in their condition, identified problems, or as clinically relevant. 5. During a tour of the Emergency Department (ED) with the ED Medical Director, Director #1 (ED Nursing Director), Manager #1 (Assistant ED Nurse Manager), and MD #3 (Associate Chairman of the ED) on 07/22/2025 at 10:00 AM, a medical supplies cart containing syringes with sharps was observed to be unlocked in the hallway outside of Room 8. Director #1 explained that the carts have an automatic locking feature that engages after a certain amount of time, though she could not specify the exact timeframe. Director #1 pressed the lock button, but the cart did not lock. The cart’s low battery indicator was not lit. Director #1 stated that the cart’s battery was dead, and she would have expected someone to notice the cart was not locking, place it in a secure location, and request that it be fixed. The Director immediately removed the syringes from the cart. During an interview with the Director of Accreditation and Regulatory Affairs on 07/23/2025 at 3:45 PM, she explained that while the hospital does not have a policy explicitly stating sharps are to be kept in a secure location, it is the expectation. 6. During a tour of the Emergency Department (ED) with the ED Medical Director, Director #1 (ED Nursing Director), Manager #1 (Assistant ED Nurse Manager), and MD #3 (Associate Chairman of the ED) on 07/22/2025 at 10:00 AM, a vital signs machine was observed in the hallway outside of Room 3. The screen on the machine identified a patient’s first and last name, their medical record number, and the patient’s recent vital signs. The ED Medical Director explained that vital sign machines have a time out feature that will lock the screen after a certain length of time to prevent patient information from being seen. He was unsure of the exact duration but indicated staff are expected to reasonably safeguard a patient’s protected health information from any intentional or unintentional access, use, or disclosure. The hospital’s “Safeguards for Protected Health Information (PHI)” policy (12/2024) directed staff to, in part, reasonably safeguard Protected Health Information (PHI) from intentional or unintentional access, use, or disclosure that violates state or federal laws or existing policies and procedures. Physical safeguards included, but were not limited to, using privacy screens or positioning computers out of general view to conceal PHI whenever possible. Electronic safeguards included, but were not limited to, locking computer workstations to prevent unauthorized access when not in use or when stepping away, and keeping all electronic devices in a secure location.”