HospitalInspections.org

Based on review of medical records (MR), staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1.) individuals who present to the Emergency Department (ED) are triaged to receive immediate and appropriate assessment and identify any life-threatening conditions, in accordance with facility policy in three of 10 medical records reviewed (MR1, MR6, and MR10) [A-1104]; 2.) patients in the ED waiting area are reassessed for a change in condition and that reassessments are documented in accordance with facility policy in two of 10 medical records reviewed (MR1 and MR6) [A-1104]; and 3.) an appropriate medical screening evaluation to identify whether an Emergency Medical Condition exists in two of 20 medical records reviewed (MR1 and MR4).

Cross Reference:
482.55(a)(3) Emergency Services: Emergency Services Policies

Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) individuals who present to the Emergency Department (ED) are triaged to receive immediate and appropriate assessment and identify any life-threatening conditions, in accordance with facility policy in three of 10 medical records reviewed (MR1, MR6, and MR10); 2.) patients in the ED waiting area are reassessed for a change in condition and that reassessments are documented in accordance with facility policy in two of 10 medical records reviewed (MR1 and MR6); and 3.) an appropriate medical screening evaluation to identify whether an Emergency Medical Condition exists in two of 20 medical records reviewed (MR1 and MR4).

Findings include:

1.) Policy titled, "ED Triage" (Effective August 2010) stated, " ...PURPOSE: The purpose of triage is to: Provide immediate and appropriate assessment and intervention to all patients in the Emergency Department; Rapidly identify patients with life threatening conditions and to determine the most appropriate treatment area for patients presenting to the department; Oversee the activity of the waiting area in times of high volume; ...Constantly reassess patients as waiting times increase. ...This change in acuity must be reflected in the EDIMS documentation progress note. ... PROCEDURE: All patients arriving to the ED through the walk in area will be seen by the Greeter Nurse. The Greeter Nurse obtains basic information about the patient as well as the reason for their visit. ID band is placed on patient and Greeter Nurse will: ... At times of high volume, patients are called into triage area based on complaint and history as Greeter Nurse. ... Triage Acuities: ... Level 2: Patients presenting problems require rapid evaluation and either stabilization or treatment which is related to critical time factor and are hemodynamically unstable. This includes but is not limited to chest pain, stroke, ...acute pain, ...neurological deficits ...Level 2 patients are high risk and require rapid intervention and evaluation. Failure to act can potentially result in the loss of life, limb, or organ. Level 3: ... require diagnostic evaluation and treatment in the ED. VS (vital signs) are stable and condition is not likely to deteriorate or require time sensitive treatment. These patients present with but are not limited to moderate pain ... Level 3 patients require multiple resources to determine illness. ... Special triage considerations: ... 3. Presumed cardiac chest pain patients are to have an EKG (electrocardiogram) done upon arrival and read by an MD. Any unstable patient is to be brought directly to a bed. ..."

On 02/10/25 at 10:25 AM, during a tour of the Emergency Department (ED), an interview was conducted with Staff (S)5. When questioned on the process for patients who arrive complaining of chest pain, S5 stated that the patient's symptoms are assessed, a cardiac alert is announced, and the patient is taken to a room where an EKG (electrocardiogram) is performed and given to a provider for evaluation. During the interview, S5 stated, "I don't triage patients, they are triaged at the bedside."

At 10:59 AM, during an interview, S7 stated, "A patient with chest pain is taken to a room for an EKG (electrocardiogram) and it should be read by a provider within 10 minutes and a cardiac alert is announced overhead." This was confirmed by S8 at 11:05 AM.

On 02/10/25 at 12:55 PM, during an interview with S4, [he/she] explained that individuals that arrive to the ED are met by an "ED Greeter Nurse" who obtains the chief complaint and determines if the individual needs to be seen immediately by the Triage Nurse for Direct Bedding. S4 confirmed that the ED Greeter Nurse does not complete the patient's ESI or enters any documentation in the patient's electronic medical record (EMR.) During times of ED surge [a high volume of people arriving to the ED], S4 confirmed that the Triage nurse is responsible for assessing the patient's acuity and documenting the patient's ESI in the patient's electronic medical record (EMR) at the time it's completed.

Review of medical record (MR)1 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 2:49 AM, with chief complaint of "CP" (Chest Pain). An EKG was completed at 3:24 AM and read by a medical provider at 7:54 AM, five hours and five minutes after the patient's arrival to the ED. The medical record lacked documentation that the patient's vital signs and pain were assessed at the time of the patient's arrival despite the patient's complaint of chest pain. Patient (P)1 was moved into a room in the ED at 6:44 AM. The patient was triaged by a Registered Nurse (RN) at 7:03 AM and was assigned an ESI level of three. The medical record indicated that the patient's triage was completed four hours and 14 minutes after P1's arrival to the ED. A Medical Screening Exam (MSE) was completed by a provider at 7:09 AM.

Review of MR6 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 3:05 AM, with complaint of abdominal pain and vomiting. The patient was moved into a room in the ED at 6:44 AM and was evaluated by a provider at 6:55 AM. The medical record lacked documentation that the patient's vital signs and pain level were assessed at the time of the patient's arrival. The triage was completed by a RN at 7:07 AM, four hours and two minutes after the patient's arrival to the ED, the patient was assigned and ESI level of three.

Review of MR10 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 4:54 AM, with a chief complaint of chest pain, shortness of breath, and productive cough. An EKG was completed at 5:02 AM. Vital signs were completed at 5:27 AM as follows: Blood Pressure: 169/103, Heart Rate: 97 BPM (beats per minute), Temperature: 98.9, Oxygen Saturation: 98%. The medical record lacked evidence that the patient's pain was assessed at the time of the patient's arrival despite the patient's complaint of chest pain. P10 was moved into a room in the ED at 6:44 AM and evaluated by a provider at 6:55 AM. The patient was triaged at 7:21 AM and assigned an ESI level of two. The patient's vital signs at the time of triage were as follows: Blood Pressure: 179/112, Heart Rate: 97, Respiratory Rate: 30, Oxygen saturation: 93%. A pain assessment was completed at 7:49 AM, and the patient reported pain rated 10 out of 10.

On 2/10/25 at 2:25 PM, S4 confirmed that the patients' ESI were not completed at the time of patient arrival to rule out life threatening emergency, in accordance with facility policy and procedures.

2.) Policy titled, "Initial and Subsequent Nursing Assessments in Patient Care Settings" (Effective 2/18/22) stated, "...1. Purpose Statement: Assessing and reassessing provides the foundation to determine the appropriate care, treatment, and services to meet the patient's changing needs ... 3. Procedure: ... Nursing/Emergency Department ... Initial Assessment-Upon Arrival; Re-Assessment-Based on Triage Category; as clinically indicated ..."

Policy titled, "ED Triage" (Effective August 2010) stated, " ... Oversee the activity of the waiting area in times of high volume; ...Constantly reassess patients as waiting times increase. ...This change in acuity must be reflected in the EDIMS documentation progress note. ..."

On 2/10/25 at 12:55 PM, upon interview, S4 stated, " ...when a patient arrives to the ED, a Greeter Nurse meets with the patient and gets their chief complaint. The Greeter Nurse is responsible for the patient flow and determines whether the patient can wait or needs to go directly to the Triage Nurse to be assessed. If there is a Cardiac Alert, there is an overhead page." During the interview, S4 stated that patients seated in the waiting room are monitored by the Triage Nurse or "PIT" (Provider in Triage) and are reassessed every 30 minutes. S4 confirmed that the Triage Nurse is responsible for documenting each reassessment in the patient's medical record.

During times of ED surge [a high volume of people arriving to the ED], S4 confirmed that the Triage nurse is responsible for reassessing patients every 30 minutes to determine if there has been any change in condition while the patient is in the waiting room. S4 explained that the average wait time in the ED is "usually under an hour" and confirmed that there was a 'Surge' overnight on 01/03/25. S4 reported that the average number of patients in 24 hours in the ED is 270, and on 01/03/25, 330 patients came to the ED.

Review of medical record (MR)1 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 2:49 AM with chief complaint of "CP" (Chest Pain). An EKG (electrocardiogram) was completed at 3:24 AM and read by a medical provider at 7:54 AM, five hours and five minutes after the patient's arrival to the ED. The medical record lacked documentation that the patient's vital signs and pain were assessed at the time of the patient's arrival. Patient (P)1 was moved into a room in the ED at 6:44 AM. The patient was triaged by a Registered Nurse (RN) at 7:03 AM and assigned an ESI level of three (3). The medical record indicated that the patient's Triage was completed four hours and 14 minutes after P1's arrival to the ED and lacked documentation that [his/her] condition was reassessed by the Triage Nurse between 3:30 AM and 6:30 AM, while the patient was in the waiting room.

Review of MR6 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 3:05 AM with complaint of abdominal pain and vomiting. The patient was moved into a room in the ED at 6:44 AM and was evaluated by a provider at 6:55 AM. The medical record lacked documentation that the patient's vital signs and pain level were assessed at the time of the patient's arrival. The patient was triaged by a RN at 7:07 AM, four hours and two minutes after the patient's arrival to the ED and lacked documentation that [his/her] condition was reassessed by the Triage Nurse between 3:35 AM and 6:35 AM, while the patient was in the waiting room.

On 2/10/25 at 2:35 PM, S4 and S11 confirmed the above findings.

3.) Policy titled, "Transfer of Patient, Acute (E.M.T.A.L.A.) (Last reviewed 9/27/2017) stated, " ... Definitions: ... Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ...) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual ( ...) in serious jeopardy ... Triage: Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel. ... Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist ... PROCEDURE: 1. Medical Screening Examination: The hospital must provide an appropriate Medical Screening Examination within the capability of its ED (Emergency Department), including ancillary services routinely available at the hospital, to determine whether an emergency medical condition exists ... ."

Review of medical record MR1 on 2/10/25, revealed the following:

The patient arrived at the ED on 1/03/25 at 2:49 AM, with chief complaint of "CP" (Chest Pain). An EKG (electrocardiogram) was completed at 3:24 AM. The medical record lacked evidence that vital signs and pain level were assessed at the time of the patient's arrival. The medical record indicated that the EKG was read by a medical provider at 7:54 AM, five hours and five minutes after the patient's arrival to the ED. The patient was moved from the waiting room to room MED048 at 6:44 AM. The medical record lacked evidence that the patient's condition was reassessed for the three hours and 20 minutes the patient was in the waiting room from 3:24 AM until 6:44 AM. The Patient Care Timeline indicated that at 6:49 AM the First Provider Evaluation was completed. The MR lacked documentation of the provider's evaluation. Triage was completed at 7:03 AM and the patient was assigned an ESI level of three. Triage was completed four hours and 14 minutes after the patient's arrival to the ED. A Medical Screening Exam (MSE) was marked completed at 7:09 AM, however the medical record lacked documentation of the provider's assessment of the patient's emergency medical condition. At 9:52 AM, P1 was discharged. The medical record lacked documentation of the patient's condition upon discharge.

A review of MR4 on 2/10/25, revealed the following:

The patient arrived at the ED on 1/3/2025 at 2:04 AM, with chief complaint of "Left arm weakness" that began at 2:00 AM. An EKG was completed at 2:50 AM. The medical record lacked evidence that vital signs were assessed at the time of the patient's arrival. Triage was completed at 4:46 AM and the patient was assigned an ESI level of three. Triage was completed two hours and forty-two minutes after the patient's arrival to the ED with [his/her] chief complaint of left arm weakness. The medical record lacked evidence that the patient's condition was reassessed while the patient was in the waiting room from 2:04 AM to 4:42 AM. The patient was moved from the waiting room to room MED014 at 6:44 AM. The MR indicated that an MSE was completed at 6:52 AM, however the medical record lacked documentation of the provider's assessment of the patient's emergency medical condition.

The above findings were confirmed by S7 on 02/10/25 at 2:25 PM.