HospitalInspections.org

Based on record review and interview the facility failed to ensure the completion and documentation of reassessments per facility policies in 7 of 20 (Patient #'s 1, 2, 8, 9, 12, 15 & 19) Emergency Department medical records reviewed in a total universe of 20 Emergency Department (ED) medical records reviewed.

Findings include:

The facility document titled "Triage in the Emergency Department" last reviewed 6/30/2017 # D17.063 was reviewed on 1/21/2020. This document revealed "B. All patients will be initially assessed by a Registered Nurse (RN) using the Five Level ESI system and triaged to an appropriate treatment area...1. The RN will use the Five Level Emergency Severity Index triage systems (ESI) and follow these guidelines to appropriately triage patients in the ED. ESI 2: High risk situation/confused, lethargic, disoriented, severe pain or distress. ESI 3: Requires two or more resources. 1. "Reassessment" includes vital signs, documentation of pain rating, and Airway, Breathing, Circulation, Disability. 2. Reassessment will be completed on all patients waiting in the lobby at 2 hour intervals (ESI 3-4-5). All ESI 2's will be reassessed within 30 minutes until placed in an ED exam room."

Patient #1's medical record was reviewed on 1/21/2020. Patient #1 went to the Emergency Department on 1/2/2020 with level 10 (out of 10) chest pain was triaged at an "ESI" 3. Vital signs were completed at 5:02 PM in triage and the next reassessment was completed again at 7:29 PM (two and a half hours later). ESI #3 patient reassessment vitals per facility policy are to be completed every 2 hours.

Patient #2's medical record was reviewed on 1/21/2020. Patient #2 went to the ED on 12/13/2019 with a chief complaint of a cough and was triaged at an "ESI" 3. Vital signs were completed at 12:38 PM in triage and the next reassessment was completed again at 3:00 PM (two and a half hours later). ESI #3 patient reassessment vitals per facility policy are to be completed every 2 hours.

Patient #8's medical record was reviewed on 1/21/2020. Patient #8 went to the ED on 12/10/2019 with suicidal ideations and having ingested Oxycodone and excessive amounts of alcohol in suicide attempt and was triaged at an "ESI" 2. Vital signs were completed at 9:09 PM in triage and the next reassessment was completed again at 2:35 AM on 12/11/2019 (five hours later). ESI #2 patient reassessment vitals per facility policy are to be completed every 30 minutes.

Patient #9's medical record was reviewed on 1/21/2020. Patient #9 went to the ED on 12/3/2019 for complaints of shortness of breath and was triaged at an "ESI" 2. Vital signs were completed at 6:31 PM in triage and the next reassessment was completed again at 9:30 PM (three hours later). ESI #2 patient reassessment vitals per facility policy are to be completed every 30 minutes. The next reassessment was completed again at 10:30 PM (one hour later). ESI #2 patient reassessment vitals per facility policy are to be completed every 30 minutes.

Patient #12's medical record was reviewed on 1/21/2020. Patient #12 went to the ED on 1/2/2020 for complaints of 4 days of vomiting and was triaged at an "ESI" 3. Vital signs were completed at 7:08 PM in triage and the next reassessment was completed again at 9:35 PM (two and a half hours later). ESI #3 patient reassessment vitals per facility policy are to be completed every two hours.

Patient #15's medical record was reviewed on 1/21/2020. Patient #15 went to the ED on 12/27/2019 with a witnessed syncopal event and was triaged at an "ESI" 2. Patient #15 had reassessment vitals completed at 12:53 PM and the next reassessment was completed at 1:50 PM (one hour later). ESI #2 patient reassessment vitals per facility policy are to be completed every 30 minutes.

Patient #19's medical record was reviewed on 1/21/2020. Patient #19 went to the ED on 1/2/2020 with a chief complaint of chest pain and was triaged at an "ESI" 2. Patient #9 had vital signs completed in triage at 4:24 PM and was documented at 6:32 PM as having left without being seen by physician. There was no documented reassessment from 4:24 PM until patient was documented as having left at 6:32 PM. ESI #2 patient reassessment vitals per facility policy are to be completed every 30 minutes.

An interview was conducted with Emergency Department Nurse Manager A on 1/21/2020 at 2:45 PM in regards to the above found chart reviews of missing documentation who stated "Yeah they are late according to policy."

Based on record review and interview the facility failed to ensure the appropriate forms were completed and documented for patients leaving the department against medical advice (AMA)in 1 of 20 (Patient #10) Emergency Department (ED) medical records reviewed in a total universe of 20 Emergency Department medical records reviewed.

Findings include:

The facility document titled "Discharge Against Medical Advice" last reviewed 3/11/2019 # CPM.0098 was reviewed on 1/21/2020. This document revealed "1. If a patient discharges him or herself against the advice of physicians, the nurse or physician attempts to have a patient sign the form, "Discharge Against Medical Advice". 2. The RN [Regisetered Nurse] and/or physician document the attempt for signature in the progress note. This documentation must include the risks and alternatives that were presented to the patient and the patient's understanding of those risks and alternatives and reason why patient is leaving (AMA). 3. If the patient refuses to sign the Discharge Against Medical Advice form, the RN and/or physician documents the patient refusal in a progress note. 4. The RN or physician places a signed copy of the form in the patient's medical record."

Patient #10's medical record was reviewed on 1/21/2020. Patient #10 went to the ED on 12/6/2019 for complaints of weakness and was triaged at an "ESI (Emergency Severity Index)" 3. Patient #10 was seen by a physician and had lab drawn. Hemoglobin (blood cell that transports oxygen in the body) resulted at 4.4 (normal range is 13.7-17.5). The physician ordered for the patient to receive a blood transfusion to increase hemoglobin level. Patient #10 signed the consent to receive blood products but refused to let the administration start. At 6:57 PM nursing notes documented " Patient requesting to leave AMA. Health risks discussed with patient prior to elopement from department. Expresses understanding. Patient encourage to return for treatment as soon as possible. Patient ambulated out of department with steady gait. No discharge instructions provided due to patient leaving prior to completion of cares." There was no documented "AMA" form on Patient #10's medical record for this visit.

An interview was conducted with Emergency Department Nurse Manager A on 1/21/2020 at 2:50 PM about the above found chart reviews of missing documentation who stated "We don't have to try to get a signature." Quality and Patient Safety Director H stated "Yes it is in our policy that you have to try to get a signature and if they refuse that needs to be documented in the medical record also."