HospitalInspections.org

Based on document review, observation and interview it was revealed the staff in the Emergency Department (ED) failed to follow their triage policy daily. This has the potential to negatively impact any patient presenting to the ED for emergency care.

Findings include:

1. A policy was reviewed titled "Triage Policy," last review date 08/20. The policy states in part: "Policy: ...One Registered Nurse on each shift in the ECC (Emergency Care Center) will be designated as the "triage" nurse. The primary responsibility of the Triage Nurse will be the timely triage of all patients who present to the ECC seeking treatment ..."

2. A policy was reviewed titled "Assessment Policy," last review date 08/20. The policy states in part: "Procedure: A triage assessment will be performed by the Registered Nurse upon arrival to the department ..."

3. The ED staffing schedule was reviewed for 07/19/21 through 08/15/21. No designation was made as to which staff was Charge Nurse or Triage Nurse.

4. An observation was conducted in the ED on 08/31/21 at 10:22 a.m. There were two (2) RNs, one (1) ED technician, and one (1) Patient Access Clerk. No assignments were listed. The Director of Emergency Services, Trauma and ICU stated, "Most of the time the staff just takes whatever. The Charge Nurse is in charge, and nurses will take turns and rotate who does triage."

5. A telephone interview was conducted with the Charge Nurse from the ED on 08/30/21 at 2:50 p.m. Regarding staffing, the Charge Nurse stated, "There is no designated Triage Nurse, everyone just does everything they can to help."

6. An interview was conducted with the Director of Emergency Services, Trauma, and ICU on 08/31/21 at 11:45 a.m. The Director stated, "The ED Charge Nurse is in charge of triage or assigning someone to triage." The Director concurred the Triage Nurse does not always get assigned.