HospitalInspections.org

Based on medical record review, document review and interview in one (1) of 27 medical records reviewed, it was determined the facility failed to maintain a central log on each patient who presents to the Emergency Department (ED). This was evident for Patient # 1

Findings include:

Review of the facility's main ED Log revealed Patient #1 was not documented on the log.

The surveyor requested assistance for locating the patient on the ED Log. Staff P, Assistant Director of Nursing Informatics and Super User, was unable to locate the patient in the ED log.

Review of Information Technology (IT) back door audit on the ED kiosk (electronic sign-in device) on patients arriving at the ED on 11/4/22, revealed Patient #1 completed a self-check-in on the kiosk at 6:57 PM. The self-check-in was deleted at 9:08 PM by Staff K, RN and ED Charge Nurse.


During interview on 1/6/23 at 11:31 AM, Staff H, Security Officer stated: " ...She (Patient #1) came in, filled out the patient kiosk. Didn't ask for any help. She sat down. Another lady came in and said she was pregnant. I got the Nurse, and the Nurse sent her upstairs. She (Patient #1) came to me (because she saw the other pregnant lady was sent upstairs). I got the Nurse. The Nurse spoke to her ..."

During telephone interview on 1/9/23 at 11:10 AM, Staff K, RN and ED Charge Nurse stated: " ...I went to the triage window. Saw a pregnant patient looking at me. I looked at Health-Bridge (a screen that shows patients who are registered and waiting), I did not see her in it. I went outside and asked her if she was seen. She said no. I asked her how far along she was, and she told me. I took her upstairs. I returned to the ED and removed the patient from the kiosk. Surveyor asked the reason for removal. Staff A said "If not triaged that would be a reason for me to remove. For example, if the patient left, I would go in and remove her. That's what we were doing until this weekend we were told not to continue."

Surveyor requested the policy on the ED Kiosk (also called IMPACT). Staffs M, Vice President and Chief Information Officer (CIO) of IT and Staff N, Assistant VP and Deputy CIO of IT, stated: "There is no written policy. The system is a sign in application."

Review of the facility document titled "Operational Electronic Sign-In" IMPACT dated May 9, 2022, states:

Workflow:
a. Patient (Pt) signs in at kiosk
b. Pt Access performs remote mini reg using WOW from cubicle using the patient's name, date of birth (DOB), and mother's maiden name obtained during IMPACT kiosk check-in
c. The Registrar clicks "mini-reg complete"
d. The Registrar prints the Pt's ID band
ID band can be printed from WOW
L. Wang confirmed forms -on-demand can be printed from WOW
e. Registrar applies ID band to Pt.
f. Nurse or Nurse Tech uses the kiosk-created worklist to escort the Pt into vital signs (VS) chair or Triage Room.
g. Based on availability in no order, the following are performed:
-VS by Nurse Tech
-Click on the "VS" box
-Nurse or Nurse Tech checks off "Pt visit initiated " on the IMPACT Worklist
-Triage by Nurse
-Click on the "Triage Complete"
-Nurse or Nurse Tech checks off "Pt visit initiated" on the IMPACT worklist.
MSE by LIP
Check on the "MSE complete" box.

The Triage Nurse will "monitor" the sign in list and click on the "complete" box to archive the Pt's name ....

h. When Triage is completed, Pt is assigned to Fast Track (FT) or Main.


At interview on 1/9/23 at 1:59 PM, Staff Q, Director of Nursing Emergency Department Stated: "The patient information crosses over to Health-Bridge (the medical record system) once the Registrar checks the patient in. The patient never got Step 1 (registration) ... so she wasn't viewable to anyone."

Registration was not completed for Patient #1, patient was not triaged and the patient's name was removed from the check in kiosk. Therefore, the patient's name did not get on the ED Log

This finding was shared with the Staff R, Director of Regulatory Affairs and Staff S, Assistant Director of Regulatory Affairs on 1/5/23 at approximately 2:00 PM, and Staff Q Director of Nursing for the ED on 1/9/23 at 1:59 PM.

Based on medical record review, document review and interview in one (1) of 27 medical records reviewed, the facility failed to ensure that a pregnant patient upon arrival to the Emergency Department (ED,) received triage and assessment. This was evident for Patient #1

Findings include:

Review of the Medical Record of Patient #1 revealed a 27-year-old pregnant female presented to the Labor and Delivery (L&D) Unit on 11/4/22 at 8:58 PM. Nursing Triage Note 8:58 PM indicated the patient walked-into the L&D with a chief complaint of lower abdominal cramping pain and headache that began the previous day.

The patient received a L&D provider assessment and treatment. She was diagnosed with a Urinary Tract Infection. She was discharged home at 2:01 AM on 11/4/22.

There was no documentation in the medical record of the patient receiving a nursing triage or provider assessment in the main Emergency Department.

Review of facility policy titled "Assessment of Patients (Reviewed 02/2022) states: "All patients presenting to the Emergency Department will have a medical screening exam completed by a medical provider within the Emergency Department."

Review of facility policy titled: "Obstetrics and Gynecology Screening Examinations, Reviewed 11/2021 states: "The Triage RN and the ED Attending Physician will conduct an initial assessment of all pregnant patients which includes assessing the gestational age and viability of the fetus, maternal vital signs, the presence or absence of labor, bleeding, or spontaneous rupture
of the membranes."

Review of IT (Information technology) audit for patients arriving in the Emergency Department on 11/4/2022, revealed Patient #1 self- checked into the main ED via the self-check-in kiosk at 6:57 PM.


Review of facility policy titled "Assessment of Patients (Reviewed 02/2022) states: "All patients presenting to the Emergency Department will have a medical screening exam completed by a medical provider within the Emergency Department."

Review of facility policy titled: "Obstetrics and Gynecology Screening Examinations, Reviewed 11/2021 states: "The Triage RN and the ED Attending Physician will conduct an initial assessment of all pregnant patients which includes assessing the gestational age and viability of the fetus, maternal vital signs, the presence or absence of labor, bleeding, or spontaneous rupture
of the membranes."

On 1/6/23 at 12:13 PM, an interview was conducted with Staff P, RN and ED Triage Nurse who was on duty on 11/4/22. Staff P. stated: "It was a long time ago. I really don't remember that patient specifically ...Surveyor asked Staff P to explain the electronic sign-in and the triage process. Staff P stated: "The steps are the patient fills out the kiosk. Sometimes a Registrar is outside to assist but due to staffing they are no longer there. The information pops up on my computer immediately. I focus on high risk patients first ...As soon as I find out they were pregnant I would expedite as quickly as possible if I knew everything that was going on with that person ..."

The registrar that was assigned on 11/4/22 was not available for interview. This employee resigned from the facility in December 2022.

At interview on 1/9/23 at 1:59 PM, Staff Q, Director of Nursing for the Emergency Department Stated: "The process is:
The patient enters their name, date of birth, mother's maiden name, phone number, pregnant or want a pregnancy test. Then the main topic screen will give a selection of complaints to choose from. For example, headache. The information populates to the IMPACT Screen seen by the Triage Nurse and Registrar. The Registrar gives the patient an ID band.
The Triage Nurse, or Tech or Doctor call the patient in. There is no specific order ...
Staff Q stated: The patient never got Step 1 (registration) ... so she wasn't viewable to anyone."
Staff Q acknowledged the patient did not receive a triage or provider assessment in the Emergency Department.

The finding was acknowledged by Staff R, Director of Regulatory Affairs on 1/6/23 at approximately 2:00 PM and Staff Q at interview on 1/9/23 at 1:59 PM.