HospitalInspections.org

Based on a review of documents and staff interviews with facility staff, they failed to ensure staff followed policies and procedures for medical care in the emergency room when staff failed to monitor and retake vitals for 1 of 20 patient reviewed (Patient #1) with an emergency acuity level 3, which applies to "conditions that could potentially progress to a serious problem requiring emergency intervention." To arrive at an emergency acuity level, the patient's vital signs are taken to include: temperature, heart rate (HR) / pulse, blood pressure (BP), respiratory rate (RR), oxygen saturation (O2 sat), pain scale score or the absence of pain as applicable; and Glasgow Coma Scale (GCS). GCS is an assessment tool that healthcare providers use to measure decreases in consciousness.

The findings were:

A review of the medical record for Patient # 1 revealed he was a 56-year-old male who arrived at the facility on 08/10/20224 at 1:32 AM. The patient's chief complaint was severe pain in the right ribs. The patient was triaged at 1:47 AM with an increased blood pressure of 172/104 and an elevated pulse of 104 beats per minute. Also, Patient # 1 reported a pain level of 10 with right upper quadrant pain; he states it hurts to breathe, and he cannot lie down or sit down. The patient remained in the waiting room standing (due to pain). The patient's past medical history was noted as unknown. The patient's acuity level was 3-urgent. Per policy, "reassessment of vitals and written documentation is to occur every 120 -180 minutes or more frequently based on clinical judgment." The Patient's total time in the ER was 185 minutes. The patient left without being seen. The ER central log revealed that 20 patients were in the ER while Patient # 1 was waiting.

A review of the document titled "Vital Signs" by Staff # 2, Emergency Medical Technician (EMT) on 08/10/2024 at 1:32 AM revealed the following:
"Temperature Fahrenheit: 97.7
Peripheral Pulse Rate:102
Respiratory Rate: 20
SpO2: 98%
Systolic Blood Pressure:172
Diastolic Blood Pressure: 104
Oxygen Therapy: Room air"

A review of the document titled "Triage" by Staff # 1, RN-ED, on 08/10/2024 at 1:47 AM revealed the following:
... "ESI
ls This Patient Dying?: No
Does This Patient Need Immediate Treatment?: No
How Many Resources Will This Patient Need?: Many
What are the Patient's Vital Signs?: Does not meet defined danger zone limits
Triage Acuity Level: 3-Urgent
Recommended ESI Level: 3."

A review of the document titled " Patient Summary ED" by Staff # 5, RN-ED, on 08/10/2024 at 4:37 AM revealed the above time and date for providing the patient discharge summary.

A review of the policy titled "ED-700.84, Vital Signs, Acuity Levels & Triage
Emergency Severity Index (ESI) in the Emergency Department": revealed the following: page 3: Appendix A: Frequency of Post Triage Reassessment and/or Vital Signs
" ESI 3- Reassessment of vitals and written documentation is to occur every
120 -180 minutes or more frequently based on clinical judgment."

An interview with Staff # 1, RN-ED on 09/18/2024 at approximately 7:30 AM revealed the following:
"I remember the patient from triage. It seemed odd that he stood behind the chair out of my eyesight. He reported right lower rib pain." I was talking to him, and he denied trauma and said it felt like he pulled a muscle. He added he took an Excedrin and a muscle relaxer but didn't remember the muscle relaxer's name. He was alert and oriented. This was at about 1:45 AM, and we were about to lose a mid-level. The ER was very busy. He said his pain was at a level 10. I did not provide any pain medication as he was in the waiting room and couldn't be monitored.