HospitalInspections.org

Based on review of documents and staff interview, the facility failed to ensure the policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff when policy and procedure for reassessment and documentation of vital signs for 1 of 12 patients reviewed (Patient #1) were not implemented for patients in the waiting room, placing patients at risk of indicators of current health condition, assessment of interventions, and abnormal vital signs not being monitored or observed.

Findings include:

Review of policy, "Vital Signs - Assessing of - Emergency," effective 9/28/22, documented in part: " ... Patients who present to the Emergency department will be provided an appropriate initial assessment by qualified personnel, as defined by Triaging Adult and Pediatric Patients in the Emergency Departments Using the Emergency Severity Index (ESI) ...
Key Points
1. Vital signs are indicators of the patient's current condition and must be evaluated in the context of the patient's overall health with serial measurements used to detect trends and to assess the effectiveness of interventions.
2. This policy and the requirements for vital sign assessment / reassessment applies to all registered ED patients regardless of location (i.e., waiting room) ...
Procedure
Vital Signs - Patients in Treatment / Waiting Room
... 2. ESI Level 2 or 3 patients with any vital signs in the "Danger Zone" ... will have heart rate, respiratory rate, and blood pressure documented every 1 hour or more frequently per nursing judgement until stabilized. When vital signs are no longer in the "Danger Zone" or the patient has stabilized, vital signs will be documented at a minimum, every 4 hours ... 3. Patients at ESI level 3, 4, or 5 with signs in the normal range will have vital signs documented at least every 4 hours ..."

In an interview on the afternoon of 2/6/25, in a facility conference room, in conjunction with a review of patient #1's electronic medical record, Staff #1 (ED Director) reported: On 1/25/2025, Patient #1 registered in emergency department. Ten minutes later, Patient #1 was assessed by the triage nurse for vaginal bleeding; vital signs were measured. Patient #1 was Acuity 3 (ESI Acuity System) generally means vitals stable, able to wait if managing multiple patients; lab and interventions based on complaint and vital signs. Triage nurse makes determination of acuity level. 'Quick Look' nurse staffed 24/7, sees patient immediately. 'Quick Look' nurse sits with registrar. 'Quick Look' nurse takes a quick pulse ox, translator line available, if needed. Charge Nurse takes lead. "Quick Look" nurse/ tech / Triage nurse priority to reassess vital signs for patients in waiting room."

In further interview on the afternoon of 2/7/25, in a facility conference room, Staff #1 (ED Director), confirmed patient #1's vital signs were not reassessed every 4 hours, as required for acuity level "3" patients by the Emergency Severity Index (ESI) policy. staff #1 (ED Director). reported facility identifed concern that patient #1 was not revitalized (vital signs were not reassessed). Discused case in meeting with ED leaders. Identifed need for education, especially because the hold situation would result in more patient waiting in the waiting room. Follow up conversation with Staff #5 to explain Staff #5 has to be able to escalate in the moment and address with charge nurse to prevent tasks not being completed.