HospitalInspections.org

Based on record review and staff interview, in three (3) of six (6) Medical Records, there was no documented evidence that the Emergency Room staff monitored patients who left after Triage prior to completing a Medical Screening Evaluation.

This lack of reassessment could result in change in patient's condition not being identified and treated.

Findings:

The facility's Policy and Procedure titled "Emergency Department Triage", last reviewed on 10/28/16, stated the following in "Section VI. Left Without Being Seen: all patient presenting for medical or psychiatric care ... will undergo a medical screening examination ... it will be determined that the patient left without being seen when they are called three times for placement ... into a clinical evaluation space and ... noted in the Emergency Department MR ... no response." Additionally, the policy noted in "Section IX. Reassessment of Patients: (a.) Waiting Room: If the patient has an extended wait time they will be reassessed at a minimum of every 1 hour."

Review of Patient #13's medical record identified that the patient presented on 05/01/17 at 7:28 PM, with a chief complaint of right side rib pain that is worse with deep breathing and movement and was triaged with an ESI (Emergency Severity Index) Level 4. The nurse's notes documented that the patient was called and not found at 11:06 PM and 12:06 AM prior to the Medical Screening Evaluation, but there was no documented evidence of any monitoring of the patient over the three and one-half (3½) hour period as required by facility policy.

Review of Patient #24's medical record identified that the patient presented on 05/04/17 at 5:46 PM, with a chief complaint of a seatbelt abrasion and shoulder pain after being in a motor vehicle accident and was triaged with an ESI Level 4. The nurse's notes documented that the patient left at 8:15 PM, prior to the Medical Screening Evaluation stating "he was leaving because he is fine", but there was no documented monitoring of the patient over the two and one-half (2½) hour period.

The same lack of documention regarding the lack of monitoring was found in the medical record for Patient #23.

These findings were confirmed by Staff Members B and F, during review of the medical records in the afternoon on 05/25/17.