HospitalInspections.org

Based on review of facility policy, review of facility Standard Work documents, review of an Emergency Medical Services (EMS) record, medical record review and interviews, the facility failed to provide a timely assessment for 1 patient (#14) who presented to the Emergency Department (ED) related to an Altered Mental Status of 24 ED records reviewed.

The findings include:

Review of facility policy "Emergency Triage", last revised 2/2022, showed "...a triage nurse is responsible for providing a timely triage to all patients to the Emergency Department. Each patient is assigned a triage classification based on the Emergency Severity Index. The Emergency Severity Index is a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs..."

Review of a Standard Work document (no date) showed "...patients not meeting immediate offload criteria will be evaluated by a Registered Nurse [RN] or Paramedic for triage, offload zone [OZ] or immediate bedding...If maintained by hospital staff these patients should be protocoled and given a room as soon as feasible while not impacting the movement of critical patient..."

Review of a Standard Work document (no date) showed "...Triage 1: Also known as "quick look" to staff. Includes vital signs, presenting complaint, comment section if needed, and a tracking acuity-this acuity can be changed during triage 2 and is a first impression only. Triage 1 is completed by nurse or medic. Triage 2: Triage part 2 is the "full triage" and includes more details about visit. This can be done after triage 1 or stand alone...a patient acuity is assigned or verified from part 1, and allergies are confirmed. Acuity can be changed during triage 2 and is a first impression only..."

Review of an EMS Patient Care Record dated 8/26/2024, showed Patient #14 was transported from home. The patient arrived at the facility's ED at 12:56 AM. The patient was transferred from the EMS stretcher to the ED bed at 4:30 AM (3 hours and 34 minutes after arrival). The report showed "...extended wait for bed placement, approximately 3.5 hrs [hours], during which time crew contacts supervisor, assistant director, ED Team Leader, and paramedic controlling bed placement with requests for bed placement repeatedly. Crew is informed they do not have any bed no prospects for crew to receive one repeatedly. During this time, no attempt is made by nursing staff or physician to assess, triage, or obtain vitals on patient..."

There was no documentation of vital signs, an assessment, or Triage 1 for 8/27/2024, from the arrival time, 12:55 AM until 4:22 AM.

Medical record review of an ED Nursing Triage Part 2 record dated 8/27/2024 at 4:22 AM (3 hours and 26 minutes after arrival in the ED by EMS) recorded Patient #14's vital signs were as follows: BP 100/67, Pulse 81, Respirations 16, Temperature 96.0° (degrees) Fahrenheit, and Pulse Oximetry 100% on room air. The patient was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent/urgent needs.

Medical record review of an ED Provider Record dated 8/27/2024 at 5:11 AM, showed Patient #14 presented with Altered Mental Status (AMS). The patient was found to be hypotensive with a BP of 90/67 and he was given IV fluids and steroids. Diagnostic testing showed a Sodium level of 109 (normal 135-145) and labs showed concerns related to acute renal insufficiency due to a Potassium of 5.9 (normal 3.5-4.5) and elevated liver function test. The Computed Tomography (CT) of the head showed persistent metastatic disease to the brain with a decrease of vasogenic edema. The Hospitalist services were contacted for admission.

Medical record review of an Admission History and Physical dated 8/27/2024 at 9:26 AM, showed Patient #14 was admitted with diagnoses including Acute Encephalopathy (likely metabolic), Severe Hyponatremia, Metastatic Adenocarcinoma of the Lung, Brain Metastasis s/p radiation, Adrenal Metastasis, Acute Renal Failure, Hypertension, and Hyperkalemia.

Medical record review of the Discharge Summary dated 8/30/2024 at 11:06 AM, showed the patient continued to have decline and expired on 8/30/2024.

During an interview on 10/2/2024 at 11:00 AM, Paramedic #1 stated on arrival in the ED, the Paramedic or nurse would document a Triage 1 assessment of the patient indicating the patient's complaint, the vital signs, and a brief assessment of the patient. The ED Paramedic or nurse would make the decision where the patient would be moved.

During an interview on 10/3/2024 at 10:15 AM, ED Nurse Manager #1, stated the facility had an EMS surge policy and ED Standard Work for patients who presented to the ED for treatment. The ED Nurse Manager confirmed there was no triage 1 documented for Patient #14 and nursing triage Part 2 was completed on 8/27/2024 at 4:22 AM for the patient (3 hours and 26 minutes after arrival in the ED by EMS).

During an interview on 10/3/2024 at 2:50 PM, the Director of Environment and Health Services and Emergency Management, stated the facility had an Emergency Surge policy which was incorporated into the Emergency Preparedness Plan. The Emergency Plan was not activated on 8/27/2024.

During a telephone interview on 10/3/2024 at 7:10 PM, Paramedic #2 stated when EMS arrived with a patient, she would obtain the patient's vital signs and document in the Triage Part 1 of the medical record. She confirmed there were no vital signs or an assessment documented in the medical record upon Patient #14's arrival in the ED.

During a telephone interview on 10/4/2024 at 7:15 PM, RN #1 stated the patient arrived by EMS and the ED was extremely busy on 8/27/2024. The patient was held in the trauma bay with the EMS provider in attendance. The EMS provider had informed the nurse they had waited for 2-3 hours for a bed. RN #1 had completed the Triage Part 2 on 8/27/2024 at 4:22 AM for Patient #14, but the Part 1 had not been completed. She confirmed Part 1 was to be performed at the EMS entrance area.

During a telephone interview on 10/4/2024 at 7:40 AM, EMS Paramedic #3 stated the ED staff did not triage the patient or get any vital signs on the patient when they arrived in the ED. She waited with the patient for 3.5 hours and the patient was not evaluated by a nurse or a physician.

During a telephone interview on 10/4/2024 at 7:50 AM, the ED Medical Director stated all EMS patients are to be evaluated by the Paramedic in the EMS entrance bay and offloaded based on the assessment. This evaluation included a quick assessment and vital signs.