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Based on record review, policy review, and staff interview it was determined the facility failed to ensure a registered nurse evaluated the care for each patient upon admission and when appropriate on an on-going basis in accordance with accepted standards of nursing practice and hospital policy for two (#3 & #7) of seven sampled records.

Findings included:

According to the facility policy titled Plan of Care for Emergency Department, effective 04/2004 and reviewed 12/2014, all patients in the emergency department will be assessed based on the patient's complaint and/or signs and symptoms and assigned a severity level. The system used for the assignment of the severity level is the Emergency Nurse Association 5-tiered Emergency Severity Injury (ESI) Triage System. The following vital sign and nursing assessment/reassessment time frames are established based on the ESI
Vitals:
ESI Level 1: Every 15 minutes until stable and revaluate change acuity level if indicated
ESI Level 2: Every 20 minutes for the first hours and then every hour
ESI Level 3: Every 3-4 hours
ESI Level 4: Every 4-5 hours
ESI Level 5: Upon discharge
Assessments/reassessments:
ESI Level 1 & 2: Every 2 hours a focused assessment is to be documented
ESI Level 3 & 4: Every 3-4 hours a focused assessment is to be documented
ESI Level 5: Within 30 minutes of the patient being discharged

A review of the facility form titled AVS report within the medical record of Patient #7, revealed that the patient came to the facility emergency department as a walk-in on 06/19/18 at 4:44 p.m. at the advice of her personal physician for abnormal laboratory values. Patient #7 was triaged at 4:47 p.m. with vital signs and a nursing assessment being completed at that time. This patient was determine to be an ESI Level 2 patient. The patient was placed in a "quiet room" on 09/19/18 at 5:31 pm., while awaiting the ED physician.

At 6:30 p.m., the next set of vital signs for Patient #7 were checked and documented in the medical record by the emergency patient care technician (PCT). Patient #7 left the facility at 6:59 p.m., 4.25 hours after arriving, without being seen at all by a physician and not being seen or assessed again by nursing. On 06/19/18 at 7:36 p.m., the assigned registered nurse entered a note in the medical record of Patient #7 stating the PCT informed the nurse that the patient could not wait any longer and left at 6:59 p.m.

After reviewing the medical record of Patient #7, the manager of ED confirmed, during an interview on 09/20/18 at 12:15 p.m., that this patient was made a Level 2 because the patient had a history of kidney transplant and due to reports from the patient that the patient had abnormal laboratory results according to the patient's physician. The manager confirmed that the Level 2 assignment was correct.

The facility failed to reassess Patient #7 according to facility policy Plan of Care for Emergency Department. The condition of Patient #7 at discharge was not documented. This was confirmed with the manager of the Emergency Department.

A review of the facility form titled AVS report within the medical record of Patient #3 revealed that the patient came to the facility emergency department as a walk-in on 04/12/18 at 4:35 p.m. for complaints of joint pain. The medical record of Patient # 3 included a history of Sickle Cell Anemia. At 4:40 p.m., Patient #3's vital signs were taken and at 5:03 p.m., the patient was triaged and a nursing assessment was completed. This patient was determine to be an ESI Level 2 patient. The patient was placed in a waiting area at 5:06 pm., while awaiting an ED room and physician exam.

The assigned registered nurse entered a note in the medical record of Patient #3 stating the patient left without being seen on 04/12/18 at 9:40 p.m., 5 hours after the first and only set of vital signs were obtained.

There is no further documentation in the medical record that Patient #3 was ever seen by a physician or by nursing staff again.

The facility failed to reassess Patient #3 according to facility policy. The condition of Patient #3 at discharge was not documented. This was confirmed with the Risk Management Specialist.