HospitalInspections.org

Based on a review of facility documentation and video and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that hospital policies and procedures were adhered to in the Emergency Department for ten of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR8, MR9, MR10, MR13, MR14, and MR18).



Findings include:


On April 22, 2024, a review of the facility policy Patient Assessment in the Emergency Department revealed, "Policy Detail: 12. Standing protocols for treatment after initial assessment can be found in the Emergency Department Protocol Book. 13. Reassessment should be documented hourly or more frequently depending upon specific patient condition, or as ordered by physician. Reassessment is also indicated to document the effects of medication or treatment or at any time patient condition changes. The RN is responsible. for notifying the ED physician of changes in patient status. Vital signs should be rechecked as noted: ... Non urgent classified patients shall have vital signs every 2 hours and prn (as needed)."



On April 22, 2024, a review of the facility policy Positive Identification of Hospital Patients (Last Reviewed: 03/2023) revealed. "Outpatient; 2. Emergency Department- Upon entry to the Emergency Department, the initial contact ER staff member obtains the patients name, date of birth, sex, social security number and chief complaint. Using this information, the patient is entered into the Emergency Department Tracking Board. The bracelet is applied per the above stated policy ...10. An additional bracelet(s) will be applied to the patient's extremity in the same location as the identification bracelet for the following reasons. These bracelets are color coded to enhance communication among caregivers: "Yellow- Fall Alert ...".


On April 22, 2024, a review of the facility policy Fall/Safety Alert Protocol (Last Reviewed: 11/2022) revealed, "II. Policy Statement: A fall-injury risk assessment will be conducted on admission, daily, and after a fall occurrence in order to determine fall-injury risk on all acutely ill or injured adult patients receiving inpatient or observation services ... Patients admitted to the Emergency Department, Behavioral Medicine and Perinatal areas would be exempt."



On April 22, 2024, a review of the facility policy revealed that the Code Amber activation will occur for patients with known cognitive impairment. Follow up phone calls to next of kin/emergency contact and patient will be attempted to determine the status of the patient's safety as well as to encourage an emergency evaluation as soon as possible."



On April 22, 2024, a review of MR1 revealed the patient was an 83 year old female who was brought to the Emergency Department via ambulance from a skilled nursing center where the patient resides on a locked Dementia unit. The record further revealed a Pre-Arrival Form, dated April 16, 2024, at 13:51 with the chief complaint of "Fall". The Registration time note in the record was 13:59. The initial Triage revealed MR1 had a head contusion after the patient tripped and fell. The initial assessment indicated the patient was alert and oriented with a Glasgow Coma scale: 14, Eye opening- spontaneous, Best verbal response-confused, Best motor response-obeys simple commands, Emergency Severity Index (ESI) 4. No Known Allergies. MR1 was triaged at 14:40, 40 minutes after arrival. Neuro Checks, Glasgow Coma Scale and Vital Signs were ordered at 1451 to be done at 1451 and repeated every hour per the facility Closed Head Injury Protocol. No fall risk assessment was completed and the patient did not receive a yellow armband to be identified as a fall risk. CT of the Head Result at 15:38. Impression: Negative for fracture or intracranial hemorrhage. Volume loss and chronic small vessel ischemic change. 18:30, 19:10, 19:25 patient was taken to the waiting room.


On April 22, 2024, review of video revealed a brief conversation between emergency medical services (EMS) and EMP11. At 14:04, it is noted that EMS moves the MR1 from the stretcher to a wheelchair. MR1 is placed, into the Emergency Department waiting room by EMS at 14:09.


Further review of MR1 revealed a lack of reassessment, repeat Neuro Checks, Glasgow Coma Scale, fall risk assessment, cognitive assessment, neuro assessment and Vital Signs for MR1. Additionally, on April 16, 2024, the patient had not yet seen by a provider at 17:04.



At 18:30, 19:10, 19:25, on April 16, 2024, staff attempted to call MR1 for reassessment, MR1 was no longer in the waiting room. Review of video revealed that MR1 left the emergency department waiting room at 17:05 with an unknown person and left the facility's premises in a black sports utility vehicle.


A review of MR2 on April 22, 2024, revealed a 34 year old who presented to the Emergency Department on January 29, 2024, with a diagnosis of foot pain and swelling. There was no documentation of a nursing reassessment on January 29, 2024, from 20:52 until January 29, 2024, at 22:57 when the patient eloped.


A review of MR4 on April 22, 2024, revealed a 14 year old who presented to the Emergency Department on February 10, 2024, with a diagnosis of agitation, violent behavior and for a psychiatric evaluation. There was no documentation of a nursing reassessment on February 10, 2024, from 16:47 until February 10, 2024, at 19:58 when the patient eloped.



A review of MR5 on April 22, 2024, revealed a 54 year old who presented to the Emergency Department on February 14, 2024, with a diagnosis of back pain. There was no documentation of a nursing reassessment on February 14, 2024, from 13:26 until February 14, 2024, at 16:37 when the patient eloped.



A review of MR8 on April 22, 2024, revealed a 43-year-old who presented to the Emergency Department on March 4, 2024, with a diagnosis of chest pain. There was no documentation of a nursing reassessment on March 4, 2024, from 14:26 until March 4, 2024, at 21:13 when the patient eloped.


A review of MR9 on April 23, 2024, revealed a 44-year-old who presented to the Emergency Department on March 4, 2024, with a diagnosis of rectal pain. There was no documentation of a nursing reassessment on March 4, 2024, from 15:23 until March 4, 2024, at 17:19 when the patient eloped.


A review of MR10 on April 23, 2024, revealed a 17-year-old who presented to the Emergency Department on March 9, 2024, with a diagnosis of mental health issues. There was no documentation of triage, a nursing assessment or reassessment on March 9, 2024, from 16:53 until March 9, 2024, at 17:00 when the patient eloped.


A review of MR13 on April 23, 2024, revealed a 15-year-old who presented to the Emergency Department on March 20, 2024, with a diagnosis of surgical problems. There was no documentation of a nursing reassessment on March 20, 2024, from 09:48 until March 20, 2024, at 13:51 when the patient eloped.


A review of MR14 on April 23, 2024, revealed a 24-year-old who presented to the Emergency Department on March 25, 2024, with a diagnosis of pregnancy complications. There was no documentation of a nursing reassessment on March 25, 2024, from 11:49 until March 25, 2024, at 15:05 when the patient eloped.



A review of MR18 on April 23, 2024, revealed a patient who presented to the Emergency Department. Review on April 23, 2024, revealed, no documentation of triage or a nursing assessment on MR18 from arrival on January 1, 2024, at 23:07 until January 2, 2024 at 01:53, when it was discovered that MR18 left without being seen.



On April 23, 2024, at 11:00 EMP2 confirmed the above.