HospitalInspections.org

Based on interview, medical record review and policy and procedure review, the facility failed to follow their policy and procedure for reassessment of an Emergency Severity Index (ESI) Level two (2) patient after triage. This affected Patient #14 and had the potential to impact all patients served.

Findings Include:

Interview with the Director of the Emergency Department on 10/12/2022 at 11:00 a.m. reveals it is expected patients waiting will be re-assessed after triage even if they are in the waiting room.

Review of Emergency Department (ED) medical record reveals Patient #14 presented to the ED on 07/08/2022 at 11:07 a.m. with left side numbness and was triaged at 11:52 a.m. with an assigned ESI Level two (2) acuity. Patient #14 received a Medical Screening Exam (MSE) at 3:03 p.m. There was no documented evidence of reassessment of Patient #14 during the three (3) hours between triage and MSE.

Review of policy and procedure; "Triage assessment," dated 06/2011, last revised date 09/2019, states " ...H. All patients in the waiting room should be reassessed to include vital signs and pain assessments with time frame appropriate to their ESI triage level, but no longer than every 2 hours ... 1. b ESI Level 2: Vital signs no less frequently than every hour for the first 4 hours ...".

During the exit conference on 10/13/2023 at 12:15 p.m. with the Chief Compliance Officer, Director of Accreditation, Vice President, and Chief Nursing Officer, survey findings were discussed. No further documentation was submitted for review.