HospitalInspections.org

Based on patient interview, clinical record review, staff interview, and facility documentation review, hospital staff failed to adhere to hospital policy for one patient, Patient (P) #3, out of a survey sample of 9 patients seeking care at the hospital's Emergency Department (ED).

The findings include:

For P #3, hospital staff failed to follow hospital policy to provide timely reassessments while seeking medical care in the ER on 7/30/25.

On 9/30/25 at approximately 11:40 AM, a telephone interview was conducted with P #3 who stated, "I arrived at the ED by ambulance, I was having chest pain like I have never experienced before and it would not go away, the nurse checked my blood pressure and got an EKG then put me out front in the waiting room with everyone else, I was sitting in the waiting room for at least 4 hours without being seen or updated by anyone, my chest pain would not go away and I was really getting more concerned, I went up to the front desk to see how much longer my wait would be to see a doctor and to report that I was still having chest pain, I was told that everyone was busy in the back and was told that I could just leave if I wanted to, I asked for my records because I wanted to go to another hospital to be seen and was told 'there is no paperwork'".

On 9/30/25 at approximately 12:15 PM, a clinical record review was conducted for P #3 and revealed the following:

P #3 arrived to the ED on 7/30/25 at 22:46 PM via ambulance, with complaints of chest pain.
At 22:47 PM, vital signs were obtained which included blood pressure 142/90, heart rate 84, respiratory rate 17, oxygenation on room air 100%, and temperature 98 F.
At 22:50 PM, "full triage" was "complete" with "Patient Acuity: Urgent, Acuity 3 Selected".
At 22:56 PM, an EKG was obtained. At 23:24 PM, P #3 was placed in the waiting room/intake waiting.
At 02:37 AM on 7/31/25, "LWBS [Left Without Being Seen] after Triage--Patient dismissed".

There were no nursing notes/narratives or healthcare provider notes documented in P #3's medical record. The assigned triage nurse was unavailable for interview.

On 9/30/25 at approximately 2:30 PM, an interview was conducted with Staff Member (SM) #1 and SM #6, the ED Director, and they were updated on the findings. SM #6 stated, "It is my expectation that my nursing staff will provide ongoing monitoring for changes in clinical condition and reassessments for patients while waiting to see a provider, we would re-prioritize getting a patient in front of a provider if needed". SM #6 reviewed P #3's medical encounter in the ED on 7/30/25 and confirmed the above findings and stated, "Based on our hospital policy and the assigned acuity level 3, vital signs were not obtained at the expected frequency for assessments, a level 3 gets vital signs every 2 hours per policy".

On 9/30/25 at approximately 2:45 PM, a review of the hospital's policy titled, "[name redacted]-Assessment/Reassessment Policy", effective date 9/08/2023, subheading, "Purpose", page 1, read, "The purpose of this policy is to provide an assessment/reassessment framework to ensure patients receive a timely assessment of their individual clinical presentation by qualified individuals within the organization". Also, subheading, "Emergency Department/Emergency Observation Unit", page 5, item A, read, "All patients presenting to the emergency room receive a quick triage assessment to determine the severity of the presenting chief complaint. An acuity level is assigned to each patient during the initial assessment. Patients are reassessed based on acuity, interventions, and changes in condition ..." and page 6, item F "Vital Signs", item 1 "Frequency ...ESI [Emergency Severity Index used to assign Acuity Level] ESI Level 3: minimum every two hours ...".