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A. Based on document review and interview, it was determined, for 1 of 5 Emergency Department (ED) clinical records reviewed (Pt.#2), the Hospital failed to ensure ED patients were reassessed in a timely manner while waiting for medical screening examination.

Findings include:

1. Hospital policy # 6-3500-114, titled, "General Patient Care Triage Protocol", revised 1/09, was reviewed on 1/22/14 at 9:30 AM. The policy required, "Priority II / Urgent. These conditions that may be triaged, but need to be seen in ED as soon as possible." There was no instruction on how frequently level II / urgent patients should be reassessed for changes in condition, vital signs, or level of pain.

2. On 1/12/14 at 10:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 37 year old female, seen in the ED on 5/6/13, for complaints of vomiting since 4/27/13 and not eating since 4/26/13. Pt. #2 arrived on 5/6/13 at 10:11 AM and was triaged at 10:14 AM as level 2 - urgent. At that time, vital signs were: blood pressure 113/89, pulse 101, respirations 14, oxygen saturation 100% on room air, temperature 97.6, and pain level 7 out of 10 (10 the worst pain). Pt. #2's pain level was not reassessed. Pt. #2 remained in the waiting area until a physician performed a medical screening exam (MSE) at 4:36 PM.

3. Pt. #2's "urgent" condition was not reassessed until the MSE, over 6 hours after triage. Vital signs were not reassessed until discharge at 4:52 PM. At that time, vital signs were: blood pressure 124/87, pulse 67, respirations 20, oxygen saturation 99% on room air, temperature 98.2. Pt. #2's pain level was not reassessed.

4. On 1/22/14 at 11:00 AM, an interview was conducted with the Chief Nursing Officer (E #4). E #4 stated that there currently is no reassessment policy for patients in the ED waiting room. The reassessment policy will be available when the triage protocol is revised, in the near future.
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B. Based on document review and interview, it was determined, for 1 of 1 record of a patient who received pain medication (Pt.#1), the Hospital failed to ensure reassessment of pain.

Findings include:

1. On 1/21/14 at approximately 11:00 am, Hospital policy titled,"Pain management" (2012) was reviewed. The policy required, "Reassessment, of the patient's pain is done following implementation of pain management interventions."

2. On 1/21/14 at approximately 11:30 am, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 60 year old female who arrived in the ED via ambulance with Chicago Police Department (CPD) notification prior to arrival. Pt. #1 arrived on 5/5/13 (Sunday) priority level 2 (urgent- seen as soon as possible per Hospital policy) at 9:39 am. Triage vital signs at 9:40 am were: temp 99.3, pulse 106, respirations 20, blood pressure 145/99 and pulse oximetry 95%. Pt. #1 was seen by the medical staff at 10:11 am. The complaint on arrival was headache (HA), dizziness related to battery,without loss of consciousness. Clinical record indicated that on arrival to the ED, Pt. #1 was alert, stated injury was caused by battery from a prior boyfriend. Pain score on a 0-10 pain score was rated at 7 on 05/05/13 at 9:40 am. Pt. #1 was given 2 tablets of Tylenol #3 (narcotic pain reliever) for complaints of head and leg pains at 5:45 pm. Pt #1 was discharged home at 6:05 pm (approximately 20 minutes after administration of the narcotic.) The clinical record lacked a pain reassessment in accordance with policy.

3. On 1/24/14 at approximately 9:30 am, the ED Nurse Manager (E#3) and Vice President of Nursing Services (E#4) in attendance were interviewed and also reviewed Pt. #1's clinical record with the surveyor. E#3, after reviewing the ED record, stated the record did not contain a pain reassessment after administration of the Tylenol #3.


C. Based on document review and interview, it was determined that the Hospital failed to ensure emergency department specific policies governing frequency of vital signs (temperature, pulse, respirations blood pressure and pain assessments) were developed and failed to ensure ongoing patient assessments for 1 of 1 patient (Pt. #1) with a potential head injury.

Findings include:

1. On 1/21/14 at approximately 11:30 am the clinical record of Pt. #1 was reviewed. Pt. #1 was a 60 year old female who arrived in the ED via ambulance with Chicago Police Department (CPD) notification prior to arrival. Pt. #1 arrived on 5/5/13 (Sunday) priority level 2 (urgent- seen as soon as possible per hospital policy) 9:39 am. Triage vital signs at 9:40 am were: temp 99.3, pulse 106, respirations 20, blood pressure 145/99 and pulse oximetry 95%. Pt. #1 was seen by the medical staff at 10:11 am. The complaint on arrival was headache (HA), dizziness related to a battery. The history included an account of being beaten at home over the head with a hammer by a former boy friend. There was no documentation that Pt. #1 received ongoing nursing assessments for a potential head injury. Vital signs were obtained once on 05/05/13 at 9:40 am. According to clinical record documentation, x-rays and wound care were completed by 11:30 am. Between 11:30 am and 4:30 pm (5 hrs) there was no nursing documentation. RN#1 reported to MD#1 that Pt. #1 was experiencing head and leg pain at 4:30 pm. At 5:45 pm Pt. #1 received Tylenol with codeine (narcotic pain reliever). Pt#1 was discharged home at 6:05 pm, approximately 20 minutes after administration of a narcotic. Pt. #1 was in the ED for approximately 8 ? hrs with no repeat vital signs, no neurological assessment or pain reassessment.

2. On 1/21/14 at approximately 11:00 am, E#3 was asked for a policy for ongoing monitoring of patients who are in the emergency department after triage. A policy titled,"charting in the medical record #6-1000-40" was presented. The policy was specific to computerized charting for the Emergency department, the Medical surgical unit, Critical care unit and Behavioral health unit. The purpose of the policy included,"to establish criteria for documentation in the medical record and to eliminate unauthorized entries." The policy was not specific for frequency of emergency department assessments and reassessments.

3. During the tour of the ED was conducted on 1/21/14 at approximately 9:30 am. The ED Nurse Manager (E# 3) was asked how often vital signs are repeated while in the ED. E#3 stated the expectation is every 2 hours if the patient is acutely ill. If the patient received pain medication then a repeat pain re-assessment is documented after 30 minutes. The nurses are also expected to write a clinical note. E#3 further there is no policy or procedure for assessing/monitoring patient in the waiting area, but the Hospital is in the process of developing a new triage system which will include frequency of vital signs and reassessments.

D. Based on document review and interview, it was determined that for 1 of 4 clinical records of patients who sustained physical abuse (Pt.#1), the Hospital failed to ensure patient #1 received information on domestic violence and contacted a social worker in accordance with policy.

Findings include:

1. On 1/24/14 at approximately 10:00 am, Hospital policy #1-2500-8 titled, "Guidelines for Victims of Suspected Abuse" was reviewed. The policy required, "Procedure, 4. contact social service staff to complete the investigation when they are available. Hospital workers will assist the victim in contacting the Domestic Violence 24-hour hotline to assist with services and available programs."

2. On 1/21/14 at approximately 11:30 am the clinical record of Pt. #1 was reviewed. Pt. #1 was a 60 year old female who arrived in the ED via ambulance with Chicago Police Department (CPD) notification prior to arrival. Pt. #1 arrived on 5/5/13 (Sunday) priority level 2 (urgent- seen as soon as possible per hospital policy) at 9:39 am. Triage vital signs at 9:40 am were: temp 99.3, pulse 106, respirations 20, blood pressure 145/99 and pulse oximetry 95%. Pt. #1 was seen by the medical staff at 10:11 am. The complaint on arrival was headache (HA), dizziness related to a battery. The history included an account of being beaten at home over the head with a hammer by a former boy friend. Pt. #1 required sutures to the scalp and was discharged on 5/5/13 at approximately 6:05 pm. Aftercare instructions included head injury; wrist sprain; wound care and the name, address and phone number of a physician to follow up within 2 days. The final diagnosis was closed head injury, wrist contusion, head laceration repair and multiple abrasions. There was no documentation that social service was contacted or that staff assist Pt. #1 by providing information regarding services available for domestic violence at the time of discharge in accordance with policy.


3. On 1/24/14 at approximately 9:30 am, the ED Nurse Manager (E#3) and Vice President of Nursing Services (E#4) in attendance were interviewed and also reviewed Pt. #1's clinical record with the surveyor. E#3, after reviewing the ED record, stated, "They should have included the domestic violence information with the discharge instructions."

E. Based on document review and interview, it was determined for 1 of 8 clinical records reviewed (Pt. #1), the Hospital failed to ensure patient who present for emergency services are registered in accordance with policy.

Findings include:

1. Hospital policy titled,"Emergency medical treatment"(signed 07/2013) was reviewed on 1/21/14 at 1:00 pm. The policy required, "All patients that present to the emergency department should be immediately referred to the triage area for a medical screening and stabilizing care."

2. Hospital policy titled,"Obtaining signatures for consent to treat" (signed 1/7/13) was reviewed on 1/21/14 at approximately 2:00 pm. The policy required,"The law mandates that all patients entering the hospital will have a signed consent to treat form unless otherwise specified. After patient has been triaged in the ER,the registrar will complete the registration process."

3. On 1/21/14 at approximately 11:30 am, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 60 year old female who arrived in the ED via ambulance with Chicago Police Department (CPD) notification prior to arrival. Pt. #1 arrived on 5/5/13 (Sunday) priority level 2 (urgent- seen as soon as possible per hospital policy) at 9:39 am. Triage vital signs at 9:40 am were: temp 99.3, pulse 106, respirations 20, blood pressure 145/99 and pulse oximetry 95%. Pt. #1 was seen by the medical staff at 10:11 am. The complaint on arrival was headache (HA), dizziness related to a battery. The history included an account of being beaten at home over the head with a hammer by her former boy friend. Pt. #1 required sutures to the scalp and was discharged on 5/5/13 at approximately 6:05 pm. Aftercare instructions included head injury; wrist sprain; wound care and the name, address and phone number of a physician to follow up with in 2 days. The final diagnosis was closed head injury, wrist contusion, head laceration repair and multiple abrasions. Pt. #1 presented to the ED the next day according to a social worker's (E#2) progress note dated 5/6/13 at 12:09 pm (Monday). The note by E#2 included, "Pt. was referred to the domestic violence 24 hour hotline. Pt says she feels safe going home with her daughter. Understands she can go to shelter if needed. Pt was given a copy of her CT for follow up treatment. "

4. On 01/23/14 at approximately 10:30 am social worker (E#2) was interviewed. E#2 stated she recalled giving the patient a copy of the CT, domestic violence information and spoke to the patient in the family quiet room on 5/6/13 but did not recall if a physician provided an assessment or if the patient was registered.

5. E#1 (Patient advocate-RN) was interviewed on 1/23/14 at 9:00 am. E#1 stated she did not keep any notes, but remembered that the patient returned to the Hospital on 05/06/13. According to E#1, the patient wanted her left knee wrapped because of pain and requested a copy of her medical record. E#1 stated she did not have the patient register, but instead asked an unknown ED physician to examine the patient's left knee. The physician examined the patient's knee and upon the physician's request, E#1 placed an ace bandage to the left knee.

6. The ED log was reviewed on 1/21/14 at approximately 12:00 pm. There was no documentation in the ED log to evidence that Pt. #1 was registered and treated on 05/06/13 with complaints of left knee pain.

7. On 1/24/14 at approximately 9:30 am, the ED Nurse Manager (E#3) and Vice President of Nursing Services (E#4) in attendance were interviewed and also reviewed Pt. #1's clinical record with the surveyor. "E#4 stated when the patient returned the next day, the patient should have been registered. E#4 stated,"This is the first time I am hearing about this. "

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