HospitalInspections.org

Based on findings from document review, medical record review and interview, the emergency department (ED) did not ensure that all patients received care according to its policies and current standards of practice related to assessments by ED nursing staff, for 3 of 10 patients. This could cause staff to have lack of awareness that a patient was unstable.

Findings include:

-- The hospital policy and procedure (P&P) titled "Triage Patient Classification-Nurse Responsibility," last reviewed 9/2015, indicated that ED nursing staff should obtain patient history and perform assessment depending on the patient's triage level; for triage levels #2 and #3 (on 5 level acuity scale, #1 being most acute) nursing staff should document the reason for the patient's visit, a review of the patient's symptoms and review of the patient's multiple body systems.

-- During interview with Staff A on 12/21/15 at 12:30 pm, in reference to the P&P above, he/she acknowledged that a "review of the patient's multiple body systems" included a physical assessment of the patient.

-- Review of Patient #1's MR revealed that the patient presented to the ED on 12/21/15 at 5:12 with complaints of abdominal pain and was assigned a triage level #3 (on 5 level acuity scale). Vital signs were obtained. At 05:15, Staff B documented that the patient appeared comfortable, behavior was cooperative and that the patient complained of abdominal pain which was 5 out of 10 (on 1 to 10) scale. Staff B documented that no gastrointestinal deficits were noted.

-- Review of Patient #2's MR revealed that the patient presented to the ED on 12/21/15 at 14:40 with a complaint of amputation of second finger right hand and was assigned a triage level #2. Vital signs were obtained. At 14:42 Staff B documented that the patient appeared in no distress, was well nourished and well groomed. behavior appropriate for age and cooperative. Patient complains of pain in dorsal and palmar aspect of right index finger.

There is no documentation by ED nursing staff indicating that nursing staff performed a physical assessment of the above patients.

The same lack of documentation of physical assessment of multiple body systems was also found in the MR of Patient #3

-- During interview with Staff C on 12/22/15 at 1:00pm, the above findings were acknowledged.