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Based on Medical Record review, document review and interview, the Emergency Department (ED) did not ensure that Patient #1 was reassessed as per facility Policy while in the Waiting Area. This potentially places patients at increased risk for delays in the accurate re-assessments of their Emergency Severity Index (ESI) Levels.

Findings:

Review of Patient #1's Medical Record identified the following information: On 03/28/16, this 88-year-old male was referred to the Emergency Department (ED) from his Primary Care Provider (PCP) for shortness of breath and right shoulder pain. The patient arrived to the ED, denied shortness of breath but complained of ten (10) out of ten (10) shoulder pain on the pain rating scale. He was triaged at 9:47AM as an Emergency Severity Index (ESI) Triage Level 3, and instructed to wait in the Waiting Area. Patient had Vital Signs (VS) re-assessed at 10:47AM and 2:30PM, not every hour as per facility Policy, and pain score was not reassessed. After an approximately five and a half (5½) hour wait in the ED Waiting Area, the patient left without being seen (LWBS) by a Physician at 3:10PM.

The facility Policy and Procedure (P&P) titled "Triage - Emergency Severity Index (ESI)" dated 12/29/15 stated "...If [Waiting Room] patients have an extended wait time, they will be reassessed at a minimum of every 1 [one] hour. The Triage Nurse is responsible to ensure reassessment of Waiting Room patients and escalation of any change in patient condition."

This same facility Policy also states "...A temperature, heart rate, respiratory rate, blood pressure, oxygen saturation level and pain score will be performed on all patients as part of the nursing assessment ... Vital Signs are utilized to determine if a patient's ESI level should be upgraded."

During interview with Staff I (ED Triage Nurse) on 06/02/16 at 11:00AM, Staff I demonstrated on the Electronic Medical Record where ED Waiting Room patients' Assessment information is documented and indicated patients are assessed every one (1) hour. When asked what exactly does the Assessment entail, Staff I explained the Assessments included observation of patients and recording of their VS.

During interview with Staff E (ED Triage Nurse) on 06/03/16 at 1:30PM, Staff E stated "Reassessments [of the Waiting Room patients] always include taking VS every hour." When asked if patients are just observed or watched for reassessments, Staff E stated "Yes, we are always watching the patients, but this is in addition to the hourly VS Assessments we are doing". This was confirmed with Staff G (Nursing Director of Patient Care Services) and acknowledged by Staff A (Associate Executive Director of Quality Management).
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Based on documentation review and interview, the Medical Staff did not establish criteria for delineating the qualifications a Medical Staff Member must possess in order to supervise the provision of Emergency Care Services.

This failure may lead to non-qualified Medical Staff Members supervising Emergency Care Services.

Findings:

A review of the Job Description of the Emergency Room Chair does not include duty of direct supervision of the Emergency Care Services Staff.

A review of the facility's Bylaws do not contain specific criteria including the necessary education, experience and training to delineate the qualifications a Medical Staff Member must possess in order to provide supervision of Emergency Care Services.

An interview with Staff H, Chair of Emergency Medicine, on 06/03/16 at 10:30AM revealed that in the event of his absence, the Associate Chairperson would be present to oversee staff in the Emergency Department. And in the event that neither of them are available, a member of the Blue Desk Team is in charge.

On 06/03/16 at 1:30PM Staff A, Quality Assurance, stated that there is no specific Policy and Procedure that denotes the specific qualifications of a Supervising Physician in order to be granted Privileges for the supervision of Emergency Care Services.