HospitalInspections.org

Based on medical record review, review of hospital video recordings, review of hospital polices, review of hospital documentation and interviews, for two of twenty-one patients (P #21 and P #12) who presented to the Emergency Department (ED), the hospital failed to ensure patients were triaged effectively to prioritze when the patient would be seen by a qualified medical personnel. The findings include:


a. Patient #21 presented to Hospital #1's ED on 11/15/21 at 4:30 AM via private vehicle and was joined by Person #1 shortly after arrival. Review of ED video on 1/10/22 at 9:30 AM identified Patient #1 went to the registration desk, spoke with Registrar #1 (Patient Access Liaison) and handed Registrar #1 a license. The video noted Registrar #1 utilized the computer, made a phone call lasting one minute and thirty seconds, appeared to converse with Patient #21 and Person #1 then handed the license back to Patient #21. Patient #21 and Person #1 left the ED at 4:34 AM (within 4 minutes of arrival). Security Officer (SO) #1 was also observed next to Registrar #1 during the video.

Review of Patient #21's clinical record dated 11/15/21 identified that the patient and Person #1 drove to Hospital #2 and Patient #21 was immediately evaluated and admitted with a diagnosis of partial small bowel obstruction. Patient #21 was treated with steroids and was discharged to home on 11/17/21.

Review of the ED staffing dated 11/15/21 from 3:00 AM to 7:00 AM noted RN #1 was both the charge and triage nurse (per routine), one RN had called out sick, and the hospital did not have the required four ED Techs per the ED staffing plan.

The hospital investigation identified that during interview with Registrar #1 on 11/24/21 Registrar #1 stated she might have told someone there was a 4-5 hour wait in an attempt to be helpful.

Hospital documentation and interview with the Nursing ED Director on 1/11/12 at 11:54 AM identified the ED had a capacity for 15 beds from 3:00 AM to 7:00 AM on 11/15/21 and the ED had a census of 28 patients registered at 4:00 AM. The ED Nursing Director further indicated he was on vacation or he or the Assistant Nurse Manager would have covered the RN call-out.

Registrar #1 did not recall the encounter with Patient #21 despite video review per interview on 1/11/22 at 9:39 AM. Registrar #1 noted it was very busy in the ED and RN #1 (charge/triage RN) was helping other nurses in the ED. Registrar #1 indicated that she has informed patients of ED wait times if patients ask and that it could be up to two hours before they are roomed. The hospital did not ensure that the Registrar functioned within her job role.

Interview with Security Officer #1 on 1/11/22 at 10:03 AM noted Patient #21 identified him/herself as a physician, grabbed his/her abdomen in pain and Registrar #1 called RN #1 to discuss Patient #21. Security Officer #1 further indicated Registrar #1 gave Patient #21 a time frame that Patient #21 would have to wait but, did not recall the timeframe that Registrar #1 gave.

Interview with RN #1 on 1/11/22 at 7:30 AM identified he did not recall a phone conversation with Registrar #1 on 11/15/21, the ED was very busy, and he had to help the other RNs in the ED. RN #1 further indicated that if he was busy, he would ask another RN or call the Clinical Manager to triage a patient. The hospital did not ensure the triage nurse was immediately available to assess incoming patients.

Interview with the ED Nursing Director on 1/11/22 at 11:54 AM identified he was on vacation, and if the ED was short by one RN that can be critical and he or the Assistant ED Director would be called and would come in to assist. The Hospital was unable to provide evidence of attempts made to improve the ED nursing staff during the period of time from 11/14/21 at 11:00 PM to 7:00 AM on 11/15/21.

Interview with Patient #21 on 1/11/22 at 12:48 PM identified s/he informed Registrar #1 that s/he was physician, was acutely ill and needed to be seen. Patient #21 further identified that Registrar #1 said it would be a 4 to 5 hour wait, there was no one in triage and then spoke to someone on the phone. Patient #21 noted that after s/he informed Registrar #1 that he could not wait 4-5 hours, Registrar #1 suggested s/he go to another hospital, informed him/her that Hospital #2 was not busy and then Patient #21 and Person #1 left. Patient #21 did not receive a medical evaluation as a result of poor communication and lack of triage availability and assessment.

A call was placed to Person #1 on 1/11/22 and returned on 1/12/22 at 7:52 AM. Interview with Person #1, on 1/12/22 at 7:52 AM identified that Registrar #1 made a call and then informed Person #1 and Patient #21 that a nurse was not available. Person #1 further indicated s/he was taken aback by the comment because when you go to an emergency room, you expect someone to be able to see you.

The hospital policy entitled, Triage in the Emergency Department, identified a purpose to determine the immediate severity of illness or injury of all patients who present to the emergency department seeking care. Triage responsibilities include in part, identify life threatening conditions, prioritize patient according to acuity, provide ongoing reassessment, and maintain ongoing communication with charge RN and other members of the healthcare team to provide appropriate care to patients waiting.

The hospital policy entitled, Chain of Command, identified a purpose to provide structure for health care providers to assure patient care needs are met in a timely manner to support patient safety Th policy further directed any healthcare provider who identifies a problem with regard to patient care and is unable to resolve it should present the issue to successively higher levels of authority by maintaining standards of care. The policy identified the chain of command may be initiated in conditions that jeopardize patient care and safety.

The Hospital job description for, Patient Access Liaison, included a responsibility to perform registration and did not include a responsibility to provide estimates regarding ED wait times or direction in the event the triage nurse was unavailable.


b. Patient #12 was 26 years old, 11 weeks pregnant and presented to the ED on 11/14/21 at 11:30 PM via private car with chief complaint of vaginal bleeding with abdominal pain. Triage documentation at 12:20 AM on 11/15/21 (50 minutes after arrival) identified stable vitals, patient rated pain as a 9 on a scale of 1-10 (10 worst possible pain), and was designated as an emergency severity index (ESI) level three (3). The clinical record identified at 2:45 AM, the patient left without being seen.

Review of the clinical record failed to indicate that the patient was reassessed minimally every two hours in accordance with hospital policy.

Review of the Emergency Department staffing dated 11/14/21 at 11:00 PM to 11/15/21 at 3:00 AM noted RN #1 was both the charge and triage nurse (staffing plan required a triage RN from 11:00 PM to 3:00 AM) and was lacking a required RN in Pod #2 during that time period per the ED staffing plan.

The Emergency Department documentation identified that the patient ED census level on 11/14/21 at 12:00 AM was capacity overload and decreased to severity overload at 2:00 AM on 11/15/21.

Interview with RN #1 on 1/11/22 at 7:30 AM identified he was both charge and triage nurse on 11/14/21, the ED was very busy and he had to help the other RNs in the ED. RN #12 indicated that if he were busy he would ask another RN or call the Clinical Manager to triage a patient.

Subsequent interview with RN #1 on 1/12/21 at 3:24 PM stated if Registrar #1 had informed him of Patient #12's chief complaint, or if he observed the patient on the ED tracker board (Registrant adds patient to the tracker upon entry to the ED) he would have triaged Patient #12 sooner.

Interview with the ED Nursing Director on 1/11/22 at 11:54 AM identified he was on vacation during this period of time, and if the ED was short by one RN, that can be critical and he or the Assistant ED Director would be called and would come in to assist. The Hospital was unable to provide evidence of attempts made to improve the ED nursing staff during the period from 11/14/21 at 11:00 PM to 7:00 AM on 11/15/21.

Subsequent interview with the ED Nursing Director on 1/12/22 at 3:33 PM identified given Patient #12's pain severity level and bleeding, he would have triaged the patient as a level "2" and the patient would have been brought to an ED room following patient location management.

The Hospital failed to ensure the patient was assessed in a timely manner and/or accurately triaged based on presenting symptoms which may have contributed to Patient #12 leaving the ED without a medical examination by an independent licensed practitioner.

The hospital policy entitled, Recommended Evaluation of Pregnant and Postpartum Patients in the ED, identified patients who are less than 20 weeks gestation who present themselves to the ED experiencing an obstetrical complication will undergo initial evaluation by the ED Provider, including documentation of fetal heart tracing (if obtainable based on gestational age).

The hospital policy entitled, Triage in the Emergency Department, identified a emergency severity index (ESI) level two (2) included severe distress, severe pain, high risk chief complaints that may rapidly deteriorate without immediate intervention.

The hospital policy entitled, Assessment and Reassessment Standards for the ED, directed that ESI level three (3) patients would be assessed minimally every two hours and ESI level two (2) patients would be assessed minimally every thirty minutes until stable then every two hours.

The hospital policy entitled Chain of Command identified a purpose to provide structure for health care providers to assure patient care needs are met in a timely manner to support patient safety. The policy further directed any healthcare provider who identifies a problem with regard to patient care and is unable to resolve it should present the issue to successively higher levels of authority by maintaining standards of care. The policy identified the chain of command may be initiated in conditions that jeopardize patient care and safety.