HospitalInspections.org

Based on observation, review of surveillance video from 12/3/24, staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure that all patients are assigned a clinical priority for treatment upon arrival to the Emergency Department (ED).

Findings include:

Facility policy titled, "Triage Procedure, Pediatric Patients," effective date 6/23, stated, "...XI Procedure: A. All patients shall be assigned a clinical priority for treatment by a professional nurse upon arrival to the Emergency Department. ..."

Facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance," effective date 4/23, stated, "...Definitions: ...3. Triage A process to determine the order in which patients will be seen by qualified medical personnel for a medical screening examination. ..."

Facility policy titled, "Triage Procedure Emergency Department," effective date 4/23, stated, "Procedure: 1. All patients shall initially be assigned clinical priority for treatment by a licensed professional nurse or physician upon arrival in the Emergency Department. 2. All patients are seen upon arrival. The nurse assesses the patient's illness or injury, determines their Emergency Severity Index (ESI) category and places them appropriately. ..."

On 1/29/25 at 9:58 AM, during the entrance conference with Staff (S)1 (Risk Safety Manager), S2 (Assistant Vice President), S3 (Vice President of Patient Care Services /Chief Nursing Officer), and S4 (Assistant Vice President, Risk and Patient Safety), S1 stated that the facility has three emergency departments (EDs) - an adult ED, a pediatric ED, and an obstetrics ED.

At 11:04 AM, a tour of the pediatric ED was conducted. A separate seated area next to registration was identified by S6 (Nursing Director of Pediatrics), as the triage area. Upon interview, S6 stated, "the triage nurse sits here. There is always a nurse present in the triage area." At 11:08 AM, during an interview with S18 (Registered Nurse), he/she stated, "we used to not have a triage nurse in the mornings until 12pm." During the interview, S6 stated that having a triage nurse at all times started approximately a month ago, "Until then, we only had a triage nurse from around 12 noon until 12 AM."

At 2:40 PM, a review of P1's medical record with S6 and S26 (Assistant Nursing Director, Pediatrics), revealed the following:

On 12/3/24 at 10:36 AM, P1 arrived at the Pediatric ED via car with his/her mother. An arrival complaint of "Rash; Post-Op Bleeding; Breathing Problem" was entered by S25, (Patient Access [registration]). At 11:35 AM, 59 minutes later, P1 was roomed in P-05. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 59 minutes P1 waited in the waiting area. At 11:38 AM, S27 (a physician), was assigned to the patient, and at 11:39 AM, a "First Provider Evaluation" of P1 by S27 was documented in the timeline, one hour and three minutes after the patient arrived. P1 was assigned an acuity level of 1, and at 3:04 PM, the patient was transferred via helicopter to a higher level of care.

On 1/30/25 at 9:59 AM, a review of the video surveillance footage of the Pediatric Waiting Room on 12/3/24, was conducted with S30 (Security), in the presence of S1, S3, and S29. S30 stated that the time of the footage is approximately two minutes later than the medical record time. The video began at 10:38 AM when P1 entered the waiting area, held by his/her mother, (identified by S1 and S3). From the time of P1's arrival at 10:38 AM until 11:39 AM, when P1 was brought in to be assessed, there were no nurses observed entering the waiting area, as confirmed by S1 and S3.

A review of the emergency department log from 12/3/24 revealed that seven patients (P1 - P7) arrived between 10:23 AM and 10:54 AM. On 1/30/25 at 2:00 PM, medical record review was conducted with S26 (Assistant Nursing Director, Pediatrics), who confirmed the triage start times and medical screening examination (MSE) times, as follows:

P5 - Arrived at 10:23 AM- Triage began at 11:39 AM, Acuity 3, Migraine; MSE 10:51 AM.

P4 - Arrived at 10:27 AM - Triage began at 11:34 AM, Acuity 4, Eye Problem; MSE 11:33 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and five minutes P4 waited in the waiting area.

P2 - Arrived at 10:29 AM - Triage began at 11:02 AM, Acuity 4, Swallowed Foreign Body; MSE 11:02 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 33 minutes P2 waited in the waiting area.

P1 - Arrived at 10:36 AM - Triage began at 12:46 PM, Acuity 1, Respiratory Distress; MSE 11:39 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 59 minutes P1 waited in the waiting area.

P6 - Arrived at 10:38 AM - Triage began at 12:14 PM, Acuity 4, Facial Laceration; MSE 1:55 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and 36 minutes P6 waited in the waiting area.

P7 - Arrived at 10:39 AM - Triage began at 12:20 PM, Acuity 4, Sore Throat; MSE 2:06 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and 41 minutes P7 waited in the waiting area.

P3 - Arrived at 10:54 AM - Triage began at 11:57 AM, Acuity 3, Breathing Problem; MSE 12:07 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and three minutes P3 waited in the waiting area.

On 1/29/25 at 3:10 PM, during an interview, S6 (Nursing Director of Pediatrics), stated that at the time of P1's ED visit, the pediatric ED did not have a dedicated triage nurse 24 hours a day. The process then was, the nurses would come out to the waiting area from the back and "triage patients as soon as possible upon arrival." S6 further stated that in order to select which patient from the waiting area would be roomed next in the main ED, the nurse would utilize arrival time, an "eyeball assessment" [of the patient], and the arrival complaint. This deficient practice resulted in delaying assessment of each patient's presenting signs and symptoms at the time of arrival in order to prioritize the time of the MSE.

In order to remove noncompliance with EMTALA requirements, S6 stated that the following changes had been implemented prior to survey: beginning on 12/20/24, a 24/7 triage nurse was assigned in the waiting area/triage room. Documentation was provided of email commuications sent to staff on 12/20/24, 12/31/24, and 1/14/25. The email included changes to staffing/scheduling to accommodate a 24/hour RN triage system, a review of triage requirements, and a PowerPoint education. S6 stated that the PowerPoint was posted on the unit, and that staff were re-educated by him/her as they came into work and asked to sign a sheet documenting their conversation. On 1/30/25 at 10:48 AM, S6 provided copies of the sign-in sheets documenting the staff education from the ED review PowerPoint. On 1/31/25 at 10:40 AM, S6 provided documentation of triage audits, which began on 1/28/25, with a goal to improve triage time. The facility was found to be in compliance, but previously out of compliance with EMTALA requirements. The facility has no previous EMTALA violations in the last 6 (six) months.

Facility Policy titled "OB [Obstetrics] Triage at Virtua Health" states, " ...XI. Procedure: ... B. Initial maternal and fetal assessment by the RN or LP should take place within 30 minutes of arrival to OB Triage. A triage acuity index of 1-5 (see Appendix) should be assigned to the patient ..."

On 1/30/25 at 11:26 AM, P21's medical record was reviewed in the presence of S33, Advance Nurse Clinician. P21, a 24-year-old patient who was 37 weeks pregnant presented to OB-triage on 9/3/24 at 12:59 PM via a private vehicle with reported contractions every 15 minutes and membranes intact. The triage RN and Provider performed an assessment together at 2:33 PM. P21 was triaged and received an MSE 94 minutes after arrival. The medical record lacked evidence of a MFTI (Maternal Fetal Triage Index) assessment. S33 confirmed no MFTI number was assigned to the patient.

On 1/30/25 at 11:37 PM, S34, Director of Clinical Practice, explained that triage time in the OB triage area is monitored and reported at the OB-ED (Emergency Department) meetings. S34 reported that the dedicated triage room opened September 10, 2025.