HospitalInspections.org

Based on document review and interviews, the facility staff failed to ensure four (4) of six (6) patient medical records reviewed, Patient #1, #5, #7 and #9, included the patients in the development and implementation of the Patients' plans of care, by not addressing pain, language barriers, elevated vitals signs, and withdrawal symptoms.

The findings include:

On January 3, 4, 5 and 6, 2022 the medical records of Patients #1, #5, #7 and #9 were reviewed. All of the Patients arrived at the facility on 12/15/21. The following information from the medical records as provided by Staff Members #1, #2 and #4 as noted below:

Patient #1:
Arrived at the facility Emergency Department (ED) at 7:00 P.M. with the complaint of back, hip and ear pain. Patient #1's triage was started at 7:00 P. M and completed at 7:03 P.M. by a Registered Nurse (RN).

There was no documentation of the level of pain Patient #1 was experiencing.

The RN assigned an Acuity of ESI 4 (Emergency Severity Index). Vital signs were recorded at 7:07 P.M. by a ED tech as: Blood pressure 150/101 (elevated), Temperature 98.4, Pulse 88, Respirations 18 and SpO2 (oxygen saturation percentage) 97%, Height 6 feet 2 inches, Weight (height and weight were patient stated) 176.9 kg (kilograms) (389 pounds, 15.9 ounces).
No other vital signs were documented after the initial set at 7:07 P.M.

Patient #1 was placed in a room (triage room number T02) at 11:39 P.M. as noted by an RN
At 1:10 A.M. on 12/16/21 Patient #1's spouse came to waiting area to try to understand why Patient #1 had not received treatment or care by that time (6 hours and 10 minutes after arrival) by a Physician or med-level provider such as a Physician's Assistant or Nurse Practitioner.

On 1/3/22 at approximately 11:00 A.M., Staff Member #2 was asked how often vital signs were performed and stated, "Vital signs should be taken at least every two (2) hours while in the waiting area."

Patient #5:
Arrived at the facility Emergency Department (ED) at 6:43 P.M. via ambulance, with the complaint of chest pain and difficulty breathing. Patient #5's triage was started at 7:14 P.M. and completed at 7:16 P.M. by a Registered Nurse (RN). At 7:15 P.M. the RN made a note that Patient #5 was Spanish speaking only. There was no documentation any type of interpretive device or an interpreter being used to communicate with Patient #5.

Patient #5 signed a Consent for Treatment on 12/15/21 at 7:43 P.M. The Consent was in English. The Consent for Treatment includes the following:
"Patient Rights: In accordance to Federal Regulation §482.11, the Patient/Guarantor signature certifies that the Patient/Guarantor has been provided and/or educated about the Patient Rights. The Patient/Guarantor understands a member of Patient Access Services is available to answer any questions regarding Patient Rights."

There was no documentation of the level of pain Patient #5 was experiencing.

There was no Acuity level assigned to Patient #5 by the RN. Vital signs were recorded at 7:15 P.M. by an RN as: Blood pressure 126/82, Temperature 98.4 (recorded at 7:28 P.M.), Pulse 88, Respirations 16 and SpO2 (oxygen saturation percentage) 97%.

Patient #5 was placed in a room (observation triage OTF) at 8:04 P.M. as noted by an ED Tech.
At 8:02 P.M. the ED Tech documents "Patient (#5) left with family member."

Patient #7:
Arrived at the facility Emergency Department (ED) at 8:00 P.M. with the complaint of "having binge drank and a history of one (1) liter of alcohol per day consumption. Concerned about withdrawals and has a history of seizures. Last drink four (4) hours ago". Patient #7's triage was started at 8:01 P. M and completed at 8:03 P.M. by a Registered Nurse (RN). There was documentation that Patient #7 was not placed on any type of seizure precautions.

Patient #7's weights were recorded in the medical record with an unknown time as 115.7 kg (255 pounds and 1.2 ounces) three (3) weeks ago, Adjusted weight is 87.3 kg (192 pounds and 8.1 ounces).

There was no Acuity level assigned to Patient #7 by the RN. Vital signs were recorded at 8:05 P.M. by an ED Tech as: Blood pressure 139/110 (elevated), Temperature 98.3 (recorded at 7:28 P.M.), Pulse 138 (elevated), Respirations 20 and SpO2 (oxygen saturation percentage) 99%.

Patient #7 was placed in a room (OTF) at 10:58 P.M. as noted by an ED Tech. Two (2) other ED tech notes:
one at 10:41 P.M. saying Patient #7 was called twice for bloodwork to be done and there was no response, and
one at 10:57 P.M. stating Patient #7 was "called three (3) times by this tech (Staff Member #5) in triage and twice outside without any response. Checked in restroom as well."

Patient #7's discharge was documented at 12:09 A.M. on 12/16/21. Patient #7 was not seen and assessed or re-assessed by an RN, physician or mid-level provider for four (4) hours and six (6) minutes.

Patient #9:
Arrived via ambulance at the facility's via Emergency Department (ED) at 4:28 P.M. with the complaint of chest pain. Patient #1's triage was started at 5:00 P.M. and was completed at 5:01 P.M. by a Registered Nurse (RN). There was no documentation of the level of pain Patient #9 was experiencing.

The Acuity level assigned to Patient #9 was an ESI of 2 by the RN performing triage. Vital signs were recorded at 5:01 P.M. by an RN as: Blood pressure 173/102 (elevated), Temperature not recorded, Pulse 78, Respirations 18 and SpO2 (oxygen saturation percentage) 98%.

The protocol order set at 5:15 P.M. included: STAT (one time immediately) EKG, to be done within 10 minutes of arrival and given to the MD (medical doctor), Saline IV lock, and various lab work.
No evidence of the EKG, Saline Lock or lab work completed as ordered by physician protocol orders.

Following Triage, there was no documentation of anyone attempting to communicate with or assess Patient #9 until 10:02 P.M. on 12/15/21 when the ED Tech documented, "Pt called 2x for blood work, no response." Patient #9 was documented discharged LWBS (left without being seen) on 12/15/21 at 11:12 P.M.



Policy: Triage in the Emergency Department #403.01 with a Last Revised date of 5/2021 documents the following in part:
I. Guidelines
A. All patients entering the ED seeking medical care shall receive a rapid assessment using the Emergency Severity Index (ESI) 5 level triage system.
B. Any appropriate triage protocols may be initiated at this time.
C. This assessment will include, but not limited to:
1. Patient's chief complaint
2. A brief visual assessment
3. Vital signs as determined by the RN using the ESI algorithm...
G. After the Rapid Assessment by the RN, the patient will be directed to the next appropriate location
H. If there are beds available, the patient will be taken to a room where the data collection portion of triage will be completed by the RN.
I. If there are no bed in the ED, the patient will then be directed back to the waiting room until a bed becomes available.
II. Procedure for Data Collection
A. Patients will be interviewed and all objective data will be documented. This will include, but not limited to:
1. Allergies, both to latex and prescription...
2. Initiation of medication and reconciliation by entering current medications in the EMR
3. Past medical/surgical/family history.
4. Pain Assessment
5. Tetanus...
6. Last menstrual...
7. Objective data from patient and significant others
B. Triage Levels...
C. ED Triage protocols...
D. The Triage nurse will be in contact with the charge nurse...
E. Primary RN...
F. Patients in the waiting area will be re-evaluated based on condition, but no less than every 2 hours. This will include, but not limited to: vital signs and complaint specific observations. Any and all acute changes will be reported to the charge nurse....