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Review of five open medical records and six closed medical records revealed that one patient did not receive care in the Emergency Department (ED) in a timely manner based on presentation.


Patient #1 presented to the ED at 9:00 A.M. with complaints of flank/abdominal pain, an elevated blood pressure of 215/100 and urinary retention for three days. Patient #1 described his pain as 10 on a pain scale of 0 to 10 with 10 being the most severe. The patient was triaged at 9:16 A.M. as ESI3. Patient #1's medical screening exam was conducted at 10:50 A.M. A urinalysis was not ordered even though the patient complained of flank pain.


Per the hospital's policy pain described as a 10 should have put the patient at an ESI of 2. The ED was not on yellow or red alert on the day of the occurrence.



Patient #1's presentation and complaints should have resulted in a higher ESI level and an earlier medical screening exam for Patient #1.

Based on observations during a tour of the ED on 9/4/15 between 8:30 AM and 12:30 PM it was determined that intravenous supply carts and suture supply carts were unlocked and unattended by staff.

The findings were:

Observations in different areas of the ED revealed that suture carts for staff use were placed in hallways. The suture carts were stocked with medical supplies such as injection needles of various sizes, suturing needles and gauges. Two suture carts were unlocked, unsecured and unattended by staff. These carts were found in the main ED area and in the flex care area of the ED.

Observations in Pods C and D of the ED revealed several treatment room supply carts unlocked and unattended. The carts were stocked with various sizes of intravenous catheters (needles).

Failure by staff to keep intravenous carts and suture carts locked and secured potentially can create delays in treatment if needed supplies are empty or missing and tampering and thievery opportunity for any individual whether a patient or a visitor present in the ED.