HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, Pt. #6, and Pt. #7) clinical records reviewed for assessment and reassessments, the hospital failed to ensure that reassessments were performed as required.

1. On 9/23/2024, the hospital's policy titled, "Assessments and Reassessments in the Emergency Department (ED)" (9/11/2023) was reviewed and included, "...Reassessment: To be carried out by an ED RN (Emergency Department Registered Nurse)...Reassessments should occur when there is a significant change in the patient's condition or if the reassessment is due per the guidelines noted below...this should include a focused reassessment, vital signs, and a pain assessment ...Level 2: < (less than or equal to) 2 (two) hours ...Level 3: < (less than or equal to) 3 (three) hours ...".

2. On 9/23/2024, the clinical record of Pt. #1 was reviewed and indicated that on 5/20/2024 at 10:31 PM, Pt. #1 presented to the Emergency Department (ED) by private vehicle with chief complaint of fever (allergic reaction). The clinical record included the following:

- On 5/20/2024 at 10:42 PM, the 'ED Triage Adult Assessment' indicated that vital signs (Temperature Oral: 37.3 DegC [degrees Celsius] (reference range: 36.1 to 37.2 Celsius) , Peripheral Pulse Rate: 122 bpm [beats per minute] (HI/reference range 60 to 100), Systolic Blood Pressure: 145 mmHg [millimeters of mercury] (HI/reference range 120), Diastolic Blood Pressure: 88mmHg (reference range: 80), Respiratory Rate: 20 br/min [breaths per minute] (reference range: 16-20), SpO2: 93% (reference range: greater than 90), Oxygen Therapy: Room air) and pain level (8 of 10) were assessed, and Pt. #1 was given an ESI (Emergency Severity Index) of 2 (Emergent: patient still very ill ...High risk situation).

- On 5/20/2024, the 'Pain Assessment and Vital Signs' flowsheets indicated that Pt. #1's pain and vitals were performed at 10:42 PM (time of Triage Assessment) and a subsequent temperature check on 5/21/2024 at 12:05 AM was performed. The clinical record lacked the complete set of vital signs or reassessment (on 5/21/2024) as required by policy. The time between the initial assessment and patient departure was 3 hours and 13 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame.

3. On 9/24/2024, the clinical record of Pt. #6 was reviewed and indicated that on 9/23/2024 at 9:54 AM , Pt. #6 presented to the ED by private vehicle with chief complaint of anuria (failure of the kidneys to produce urine). The clinical record included the following:

- On 9/23/2024 at 9:57 AM, the 'ED Triage Adult Assessment' indicated that vital signs and pain level were assessed, and Pt. #6 was given an ESI (Emergency Severity Index) of 3 (urgent/care required as soon as possible: condition presents a danger if not treated).

- On 9/23/2024, the 'Pain Assessment and Vital Signs' flowsheets indicated that Pt. #6's pain and vitals were performed at 9:57 AM (time of Triage Assessment) and 1:42 PM (time of Nurse Reassessment). Vital signs at 9:57 AM were: Temperature 36.3 celsius, Pulse 79, Respirations 18, Blood pressure 116/69 and oxygen 99% on room air. Vital signs at 1:42 PM were: Temperature (not assessed), Pulse 84, Respirations 20, Blood pressure 121/59, oxygen 98% on room air, and pain 0 out of 10 (10 being worse pain). The time between assessments was 3 hours and 45 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame, as required.

4. On 9/24/2024, the clinical record of Pt. #7 was reviewed and indicated that on 9/23/2024 at 2:37 PM, Pt. #7 presented to the ED by private vehicle with chief complaint of fever for three days. The clinical record included the following:

- On 9/23/2024 at 2:43 PM, the 'ED Triage Adult Assessment' indicated that vital signs and pain level were assessed, and Pt. #7 was given an ESI of 3. Vital signs at 2:43 PM were: Temperature 37.9 celsius, Pulse 103, Respirations 20, Blood pressure 171/91 and oxygen 98% on room air. Vital signs at 8:20 PM were: Temperature (not assessed), Pulse 87 (on heart monitor), Respirations 20, Blood pressure 175/94, oxygen 96% on room air and pain 0 out of 10.

- On 9/23/2024, the 'Pain Assessment and Vital Signs' flowsheets indicated that Pt. #7's pain and vitals were performed at 2:43 PM (time of Triage Assessment) and 8:20 PM (time of nurse reassessment). The time between assessments was 5 hours and 37 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame, as required.

5. On 9/25/2024 at approximately 10:00 AM, an interview with the ED Manager (E #5) was conducted. E #5 confirmed, after review of patient's (Pt. #1, Pt. #6, and Pt. #7) medical record, that vital signs, pain, and focused reassessments were not completed, as required per policy.