HospitalInspections.org
Bringing transparency to federal inspections
OAK VALLEY HOSPITAL DISTRICT
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on observation, interview, clinical record and administrative document review, and review of Department of Health & Human Services publication, the hospital failed to provide an appropriate and timely Medical Screen Examination (MSE) within the capability of the Emergency Department (ED) for 5 of 24 sampled patients (Patients 1, 6, 14, 15, 22) when the triage and MSE process was delayed between the time of registration and triage by the assigned registered nurse (RN). Patient 1's triage was delayed 88 minutes and delayed the MSE process by the Qualified Medical Provider (QMP) and possibly contributed to the death of Patient 1. The delay in triage for Patients 6, 14, 15 and 22 led to a delay in the QMP assessing the patients and/or contributed to the patient leaving the hospital without being seen.
Findings:
The clinical record indicated Patient 1, a 12 yr. old male, arrived by private vehicle to the ED, on 2/19/15 at 9:32 p.m. Patient 1, accompanied by a parent, presented to the registration desk complaining of abdominal (Abd - digestive tract) and flank (rib and hip) pain. Patient 1 was registered and took a seat in the lobby (waiting room). No vital signs were taken at the registration desk. Patient 1 was not seen by a nurse until he was called in for triage at 11 p.m., which was 1 hour and 28 minutes later. At triage, Patient 1's pulse was recorded at 258 beats per minute and the triage nurse documented Patient 1's color as "sallow" (an unhealthy yellow or pale brown skin tone). Patient 1 was then assigned an ESI of 1 (unstable- required immediate life-saving intervention) and was walked to a room in the ED. A MSE was started at 11:02 p.m., 2 minutes after triage, 1 hour 30 minutes after registration. Patient 1 went into cardiopulmonary arrest, received cardiopulmonary resuscitation (CPR), and expired at 2:14 in the morning.
The U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality (AHRQ) Publication # 11(12)-P014 - Emergency Severity Index (ESI): A Triage Tool for Emergency Department Implementation Handbook, 2012 Edition; Version 4 indicated, "Introduction to the Emergency Severity Index: A Research-Based Triage Tool Standardization of Triage Acuity in the United States, The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment... The Centers for Disease Control and Prevention National Center for Health Statistics reports national level data regarding ED visits (Niska, Bhuiya, & Xu, 2010
The hospital's ED P&P titled, "Triage," dated 5/2013, indicated, "Triage Protocol - Purpose - To ensure an effective method to separate those patients who require immediate medical attention from those patients who have non-urgent problems, to ensure prompt evaluation of all patients entering the Emergency Department... Triage Procedure - Purpose - To provide registration and emergency personnel guidelines to ensure that all emergency department patients receive appropriate care in a timely [timely was not defined] manner... Content - 1. Patient will be clocked in by ER [Emergency Room] admitting staff and brought back to triage room for triage..."
On 4/8/15 at 11:27 a.m., a guided tour demonstrating patient traffic flow through the ED and concurrent interview with the Interim Director (ID) of the ED was conducted. The lobby was located next to but was not in direct view of the triage room or the registration desk. The ID stated patients entered the department through the ambulance entrance or through the front entrance. Those arriving by ambulance were triaged immediately. Patients that arrived other than by ambulance presented to the registration desk and could go directly from registration to triage. However, if the department was impacted with an influx of patients, as it often was, they would be directed to wait in the lobby until triage. Depending on the ESI level assigned at triage, patients were then either taken to the back for a MSE, or sent back to the lobby to wait. The ID stated wait time between registration and triage should not be greater than ten minutes, and the wait time from triage to MSE depended on the ESI assigned at triage.
On 4/9/15 at 10:40 a.m., during an interview with the nurse that performed the triage on Patient 1, Licensed Nurse (LN) 1 stated she was an experienced travel nurse. She stated the day in question was her second day on the job at the hospital. The preceptor who had been assigned to her had been allowed to go home early. She was working independently; she had not been assigned to a substitute preceptor. LN stated, she was unable to see the lobby from the triage area. She was able to view via a computer screen, patients' names, birth dates, and chief complaints as they registered and their information was entered into the computer. LN 1 stated she selected the order to triage patients based on data entered by registration staff (patient ages and chief complaints) without ever laying eyes on the patients. LN 1 stated (at triage) Patient 1's vital signs, taken by a machine, indicated a heart rate of over 236. LN stated she noticed Patient 1's skin tones were "sallow". LN 1 stated she listening with a stethoscope to check Patient 1's heart rate and determined it was too fast to count. She notified the charge nurse and walked the patient to a room. LN 1 stated, "It should take three to seven minutes to triage a patient." LN 1 stated her decision was to triage infants and others with respiratory (breathing) problems before she saw a [seemingly healthy] 12 year old with abd/flank pain which was able to walk into the department.
On 4/9/15 at 11:50 a.m., during an interview, the Registration Clerk (RC) 1 who registered Patient 1 on 2/19/15, stated if a patient comes in complaining of chest pain, difficulty breathing, possible stroke or any trauma, she would call the triage nurse or the nurses station immediately. Otherwise, she sends the patient to the lobby and places the paperwork on the counter, (in a pile, if multiple patients arrived at or near the same time) for the triage nurse.
On 4/9/15 at 12:35 p.m., during an interview, LN 2 stated she was a per diem nurse who worked in the ED on 2/19/15. She stated 2/19/15 was her second day as an ED nurse at the hospital and she had a preceptor she worked with. She stated a patient should not have to wait more than 10-15 minutes to be triaged.
On 4/9/15 at 5 p.m., during an interview, the Charge Nurse (CN) stated he had been a nurse for approximately 22 years, 6 years experience in the ED. He was CN on 2/19/15. CN stated, "Triage should occur within a short time [of registration/arrival to the ED], 10-15 minutes [maximum]."
On 4/9/15 at 5:25 p.m., during an interview, LN 3 stated she was a travel nurse with 21 years experience. She stated, "When I triage I want to see the patients within ten minutes of registration."
On 4/10/15 at 11:55 a.m., during an interview, the House Supervisor (HS) stated he expected a patient to be triaged within 10-15 minutes of presenting to the ED and registering.
The clinical record indicated Patient 6, a 32 yr. old female, arrived to the ED, on 12/10/14 at 2:36 p.m. Patient 6 presented to the registration desk complaining of nausea, vomiting, and diarrhea. Patient 6 was registered and took a seat in the lobby until the nurse called her in for triage at 3:45 p.m., one hour and nine minutes later. At triage, Patient 6 was assigned an ESI of 2 (likely life threatening- high risk situation). A MSE was started at 3:51 p.m., 6 minutes after Patient 6 was triaged, 1 hour and 15 minutes after registration. Patient 6 was transferred to a higher level of care at 8:25 p.m. with acute renal (kidney) failure and diabetic ketoacidosis (uncontrolled high blood glucose due to severe insulin insufficiency).
The clinical record indicated Patient 14, a 22 yr. old male, arrived to the ED, on 2/19/15 (same night as Patient 1) at 8:42 p.m. Patient 14 presented to the registration desk complaining of abd pain. Patient 14 was registered and took a seat in the lobby until the nurse called him in for triage at 9:44 p.m., one hour and two minutes later. At triage, Patient 14 was assigned an ESI of 3 (stable- unlikely but possibly life-threatening). A MSE was started at 10:58 p.m., 1 hour and 14 minutes after triage, 2 hours and 16 minutes after registration. Patient 14 left before medically discharged.
The clinical record indicated Patient 15, a 25 yr. old female, arrived to the ED, on 2/19/15 (same night as Patient 1) at 9:14 p.m. Patient 15 presented to the registration desk complaining of knee pain. Patient 15 was registered and took a seat in the lobby until the nurse called her in for triage at 10:07 p.m., 53 minutes after registration. At triage, Patient 15 was assigned an ESI of 4 (stable- not life-threatening). A MSE was done at 10:56 p.m., 49 minutes after triage, 1 hour and 42 minutes after registration.
On 4/10/15 at 1:35 p.m., during concurrent interview and clinical record review, LN 4, a staff ED nurse, stated, "Fifty-three minutes is a long time to wait for triage! The target time from registration to triage is 10 minutes."
The clinical record indicated Patient 22, a 61 yr. old female, arrived to the ED, on 3/30/15 at 8:19 p.m. Patient 22 presented to the registration desk complaining of abd/flank pain. Patient 22 was registered and took a seat in the lobby until the nurse called her in for triage at 9:14 p.m., 55 minutes later. At triage, Patient 22 was assigned an ESI of 2 (likely life threatening- high risk situation). A MSE was done at 9:42 p.m., 28 minutes after triage, 1 hour and 23 minutes after registration. Patient 22 was admitted as an in-patient with a small bowel obstruction.
The hospital ED P&P titled, "Triage," dated 5/2013, indicated, "...Triage Acuity Category- Resuscitation- Level I (Is patient dying?)... Emergent- Level II (Can patient wait?)... Urgent- Level III (Stable, requires moderate to extensive workup.)... Less Urgent- Level IV (Stable, requires minor workup.)... Non-Urgent- Level V (Stable)..."
The outline of the mandatory ED ESI Triage Class, given in 2/2015, was provided by the facility. The outline indicated the following descriptions: ESI of 1 was unstable- required immediate life-saving intervention. ESI of 2 was likely life threatening but not always obvious. ESI of 3 was stable- unlikely but possibly life-threatening. ESI of 4 was stable- not life-threatening. On page 8 of the outline, slide 3 indicated, "...Patients NOT triaged (in a timely manner) are the Achilles heel (a vulnerable point) of the emergency department. PATIENT SAFETY ISSUE!!!..."