HospitalInspections.org

Based on record review, document review, and staff interview, it was determined the facility failed to follow their policy for reassessing patients in the Emergency Department (ED) waiting room every two (2) hours for one (1) of one (1) patient admitted into the hospital from the ED waiting room, Patient #1. This failure has the potential to negatively impact all patients presenting to the ED for treatment and admission to the hospital.

Findings include:

A record review was conducted for patient #1. The patient presented to the ED with confusion on 10/19/22 at 12:55 p.m., accompanied by family, upon the advice of their primary care physician (PCP). The documented ED Course included, but was not limited to:

1:01 p.m. Vital Signs were recorded. No additional documentation of vital signs was noted.
1:08 p.m. Triage was completed by Registered Nurse (RN) #1; the acuity level was documented as three (3). No additional documentation of a nursing assessment or reassessment was noted.
1:14 p.m. Electrocardiogram (EKG) was obtained.
2:31 p.m. Assessed by Physician Assistant (PA) #1.
3:04 p.m. Lab Work was obtained.
3:32 p.m. Chest X-ray was performed.
3:54 p.m. Urine for analysis was obtained.
5:24 p.m. Computed Tomography (CT) scan of the head was performed.
5:26 p.m. Decision was made to admit Patient #1 to the hospital under the care of the PCP.

During the stay in the ED, the patient was returned to the ED waiting room after each assessment or procedure. At 9:20 p.m., the patient was still in the ED waiting room. The family told PA #1 they were leaving against medical advice (AMA) and left prior to signing the paperwork.

The policy titled "Assessment and Reassessment Policy - Emergency Department," last effective 04/22, was reviewed. The policy states in part: "Ongoing Assessment ... Level 3 Urgent. Conditions that could potentially progress to a serious problem requiring emergency intervention ...Vital Signs and reassessment as clinically appropriate ... Waiting room reassessment - If a patient is placed back into the waiting room a reassessment of the patient's condition and/or symptoms needs to be performed ... Patient reassessment in the waiting room is required every [two] 2 hours. The reassessment may include some or all of the following: vital signs, physical assessment, pain assessment, general appearance, and/or responses to intervention and treatment."

The policy titled "Triage," last effective 06/22, was reviewed. The policy states in part: "Emergency Severity Index Levels ... Level 3 - Patient will need several resources ... Waiting room reassessment - If patient is placed back into the waiting room a reassessment of the patient's condition and/or symptoms needs to be performed ... Patient reassessment in the waiting room is required every [two] 2 hours. The reassessment may include some or all of the following: vital signs, physical assessment, pain assessment, general appearance, and/or responses to intervention and treatment."

The facility's Nursing Matrix, dated 08/13/20, was reviewed. The staffing ratios of nurses per patients for each department was delineated.

A telephone interview was conducted on 11/29/22 at 1:53 p.m. with ED Physician #1 regarding patient #1's ED visit on 10/19/22. Physician #1 stated PA #1 assessed and treated Patient #1 throughout the ED visit on 10/19/22; the chart was reviewed and signed by [Physician #1], but no eyes-on assessment was performed, as there would only be a consult during patient #1's ED stay if the patient was unstable or critical. Physician #1 stated in part, "There are prolonged wait times, and it is concerning that the vital signs were not repeated, but the blood pressure was not medically unstable. Had the patient been considered unstable, we would have pulled [Patient #1] from the waiting room and into an ED bed at triage." Regarding transferring patients to other facilities when beds are not readily available, Physician #1 stated, "We try to transfer to other facilities when the patient requests it, but it is nearly impossible to get the facility to accept the admission post COVID. We hold them in the ED categorized as transitional patients until a room opens up in the hospital."

An interview was conducted on 11/28/22 at 1:10 p.m. with PA #1 regarding patient #1's ED visit on 10/19/22. PA #1 assessed and treated Patient #1 throughout the ED visit on 10/19/22 and stated the ED Physician is not consulted on every patient being seen, only if the patient becomes unstable or critical. PA #1 stated, "We treat patients in the waiting room all the time. Several patients have waited more than twenty-four (24) hours for a bed. The patients in the waiting room need to have their vital signs checked and be reassessed every two (2) hours. The triage nurse takes care of that." PA #1 further stated, "The PCP wanted [Patient #1] admitted to the hospital for a Neurology consult and an MRI [magnetic resonance imaging] for sub-acute [recent] changes on the CT of the head. There was an old stroke, but nothing acute that needed immediate treatment." PA #1 had explained to the family there would be a wait on the room (both in the ED and hospital), and the family did not request a transfer to another facility. PA #1 confirmed that transfers are not routinely offered as a result of long waits for beds but are offered for the need for increased level of care above what the hospital offers.

An interview was conducted on 11/29/22 at 12:45 p.m. with RN #1 regarding patient #1's ED visit on 10/19/22. RN #1 had triaged and assumed the care of patient #1 while in the waiting room. RN #1 stated the standard of care was to obtain vital signs and reassess patients every two (2) hours while they were in the waiting room of the ED. RN #1 confirmed that Patient #1 remained in the waiting room when not receiving testing during the entire stay until leaving AMA and conceded there was no documented evidence of a reassessment or vital signs obtained every two (2) hours.

An interview was conducted on 11/29/22 at 12:10 p.m. with RN #2 regarding bed assignments for patients in the ED. RN #2 stated that as the Nursing Supervisor, all bed assignments for ED admissions went through whoever was on shift as the Nursing Supervisor. RN #2 stated the nursing matrix was followed closely, and although the facility had beds available, due to the lack of availability of nurses, it caused a back-up of patients in the ED and long wait times.