HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure a reassessment was completed every two (2) hours for two (2) of eleven (11) Emergency Department (ED) records reviewed (patients #1 and 8). This failure has the potential to cause harm to all patients seeking medical care in the ED.

1. Review of the medical record for patient #1 revealed the patient arrived at the ED on 12/29/16 at 4:11 p.m. with complaints of runny nose, tugging of the ears and fussiness, and was triaged at 4:12 p.m. An assessment was completed and vitals signs were taken. No further nursing assessments or vital signs were taken before the patient was discharged at 10:40 p.m.

2. Review of the medical record for patient #8 revealed the patient arrived at the ED on 12/29/16 at 4:33 p.m. with complaints of cough, congestion and shortness of breath, and was triaged at 4:39 p.m. An assessment was completed and vital signs were taken. No further nursing assessments or vital signs were taken before the patient was discharged at 8:45 p.m.

3. An interview was conducted on 2/7/17 at 10:05 a.m. with Registered Nurse #1. When asked if she remembered patient #1, she stated, "No". When asked the normal procedure for reassesment of patients in the ED waiting room and documentation of vital signs, she stated, in part: "We reassess the patient at least every two (2) hours and try to every one (1) hour. We do complete vital signs but sometimes we are just so busy they don't get documented."

4. Review of the hospital policy titled "Triage", last reviewed 1/5/17, revealed it states, in part: "Level lll non-urgent patients must be reassessed every 2 hours to determine change of condition."

5. An interview was conducted on 2/7/17 at 3:30 p.m. with the ED Charge Nurse. After reviewing the medical records of patients #1 and 8, she concurred with the above findings.