HospitalInspections.org

Based on record review and interview, the facility failed to ensure that patients were assessed according to the Facilities Emergency Severity Index (ESI- Facility level rating for level of severity of symptoms as per facility). This failed practice is likely to cause patient harm.

The findings are:

A. On 12/16/21, review of the facility's policy titled, "Triage in the Emergency Department," effective 02/08/2021 reveals " Vital signs are a part of the on going patient assessment and should follow the recommended ESI guidelines according to the patients ESI classification or more frequently as the clinical judgement and patient condition warrants. This includes patients in the waiting room."

B. Record review of Policy titled: "Triage in the Emergency Room" dated 02/08/21 #6 confirms, "Vital signs are a part of the on-going patient assessment and should follow the recommended ESI (Emergency Severity Rating, the algorithm yields rapid, reproducible and clinically relevant stratification of patients into five groups from level 1 (most urgent) to level 5 (least urgent) guidelines according to the patient's ESI classification or more frequently as clinical judgement and patient condition warrants. This includes patients in the waiting room. 6.1 ESI 1 frequency based upon the severity of patient's condition. 6.2 ESI 2: every 1-2 hours. 6.3 ESI 3: every 2-3 hours. 6.4 ESI 4and 5: every 3-4 hours. 6.5 Within 30 minutes of discharge from the ED. This should include a full set of vital signs. 6.6 Revitalization of patients waiting in the lobby will occur according to ESI scores.

C. On 12/16/2021, at 10:00 am during interview with Staff (S)#14 (Triage Nurse) confirmed that patients with an ESI of 3 are to have vitals conducted every two to three hours as per facility ESI Policy.

Based on record review and interview the facility failed to assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available for proper monitoring of patients for 2 of 10 patient records reviewed (P(Patient) 1 and 9). This failed practice increases the likelihood of patients not receiving the care prescribed.

The findings are:

A. Record review of Emergency Department medical record for P1 date of admission 09/27/21 reveals patient was seen in the Emergency Department with a diagnosis of Dementia (A chronic or persistent disorder of the mental processes) and symptoms of a Urinary Tract Infection (infection of the urinary system) and given a Triage Rating of Level 3 ( the algorithm yields rapid, reproducible and clinically relevant stratification of patients into five groups from level 1 (most urgent) to level 5 (least urgent) guidelines according to the patient's ESI classification or more frequently as clinical judgement and patient condition warrants) and was sent to the waiting room to await treatment. During the day-shift, patient was admitted at 5:27 pm and patient was seen for vitals and lab draws, had labs drawn at 6:30 pm and the specimen was clotted and was redrawn but no evidence of it getting to the lab or any follow-up on results. Last time patient was seen was 6:30 pm. Patient had no follow-up, vitals or labs from that time to the time he was discovered to have eloped at 7:48 am (first check), 10:44 am (second check), 10:52 am patient documented as eloped. No patient contact made for over 13 hours. The patient was in the Emergency Department for his entire stay and was later found at the bus station by the fire department and was transported to his living facility safely.

B. Record review for P9 date of admission 09/27/21 reveals patient was seen in the Emergency Department with a diagnosis of Altered Mental State (A disruption in how your brain works that causes a change in behavior) and was given a Triage Rating of Level 3 and was sent to the waiting room to await treatment. Last time patient was seen was 10:24 pm. Patient had no follow-up, vitals or labs from that time to the time patient was discovered to have eloped at 10:54 am. No patient contact made for 12 hours.

C. Record review of Policy titled: "Triage in the Emergency Room" dated 02/08/21 #6 confirms, "Vital signs are a part of the on-going patient assessment and should follow the recommended ESI (Emergency Severity Rating, the algorithm yields rapid, reproducible and clinically relevant stratification of patients into five groups from level 1 (most urgent) to level 5 (least urgent) guidelines according to the patient's ESI classification or more frequently as clinical judgement and patient condition warrants. This includes patients in the waiting room. 6.1 ESI 1 frequency based upon the severity of patient's condition. 6.2 ESI 2: every 1-2 hours. 6.3 ESI 3: every 2-3 hours. 6.4 ESI 4 and 5: every 3-4 hours. 6.5 Within 30 minutes of discharge from the ED. This should include a full set of vital signs. 6.6 Revitalization of patients waiting in the lobby will occur according to ESI scores.

D. Record review of "ESI Triage Guidelines - Adult" dated 2021, confirms "patient at a level 3 as Non-urgent, requires evaluation and treatment but will not cause loss of life or limb if left untreated for several hours. Recommended Assessment every 2-3 hours".

E. On 12/15/21 at 1:30 pm during interview with Staff (S)8, Lab Manager, S2 Clinical Regulatory Accreditation and S1 Chief Nursing Officer, confirmed "If a lab is to be collected but is not received the lab will follow-up. If it shows up as lab to collect and if it has not been received, they would go to the ED to collect or ask if it needs to be drawn. The lab would not know if labs need to be collected." Our systems are interfaced but we do not have a way to show if labs are pending collection. If a patient is in a waiting room at level 3,4,5 it is very easy to not pick up on missed labs. This patient symptoms did not trigger follow-up. It was a different day and we do have processes in place but even if we had a hundred beds we couldn't follow up on all of them. If they are higher risk there would be more closely followed."

F. On 12/16/21 at 9:30 am during interview with S14 Triage Nurse, confirmed, "I don't recognize the name of P1. I no longer work for Presbyterian Hospital. I don't remember anything about this patient. Honestly, I don't remember him. S14 answered questions related to the case based on facility records. Our process through EMS (Emergency Medical Services) would bring them to triage and give report with patient present. As far as paperwork it goes in their chart. Any significant test results is put in chart. If the patient brings in paperwork it is scanned into the chart later. It depends on how a patient presents if a patient is altered we keep them up in the front, especially older patients or with a UTI. When shift changes we go over any patients we are concerned about and how they are presenting. Patients we are concerned about are in the bay with us. We discuss patients who are in the lobby. The lab calls the ER to let them know if labs are clotted. They will tell triage nurse or charge nurse. We use the comments section to communicate. We try to make sure all comments related to labs are current. I wouldn't say I tell them personally but we go over it side by side. General rule is to check on the person every 2 hours if they have abnormal signs or vital signs. Some patients don't have serious vital signs still every 2 hours. The goal is to make sure the patient is still there. We try to get vital signs any time there is contact with patient. This would be charted in the permanent chart. The role call would be charted in the comment section that is not retained as a part of the permanent chart.