HospitalInspections.org

Based on clinical record review, staff interview, review of facility documents and during the course of a complaint investigation, the facility staff failed to ensure the assessment of a patient's health status was evaluated periodically when the patient was awaiting care in the Emergency Department for one (1) patient Patient #4.

The findings included:

Patient #4 presented to the Emergency Department with complaints of abdominal pain and was not reassessed for approximately six hours. The patient was designated as AMA (against medical advice), when after a total of approximately eight (8) hours from triage/sign in, the patient left the ED.

A Review of the Medical record for Patient #4 revealed the patient presented to the ED (Emergency Department) at 14:37 (2:37 p.m.) on 9/21/2020. The medical record documents the patient was triaged at 15:10 (3:10 p.m.) and assessed by Staff Member #26 Emergency Room Physician. Patient #4 was assigned "Acuity and ESI" (emergency Severity Index) "3", which according to the facility Policy indicated "Level III - many resources needed and abnormal vital signs". A Urinalysis was ordered and collected at 15:11 (3:11 p.m.). Other Lab work was ordered and collected at 17:41 (5:41 p.m.) The lab work was returned and reviewed by the physician and according to the results indicated abnormal values for the urinalysis (moderate blood present). Other labs showed abnormal glucose -136 (normal range 70-100) Co2-29- (normal range 20-28), Glomeular filtration rate- 58 (normal range greater than or equal to 60) and alkaline phosphatate 167 (normal range 40-150). The clinical record documented the patient was discharged from the ED at 23:37 (11:37 p.m.) AMA (against medical advice). Further review of the record revealed no documentation of the patient having been reassessed from the time the lab was collected at 5:41 p.m. until discharge at 11:37 p.m. (almost 6 hours).
There was no documentation that the patient had been asked to or informed staff that they were to wait in the car.

On 11/9/2020 at 1:50 p.m., the surveyor asked for an explanation of the ESI level III (3) index. It was explained by Staff Member #28 that the acuity three was in the middle of the scale and that it could "go either way" (either more severe or less) depending on the results of any labs and provider assessment. If the patient has no change in condition and labs are not seriously concerning then "higher level acuity" would be taken for treatment first..."

At 8:40 a.m., on 11/11/2020, Staff Member #27, A ED Registered Nurse stated, "The process is to call the patient up every hour and repeat the vital signs and evaluate how the patient is doing. We do not encourage patients to wait in their car but some do since the COVID pandemic. We tell them we cannot see them if they are in their car and that we can't assess them, and encourage them to wait in the waiting room where we can see them... if they tell us they are going to their car we ask for a number where we can reach them... if lab work is obtained on a patient and it is abnormal the physician will review it and if necessary the patient will be taken in and reassessed as soon as the results come back of they indicate a problem that needs to be addressed immediately...there should have been a note if the patient told us they were going out to their car, but we would have to have been told they were doing that...there should also be a note saying they were called back to triage for reassessment and vital signs..."

On 11//12/2020 at 915 a.m., Staff Member #28, ED Director stated, "Our policy does not specify how often reassessment occurs- there are no specific timeframe's...it is based on any change in the condition..."

The facility policy for "Triage Process" was reviewed and documented, in part, "Reassessment of patients in the Emergency Department Lobby: Shall be completed by the triage nurse based on acuity and with any change in condition. Patients may remain in the lobby if their condition remains stable. Patients will be transported immediately to the treatment area of their condition deteriorates..." The policy did not evidence any specific time frame (one hour) for reassessment.

The surveyor discussed the concerns regarding no documented check or assessment of the patient for the almost 6 (six) hours after lab work was obtained. There was no documentation of the patient being recalled to see if they were still present in the ED or if their condition had changed. Even though the facility policy did not specify the time frame for reassessment, the surveyor discussed the concern that not once during the patients time in the ED were vital signs reassessed/documented. These concerns were discussed on 11/10/2020 at 11:00 a.m. with Staff Members #4 (director of Accreditation and licensure), #6 (Accreditation and Licensure Specialist), #7 (Senior Director Legal services) and #9 (Licensure and Accreditation Specialist). The findings were again reviewed at the exit conference on 11/12/2020 at 11:15 a.m. with the above staff and multiple facility Administrative Leaders.

Based on observation, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to ensure proper infection control procedures were taken for the mitigation and prevention of the spread of infection including COVID19.

The findings included:

Hand sanitizer was not accessible/visible to visitors who came in through the main entrance screening station. The hand sanitizer was placed in an area that was in an alcove where wheelchairs were stored and visitors were not directed to this area in order to perform hand hygiene prior to entering the facility.

The waiting area of the Emergency Department had chairs which were accessible for use by patients/visitors that were not designated/spaced for social distancing and there was a small table in the vending area that had chairs placed around it with no ability to social distance when using the area.

Upon arrival to the facility on 11/4/2020 at 12:15 p.m., at the "main entrance" screening station, there was no hand sanitizer visible to visitors who were entering the facility. After being screened, the surveyor was not able to locate hand sanitizer to use before entering and asked the screening staff where to find sanitizer. The staff directed the surveyor to a wall mounted sanitizer station which was located behind the screening podium in an alcove where wheelchairs were kept. The sanitizer was not accessible/visible to anyone coming in and staff were not directing visitors where to find the sanitizer.

On 11/4/2020 at approximately 1:40 p.m., the survey team toured the facility emergency department. It was observed in the Emergency Department (ED) waiting room there were chairs which contained signage indicating they were not to be used in order to promote social distancing, however there were areas in which chairs were not designated (lined up arm to arm in rows) and patients/visitors in the ED were observed changing seats and moving around the room- going from chair to chair, especially in the areas which had no signage on the chairs to promote social distancing. There was a small vending area at he back of the ED waiting room which had two vending machines. There was also a small table surrounded by four chairs, which did not allow for adequate spacing between the chairs. The chairs were arm to arm around the table. Staff Member #2 (Managing Director Acute Care) was present at the time of the observation and the concerns were discussed at that time. The surveyor also discussed the concern regarding the hand sanitizer station and availability at the facility main entrance.

The surveyor requested and received the cleaning schedule for the ED waiting room. This schedule indicated the waiting room, including chairs were cleaned by Environmental services at approximately 6:40 a.m., 2:45 p.m., and 10:40 p.m.

The surveyor also discussed the concerns regarding the observations of the lack of signage and placement of chairs/table in the ED waiting area to encourage/ensure social distancing. These concerns were discussed on 11/10/2020 at 11:00 a.m. with Staff Members #4 (director of Accreditation and licensure), #6 (Accreditation and Licensure Specialist), #7 (Senior Director Legal services) and #9 (Licensure and Accreditation Specialist). The findings were again reviewed at the exit conference on 11/12/2020 at 11:15 a.m. with the above staff and multiple facility Administrative Leaders.