HospitalInspections.org

Based on staff interview, clinical record review, and in the course of a complaint investigation, it was determined that the hospital staff failed to ensure that only registered nurses (RN) were responsible for triage in the emergency department (ED). A licensed practical nurse (LPN) also performed triage duties. The facility staff also failed to ensure adequate staffing to ensure policies and procedures related to documentation were followed.

The findings include:

In the course of the clinical record review for Patient #6 in the survey sample, the surveyor noted LPN #1 had done the triage and care of the patient. This was also found in the review of several other patients in the survey sample.

The survey team toured the ED, with the hospital CEO, on 1/5/10 at 1:40 PM. The ED had six beds. During the tour, the survey team asked about the triage process. The CEO responded the ED did not have specific staff assigned to triage. All nurses working in the ED were responsible to do triage. The CEO also stated that all hospital nurses were cross-trained to the ED, though ED nurses did not rotate to other units.

The emergency department nursing schedules were reviewed for 9/14/09 - 10/11/09, and 12/7/09 - 1/31/10. Each schedule included the name of one licensed practical nurse, LPN #1. The LPN was listed as working full-time on the night shift (7:00 PM through 7:00 AM).

According to the schedule, two or three nurses were scheduled to work the day shift (7:00 AM - 7:00 PM) and two at night.

The survey team interviewed the Chief Nursing Officer (CNO) on 1/7/10 at 10:58 AM regarding an LPN doing triage in the ED. The CNO stated only one LPN worked in the ED. She acknowledged that LPN #1 did perform triage duties in the ED. The CNO further explained that triage was complaint driven and the LPN knew what acuity to assign for specific complaints.

On 1/6/10 at 11:30 AM, the surveyor asked the House Supervisor about the education of nurses doing triage. She stated that most of the nurses had worked in the ED for a long time. She stated the hospital did not have a specific class or education related to triage, though triage was included in the annual competency testing for the ED nurses.

RN #1, an emergency department nurse, with approximately nineteen years of experience, was interviewed on 1/7/10 at 9:08 AM. RN #1 explained that all ED nurses did triage and that she had been trained in triage years ago.

The surveyor asked RN #1 about triage at the ED. She stated that all of the ED nurses did triage. Triage included; vital signs, a history, allergies, a review of current medications, the chief complaint, and a brief assessment related to the chief complaint. As part of triage, the nurse assigned an acuity level between one and five (the acuity system changed in the summer of 2009). If the individual being evaluated had a high acuity, a '1', '2', or possibly a '3', they would be taken directly to a bed in the ED. If the acuity level was low, the patient would go to register and perhaps to the waiting area if no beds were available.

The survey team interviewed LPN #1 on 1/6/10 from 3:42 PM through 4:20 PM. The surveyors asked about the nurse's experience. LPN #1 stated that she had been a LPN for approximately five years. She had worked a medical-surgical unit for three to six months and then transferred to the ED.

The surveyors asked the nurse to describe the triage process. LPN #1 stated that all ED nurses were responsible for doing triage. The triage nurse assigned an acuity level to each patient, with a '1' being the most serious, requiring immediate help. When asked about her training related to triage, LPN #1 stated that she had approximately ninety days of orientation to the ED, which included working with an RN on the day shift, and later on the night shift.

Portions of LPN #1's personnel file were reviewed, including competency testing for 2009. The competencies included "Completes the Patient Assessment to include Learning Needs/Barriers, Functional, Social Services, ...". "Perceives Patient Problems and/or Complications." "Plans for Care that Reflects the Patient's Individual Needs." No competencies specific to triage were found.

LPN #1 did attend a departmental meeting on 6/25/09, which included a review of the new acuity levels and the revised Triage Policy.

Staff provided a copy of the hospital's Triage Policy to the survey team. The policy originated in 05-2007 and was last updated in 07-2009. In the area titled Procedure, "A. A qualified licensed Emergency Nurse with a minimum of six months experience (or less at the discretion of the manager/director) will triage every patient entering the ED and will determine priorities of care based on the physical and psychosocial needs, as well as factors influencing patient flow through the ED care system." "B. The triage nurse will demonstrate a broad knowledge of patient assessment and care and should be able to utilize the nursing process effectively. He/she should demonstrate competence evidenced by completion of the triage competency and preceptor evaluation."

In the section titled Other Issues/Concerns, "C. Staff will be educated and their competency validated on the triage policy." "D. Education and competency validation is based on the needs of the patient population served and within the scope of specific licensure and certification requirements."

On 1/8/10, a Department of Health Professions Board of Nursing staff member provided the Office of Licensure and Certification documentation that showed that conducting triage assessments was outside of the scope of practice for Licensed Practical Nurses.

It was also noted in a complaint investigation related to Patient #6, that the clinical record lacked documentation of an assessment after a fall in the ED. The patient was later found to have a fracture. Patient #6's clinical record also lacked documentation of a MSE and reassessment by the physician.

The clinical record gave no indication that Patient #6 had fallen or that a post-fall assessment had been done by the nurse or physician. The surveyor reviewed the policy and procedure titled ' Fall Prevention' . The area titled 'Monitoring, Documentation, and Compliance' included the following instructions; 1. "Documentation will include all patient behaviors, interventions, education, and follow-up." 2. "Physician will be notified of any fall issues." 3. "The nurse will document that the physician was notified, date and time and if orders received." In interviews, both the nurse and physician stated that post-fall assessments had been done for Patient #6. Both acknowledged that such assessments should have been documented in the record.

The lack of documentation in other clinical records also made it difficult to see a clear picture of what had happened to individuals during their visit to the ED.

In the interview with RN #1, the surveyors asked about documentation. RN #1 responded, "I'm certain" the clinical records do not always reflect the care that was done. She stated that care may not be documented when staff were busy.

ED nursing department meeting minutes were reviewed for the previous six months. On 6/25/09 (attended by LPN #1 and RN #1), documentation was included on the agenda. The ED changed to an electronic record later in June 2009. "Please remember that the medical record still needs to be viewed as a complete "story" and it needs to be complete. If it is not documented it has not been done. Be aware of times and tell the entire story, vital signs, rechecks, and document, document, document, consistently and follow policies."

The ED physician's schedules were reviewed for September 2009 through January 2010. Physicians were usually scheduled for twenty-four hour shifts (9:00 AM - 9:00 AM), with one physician working at a time.

The 'Assessment/Reassessment - Emergency Services (Physician)' policy and procedure was reviewed. Medical History - "All patients presenting to Emergency Services shall have a medical history assessment pertinent to their clinical needs. Documentation of the medical history shall be made at the time of the patient visit in the EMR (Electronic Medical Record)."

The survey team met with the Director of Clinical Effectiveness (QAPI nurse) and Chief Nursing Officer (CNO), on 1/7/10 at 1:47 PM, to discuss the facility's performance improvement program. The QAPI nurse stated "issues with inadequate documentation" had been discussed in the senior leadership committee, "particularly on the ER charts".