HospitalInspections.org

Based on clinical record review, staff interview and review of policy and procedure it was determined the Emergency Department (ED) failed to implement policy and procedures to provide care and services for one (#1) of ten sampled patients.

Findings include:

1. Patient #1 presented to the ED on 2/3/14 at 9:34 p.m. via ambulance. The patient was triage at 9:46 p.m. with a chief complaint of a headache and seizures 1-2 hours ago. The vital signs did not include the heart rate and temperature. The pain level of the headache was not assessed. The acuity was noted as 3H (horizontal).

Review of Policy and Procedure "Plan of Care for Emergency Care Center" #ET-4 revised 1/14 section A. 2. Vital Signs are taken on arrival, repeated based on the triage category or any change in condition. Level 3 indicated vital signs were to be reassessed very 3-4 hour. Vital signs include temperature, blood pressure, respiration, heart rate and oxygen saturation level. Pain score should be considered for patients in pain. #8. triage category 3 was noted as Urgent. There were no indications for the level of 3H.

ED Registered Nurse (RN) nursing notes dated 2/4/14 at 12:24 a.m., approximately three hours after arrival, indicated the RN was called to the quiet room for "having a seizure". The patient was noted to be moving bilateral upper and lower extremities in a jerking motion. The patient was awake but not answering question. The documentation noted the RN questioned a postictal state. There was no evidence the physician was notified or the vital signs assessed for the change in condition. The documentation noted the patient was taken a room.

ED RN nursing documentation at 1:00 a.m. indicated the patient was taken a room with a steady gait. This was not consistent with the documentation that the patient was taken to a room at 12:26 a.m. ED RN documentation revealed an assessment was performed. The vital signs at 1:09 a.m. were the blood pressure, heart rate, respirations, and oxygen saturation level. There was no pain assessment of the presenting symptom of the headache or temperature. The documentation noted peri orbital swelling and bruising to the right eye. The documentation noted abrasion to the right upper forehead and right elbow and forearm. There was no documentation on how or when the injuries were obtained in a patient with seizures.

Review of ED physician documentation revealed the patient was seen at 2:00 a.m. The documentation noted the patient had low back pain, right elbow pain and bilateral temporal headache. Review of the physical exam revealed a small hematoma to right forehead with abrasion and bruising of right eyelids multiple bruises of right arm and lower extremities. There was no evidence of how the injuries were obtained.

ED RN nursing documentation at 4:00 a.m. revealed the patient left the ED without completing the intravenous anti-seizure medication. There was no evidence the physician was notified the patient left without completing the anti-seizure medication.

Interview with the Director of Emergency Services and Chief Nursing Officer on 3/24/14 at approximately 2:20 p.m. revealed
if a patient is a horizontal 3 triage level they will be seen within 3-4 hour and reassessed within 3-4 hours as needed. The Director of Emergency Services confirmed there was no documentation of when or how the bruising occurred or any further documentation of the vital signs.

There was no evidence of a policy addressing the care of a Level 3 horizontal patient.