HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of 17 medical records reviewed, the facility did not implement its policy and procedure to ensure that patients received timely medical evaluation in the Emergency Department (ED).

Findings include:

Review of medical record for Patient # 2 identified: A 28-years-old at seven weeks gestation who presented to the ED on 11/26/18 at 10:41 pm with complaints of vaginal spotting for one week. The patient was triaged at 11:55 pm, and she was assigned an Emergency Severity Index - Level 3 (Urgent medical conditions). The patient waited to be called for a physician evaluation.

On 11/27/2018, at 06:30 am, nurse notes, "Patient voluntary left the ED."

Review of policy titled "Emergency Department Triage" last revised 07/03/17, notes that ESI level 3 are patients presenting problems that require diagnostic evaluation and treatment in the ED but are not time critical in nature and the patient's vital signs are stable. The timeframe for initiation of treatment by a physician is within 4 hours.

There was no documented evidence that the patient was evaluated by a physician within four hours of triage.

Review of policy titled "Vital Signs" last revised on 12/21/17, revealed that patient's vital signs should be obtained on admission, transfer, on arrival to the unit post procedure, and every 4 hours, or as ordered by the physician.

There was no documented evidence of a reassessment of the patient's vital signs within the timeframe specified by the policy.
The patient's vital signs were taken on 11/26/18 at 11:55 pm, during triage, and on 11/27/2018, at 05:58 am which was approximately 6 hours after the first set of vital signs were obtained.

During interview on 01/31/19 at 1:09 pm with Staff C (Director of Regulatory Affairs); and on 02/01/19 at 2:00 pm with Staff B (MD, Emergency Department Chief) they acknowledged findings.