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Based on staff interview, policy and record review it was determined the facility failed to comply with 42 CFR 489.24 related to failure to ensure a Medical Screening Examination (MSE) was performed in a timely manner according to the patient's presenting signs and symptoms for 1 (#1) of 10 sampled patients. A Medical Screening Examination (MSE) was delayed secondary to a patient not receiving an accurate acuity level from the triage nurse according to facility policy. This practice does not ensure patients received timely care/treatment for their emergent condition that may result in a negative outcome.

1) The facility failed to ensure the ED triage nursing staff followed policies and procedures approved by the Medical Staff related to the assignment of an acuity level to determine the need of which patients need to be seen as a priority. Patient #1's triage record revealed the patient presented via ambulance to the ED on 7/28/11 at 3:27 p.m. with a chief complaint of abdominal pain. Triage documentation noted the patient was in distress, cool to touch, diaphoretic, tachycardia, hypotensive (Low blood pressure)and in pain. The pain level was 8 on a scale of 1-10. The abdomen was firm, distended with diffuse tenderness. The vital signs were blood pressure of 95/49, heart rate of 112 (normal heart rate 60-100) respirations of 22, and a temperature of 96.8. The abdominal pain was described as sharp. The patient related the location as generalized and across the abdomen. The triage nurse documented the patient indicated she had centralized chest pain and vomiting. The triage assessment noted the patient was alert, appeared anxious, agitated, was pacing, and unable to sit still. The triage nurse assigned an Acuity Level 3, stable. Review of the main ED nursing progress notes dated 7/28/11 at 5:57 p.m. (almost 2 hours later) revealed "the patient was brought to exam room 5 from triage with no spontaneous respirations, no heartbeat, and was unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated in the examination room".

An interview with the Director of Quality was conducted on 12/8/11 at 1:15 p.m. She stated the patient was found unresponsive by a security guard in the waiting room. The security guard called the ED technician for assistance. The ED technician attempted a sternal rub but the patient did not respond. The guard stayed with the patient while the ED technician went to get assistance. The ED Physician's Assistant (PA), ED technician and two security guards placed the patient on a stretcher and took her to the an examination room. The patient subsequently expired three days later.

There was no documentation of the ED technician assessing the patient for a heart rate or respirations or initiating CPR while the patient was in the waiting room before leaving to obtain assistance. The main ED nurse documentation noted the patient came from triage and not the waiting area. Refer to A 2406.


2) An interview with the ED Director was conducted on 12/8/11 at 2:00 p.m. The ED Director was questioned on the event involving patient #1. The ED Director stated she looked into the patient flow but denied looking at the triage process.

3) An interview was conducted with an ED Triage/Registered Nurse on 12/8/11 at 9:30 a.m. During the interview, the ED triage process was discussed. The nurse stated the ESI (Emergency Severity Index-5 level triage algorithm that categorizes ED patients by evaluating both patient acuity and resource needs...high acuity level criteria (ESI Level 1 or 2)
training was given initially and when updates come through. The only staff that attends the training is staff that will be working in triage.

4) An interview was conducted on 12/8/11 at approximately 2:20 p.m. with the ED Clinical Director. The Director stated,"the assigned acuity levels are not important because patients are seen in the order that they come in". Refer to A 2406.

5) An interview was conducted with the Quality Director on 12/8/11 at 1:15 p.m. The Quality Director was questioned as to what kind of follow up process was completed for the event involving patient #1. The Quality Director responded she reviewed the patient records of the triage nurse involved to ascertain a trend in her triage skills. The Quality Director did not find a trend and thus did not feel any further action was necessary.

Patient #1 did not receive a Medical Screening Examination in a timely manner due to the lack of an appropriate acuity level being assigned by the triage nurse and according to facility policy. There was an approximately 2 and one half hour delay for the provision of an appropriate MSE and treatment in a patient with an emergent condition. The patient did not receive an assessment of heart rate or respiration or CPR being initiated in the waiting room when found unresponsive by a security guard.

Based on clinical record review, staff interview and policy review it was determined the facility's Emergency Department (ED) nursing staff failed to accurately triage a patient's acuity level as it related to the patient's presenting signs and symptoms to the emergency. As this lead to the physician's medical screening examination not being performed in a timely manner to determine whether or not an emergency medical condition existed for 1 (#1) of 10 sampled patients. This practice caused a delay in treatment and may have resulted in a negative outcome.

Findings include:

Patient #1's presented to the ED via ambulance on 7/28/11 at 3:27 p.m. Review of the ambulance run record noted the patient was a 54 year old female with complaints of "abdominal pain". Her vital signs were a blood pressure of 148/104, a heart rate of 100 with a heart rhythm of sinus tachycardia, and respirations of 18. At 3:23 p.m., just prior to arrival to the ED, the vitals were a blood pressure of 142/98, a heart rate of 102 and a heart rhythm of sinus tachycardia.
The patient was triaged at 4:03 p.m. on 7/28/11 with a chief complaint of abdominal pain and constipation. The vital signs were blood pressure of 95/49, heart rate of 112, respirations of 22, a temperature of 96.8, and an oxygen saturation level of 100% on room air. Triage nursing documentation revealed the abdominal pain began on 7/27/11. The pain was described as sharp. The patient related the location as generalized and across the abdomen. The patient's pain level was 8 on a scale of 0 to 10 with 10 being the worst pain. The triage nurse documented the patient indicated she had centralized chest pain and vomiting. The triage assessment noted the patient was alert, appeared anxious, agitated, was pacing, and unable to sit still. The abdomen was distended, firm, and with diffuse abdominal tenderness. The skin was cool and diaphoretic. The triage nurse assigned an Acuity Level 3, stable.
The ED Technician performed electrocardiogram (EKG) at 4:16 p.m. and gave it to the ED physician to read. The ED Technician drew blood and sent it to the lab at 4:34 p.m. Triage documentation noted the patient was sent to a room at 4:10 p.m. The documentation did not reveal to what room the patient was sent.

Review of the main ED nursing progress notes dated 7/28/11 at 5:57 p.m. (almost 2 hours later) revealed "the patient was brought to exam 5 from triage with no spontaneous respirations, no heartbeat, and was unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated in the examination room".

An interview with the Director of Quality was conducted on 12/8/11 at 1:15 p.m. She stated the patient was found unresponsive by a security guard in the waiting room. The security guard called the ED technician for assistance. The ED technician attempted a sternal rub but the patient did not respond. The guard stayed with the patient while the ED technician went to get assistance. The ED Physician's Assistant (PA), ED technician and two security guards placed the patient on a stretcher and took her to the an examination room.

There was no documentation of the ED technician assessing the patient for a heart rate or respirations or initiating Cardiopulmonary Resuscitation (CPR) while the patient was in the waiting room before leaving to obtain assistance. The main ED nurse documentation noted the patient came from triage and not the waiting area.

The ED physician's documentation at 6:00 p.m. noted the history of the present illness as Cardiac Arrest and Abdominal pain. The documentation indicated the patient collapsed in the waiting room and the Cardiac Arrest was witnessed. The ED physician's clinical impression was "cardiac arrest, abdominal aortic dissection (highly suggestive as a result of presentation, and sepsis (secondary to toxic colon)". Review of the "Course of care" physician documentation revealed advanced cardiac life support (ACLS) was initiated upon entry to room 5. The patient was intubated and a bedside ultrasound was obtained. The results were consistent with a ruptured aneurysm.


ED nursing documentation showed at 6:15 p.m. that the patient had spontaneous pulses with sinus tachycardia. At 6:25 p.m. the vital signs were blood pressure 113/25, heart rate 124, sinus tachycardia, and respirations 20 assisted. At 7:15 p.m. the patient was transported to intensive care unit. Intensive Care nursing documentation revealed the patient expired on 7/31/11 at 5:02 p.m.
Based on the "Emergency Severity Index (ESI)", Triage Algorithm, used by the facility's ED staff revealed patient #1 should have been assigned an acuity level "2" per the algorithm. The patient expressed a pain level of 8 out of 10. According to the algorithm a level "2 " should have been considered based on the patient ' s pain level. The algorithm acuity level "2" indicates a severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. Another indicator on the Algorithm is the " danger zone" diagram. If the patient's heart rate is greater than 100 and respirations are greater than 20 the patient should be considered for an acuity level " 2".

The patient's heart rate was 112, respirations were 22, and the pain level was eight. The patient triggered for a level 2 acuity.

Review of the facility's policy, " Triage: Initial Emergency Department Assessment" # T-025 revised 11/2008, revealed an acuity level 2 required a patient to be assessed every hour or more often as indicated. A patient who is unstable requires a timely response by the physician and nursing staff. Patient #1 arrived at 3:27 p.m. and was treated at 5:57 p.m. for a cardiac arrest, approximately 2 and one half hours later. The was no documentation of the patient being reassessed.

An interview was conducted with the ED Medical Director on 12/6/11 at approximately 3:30 p.m. The Medical Director was given patient #1 ' s triage scenario. She was questioned as to what acuity level should be assigned to this patient. The physician relied,"I would have liked the patient to be assigned a level "2".

An interview with the ED Director was conducted on 12/8/11 at 2:00 p.m. The ED Director was questioned on the event involving patient #1. The ED Director stated she looked into the patient flow but denied looking at the triage process.

An interview was conducted with an ED Triage/Registered Nurse on 12/8/11 at 9:30 a.m. During the interview, the ED triage process was discussed. The nurse stated the ESI training was given initially and when updates come through. The only staff that attends the training is staff that will be working in Triage.

An interview with an ED staff nurse/ relief Charge Nurse was conducted on 12/8/11 at 10:00 a.m. The nurse was questioned on the triage training process. She stated the Triage ESI class was given prior to working in the triage area. When the nurse was questioned concerning the bedside triage process, she stated the nurses are orientated for several weeks. The new orientee learns the Acuity levels through their preceptors. The nurse stated there has not been any formal triage training since July 2011.

An interview was conducted on 12/8/11 at approximately 2:20 p.m. with the ED Clinical Director. The Director stated, " the assigned acuity levels are not important because patients are seen in the order that they come in ." The facility failed to ensure that Patient #1 received a Medical Screening Examination in a timely manner due to the lack of an appropriate acuity level being assigned by the triage nurse and according to facility policy.


A telephone interview was conducted on 12/8/11 at approximately 3:00 p.m. with an ED Physician. The physician was questioned as to how important was it to obtain an accurate acuity level is. The physician stated it was very important as the patients are seen by the physician according to their acuity level is.

An interview was conducted with the Quality Director on 12/8/11 at 1:15 p.m. The Quality Director was questioned as to what kind of follow up process was completed for the event involving patient #1. The Quality Director responded she reviewed the patient records of the triage nurse involved to ascertain a trend in her triage skills. The Quality Director did not find a trend and thus did not feel any further action was necessary.

A review of the facility's policy " Medical Screening, Stabilization, and Transfer " , policy # M-010, revised 11/2008, revealed section: Procedures, paragraph (1), Medical screening examination: a) each individual who presents to the facility and requests an examination or treatment shall receive an appropriate screening examination, c) the screening will be sufficient to determine if the individual is suffering from an emergency medical condition.

The failed to ensure that Patient #1 received a Medical Screening Examination in a timely manner due to the lack of an appropriate acuity level being assigned by the triage nurse and according to facility policy. The patient did not receive an assessment of heart rate or respiration or CPR being initiated in the waiting room when found unresponsive by a security guard.