HospitalInspections.org

Based on clinical record review and staff interview it was determined the facility failed to ensure a complete investigations of an adverse patient event for 1(#1) of 30 sampled patients. The continued use of this practice could result in the missed opportunities to improve patient safety practices.

Findings include:

A review of patient #1's clinical record revealed the events from the time the ambulance arrived at the scene to the time the patient left the emergency department. The patient expired on 12/3/11.
The ambulance vital signs at 3:08 pm were blood pressure 148/104, heart rate 100, sinus tachycardia, respirations 18 normal, at 3:23 pm vitals blood pressure 142/98, heart rate 102 sinus tachycardia and at 3:27 pm the patient arrived at the ER.
The patient was triaged at 4:03 pm on Jul 28, 2011 and assigned an Acuity Level 3.
The patients chief complaint abdominal pain and centralized chest pain with vomiting and her vital signs were blood pressure 95/49, heart rate 112, respirations. 22, temperature 96.8, oxygen saturations 100% on room air. The patients history of present illness was the abdominal pain started yesterday, describes the quality of pain as sharp and relates the location as generalized across abdomen. The patients pain level was 8 out of 10. the ED Technician performed 12-lead EKG at 4:16 pm and gave it to the physician to read. ED Technician drew blood and sent it to the lab at 4:34 pm.

At 5:57 pm a review of the nursing progress notes, revealed "pt. brought to exam 5 from triage with 0 spontaneous respirations, 0 heartbeat, and unresponsive. CPR initiated and respirations assisted via bag valve mask BVM,
The patient was seen and evaluated by ED physician at 6:09 pm; the patients past medical history was hypertension and diabetes. The clinical impression was cardiac arrest, abdominal aortic dissection, sepsis.

( Course of care documentation )- ACLS was initiated upon entry to room 5, pt. was intubated, and bedside ultrasound obtained results consistent with a ruptured aneurysm. Medications given per ACLS protocol.


An interview was conducted with the Quality Director on 12/8/11 at 1:15 pm. The Quality Director was questioned as to what kind of investigative 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.

Based on clinical record review, staff interview and policy review it was determined the facility failed to monitor for the effectiveness and safety of service and quality of care in the emergency department following an adverse event for 1(#1) of 30 sampled patients. The continued use of this practice has the potential for a lack of monitoring of patient safety.

Findings include:

A review of patient #1's clinical record revealed the events from the time the ambulance arrived at the scene to the time the patient left the emergency department. The patient expired on 12/3/11.

The ambulance vital signs at 3:08 pm were blood pressure 148/104, heart rate 100, sinus tachycardia, respirations 18 normal, at 3:23 pm vitals blood pressure 142/98, heart rate 102 sinus tachycardia and at 3:27 pm the patient arrived at the ER.

The patient was triaged at 4:03 pm on Jul 28, 2011 and assigned an Acuity Level 3.
The patients chief complaint abdominal pain and centralized chest pain with vomiting and her vital signs were blood pressure 95/49, heart rate 112, respirations. 22, temperature 96.8, oxygen saturations 100% on room air. The patients history of present illness was the abdominal pain started yesterday, describes the quality of pain as sharp and relates the location as generalized across abdomen. The patients pain level was 8 out of 10.

An interview was conducted with the Quality Director on 12/8/11 at 1:15 pm. The Quality Director was questioned as to what kind of investigative 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.
An interview with the ED Director was conducted on 12/8/11 at 2:00 pm The ED Director was questioned on the event involving patient #1. The Ed Director looked into the patient flow but denies looking at the triage process.

A review of the "Quality Plan", policy # P1601, review 1/2011, revealed the facility's philosphophy. "Initiatives are intended to attain optimal patient out comes and patient/family experience, enhance appropriate utilization and minimize risks and hazards of care."

Based on clinical record review, staff interview and policy review it was determined the facility failed to identify opportunities for improvement and changes related to an adverse event for 1 (#1) of 30 sampled patients.
Findings include:
An interview was conducted with the Quality Director on 12/8/11 at 1:15 pm. The Quality Director was questioned as to what kind of investigative 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.
An interview with the ED Director was conducted on 12/8/11 at 2:00 pm The ED Director was questioned on the event involving patient #1. The ED Director looked into the patient flow but denies looking at the triage process.
An interview was conducted with an ED Triage/Staff Registered Nurse on 12/8/11 at 9:30 am. 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 am. The nurse was questioned on the Triage training process. The nurse stated the Triage ESI class is given prior to working in the Triage area. When the nurse questioned concerning the bedside triage process stated nurse 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, but she has been receiving " Triage Tips " in her email
A review of the "Quality Plan",policy # P1601, review 1/2011, revealed the facility's philosphophy. "Initiatives are intended to attain optimal patient out comes and patient/family experience, enhance appropriate utilization and minimize risks and hazards of care."

Based on Clinical record review, staff interview and policy and procedures it was determined the facility failed to ensure an accurate acuity assessment was completed on 15 (#7, #10, #11, #12, #14, #20, #21, #23 and #25-30) of 30 sampled acutely ill patients by nursing. The continued use of this practice could possibly result in a delay in treatment and/or loss of life.

Findings include:

(1) Patient #1 presented to the emergency department (ED) on July 28, 2011 by ambulance. The patient was triaged at 4:03 p.m., and assigned an Acuity Level 3. The patient's chief complaint was abdominal pain and the patient's vital signs were blood pressure 95/49, heart rate 112, respirations. 22, and temperature 96.8, and oxygen saturations 100% on room air. The patient's pain level was listed as 8 on a scale of 0 to 10, with 10 being the worse pain. The patient also complained of centralized chest pain associated with vomiting. Based on the patient's pain level and clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(2) Patient #7 presented to the ED on November 20, 2011 by private vehicle. The patient was triaged at 7:14 pm and assigned an Acuity level 3. The patient's chief complaint was listed as a fast heart rate and left knee injury. The patient's vital signs were blood pressure 114/73, heart rate 147, and respirations 18 oxygen saturations of 95% on room air and a pain level of 10 on a scale of 0 to 10, with 10 being the worst pain. Based on the patient's pain level, elevated heart rate and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(3) Patient #10 presented to the ED on December 3, 2011 per private vehicle. The patient was triaged at 8:44 pm and assigned an Acuity level 3. The patient's chief complaint was upper right abdominal pain, diarrhea, nausea, and constipation. The patient's vital signs were listed as blood pressure 126/79, heart rate 88, and respirations 18 oxygen saturations of 99% on room air and a pain level of 10 on a scale of 0 to 10 with 10 being the worst. Based on the patient's pain level and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(4) Patient #11 presented to the ED on November 10, 2011 at 1:27 pm, per ambulance. A review of the ambulance run sheet revealed the reason for the call was stroke. The patient's vital signs in the ambulance at 12:50 pm were blood pressure 200/110, heart rate 94, and respirations 16. The patient was triaged at 2:04 pm, 33 minutes after arrival to the ED. The patient's chief complaint was listed as " patient with confusion and altered speech " and an Acuity Level 3 was assigned. The patients triage vital signs were blood pressure 183/108, pulse 90, respirations 16 and oxygen saturations of 99%.Based on the patient's clinical presentation, vital signs and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(5) Patient #12 presented to the ED on November 3, 2011 at 4:00 pm., per ambulance. The patient was triaged at 4:06 pm and assigned an Acuity Level of 3. The patients chief complaint was listed as " the patients pacemaker exchanged today , spent 1.5 hours in recovery and attempted to leave , experienced a syncopal episode and was hypotensive on EMS arrival. " The patient's vitals were blood pressure 119/54, pulse 60, respirations 18, and oxygen saturations 99%. Based on the patient's clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(6) Patient #14 presented to the ED on July 28, 2011 per private vehicle. The patient was triaged at 10:39 am and assigned an acuity level 4. The patient's vital signs were blood pressure 158/84, heart rate 84, respirations 16, temperature 97.5 and pain level of 7 on a scale of 0 to 10 with 10 being the worst. The patient required laboratory work and commutated topography (CT) of abdomen. According to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 3. ( more than 1 resource needed and pain scale)
(7) Patient #20 presented to the ED on November 10, 2011 per ambulance. A review of the ambulance run sheet dated 11/9/11, revealed the Type of Patient was Difficulty Breathing/Respiratory Distress; severity impression STEMI alert; EKG performed by paramedics showed an elevation in leads V1, V2, V3, and a Stemi alert called to the facility. The ambulance vital signs were blood pressure 225/125, pulse 114, and nitroglycerin was given enroute to the hospital. The patient was triaged at 12:17 am as an acuity level "3", with the chief complaint of shortness of breath. The patient was assessed as alert and oriented x4, and presented with Bipap on for oxygen. The patient's vitals in triage were blood pressure of 141/82, heart rate of 81; respirations 20 on Bipap, no pain level was documented. Based on the patient's clinical presentation, shortness of breath and STEMI alert and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(8) Patient #21 presented to the ED on November 10, 2011 per ambulance. A review of the ambulance run sheet revealed the patient had a " Syncopal episode with fall ", vitals at 3:50 pm were 88/64, and pulse 80. The patient was triaged on 11/10/11 at 4:31 pm and was assigned an acuity level " 3 " . The patient's chief complaint was listed as Hypotension and weakness. The patient's vitals were blood pressure 127/103 and pulse of 69, at 5:36 pm the blood pressure was 105/55, pulse rate of 69 and on admission at 10:18 pm, the patient's blood pressure 88/49 and pulse 61. The patients Laboratory results at 4:21 pm revealed a HBG of 5.0 and HCT of 16.4
The ED physicians impression was the patient's condition was guarded. Based on the patient's clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(9) Patient #23 presented to the ED on November 17, 2011 per ambulance. The ambulance run sheet reported the patient's complaint as Chest pain non trauma. The patients vitals per paramedics at 12:12 am were blood pressure 186/108, pulse 70. The patient was triaged at 12:52 am and assigned an Acuity level 3 with the chief complaint of chest pain. The triage vital signs were blood pressure 164/92; heart rate 69, no pain level was assessed. The patient was admitted to the facility with a diagnosis of unstable angina; chest pain. Based clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(10) Patient #25 presented to the ED per ambulance on November 17, 2011. The ambulance run sheet reported the patient was hypotensive with a medical history of end stage lung cancer, currently undergoing treatment. The patients vital signs per paramedics at 10:21am were 78/56, pulse 101. The patient was triaged at 10:37 am and assigned an Acuity level of 3. The patient's chief complaint was fever, possible urinary tract infection. The triage vitals were blood pressure 82/52, pulse 102, respirations 14, temp 102.7, and pain level 8/10. The nursing Assessment revealed the patients lungs diminished, speech is slow, strength is weak, and bowel sounds hypoactive. The ED Physician evaluated the patient at 11:05 am and documented, " the patient presents with fever and end stage lung cancer, has undergone decompressive spine surgery for metastatic disease of her cervical spine and cord. She is presently paralyzed from this lesion with left arm and bilateral paraplegia. She recently had gamma knife therapy for mass lesion in upper thorax and is under hospice care. Risk factors consist of immunocompromised patient. The physicians Impression/ Plan revealed a diagnosis of fever, pneumonia, end stage lung disease, renal insufficiency, wound dehiscence of cervical spine and stage IV sacral decubitus. The patient's condition was listed as Critical. Based on the patient's clinical presentation, vital signs and history and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.

(11) Patient #26 presented to the ED on November 17, 2011 per private vehicle. The patient was triaged at 5:15 pm and assigned an Acuity level of 3. The chief complaint was listed as vaginal bleed, suprapubic and back pain. Pain started yesterday, bleeding this am, (19) pads today, red blood. The patient's vital signs were blood pressure 207/87, pulse 82, and pain level 10/10. Based on the patient's vital signs and pain level and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(12) Patient #27 presented to the ED on November 24, 2011 per ambulance. The ambulance run sheet reported the patient's complaint as respiratory distress/shortness of breath. The patient was triaged at 12:09 am and assigned an Acuity level 3. The chief complaint was listed as respiratory distress and dyspnea. The patient's vital signs were blood pressure 138/90, pulse 106, and respirations 16, oxygen saturations 98% .The ED physician evaluated the patient at 12:26 am and documented " the patient presents with difficulty breathing and wheezing ". The ED Physicians diagnosis was acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Based on the clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(13) Patient #28 presented to the ED on November 24, 2011 per private vehicle. The patient was triaged at 10:50 am and assigned an Acuity level 3. The patient chief complaint was " near syncope last night and feels no better today. " The patients past medical history included atrial fibrillation. The patient's vital signs were blood pressure 126/88, pulse 66, and respiration 16. An electrocardiogram (EKG) at 11:02 am showed atrial fibrillation.
ED physician evaluation revealed a chief complaint listed as "near syncope light headed and weakness. " The diagnosis the ED physician listed for the patient was "near syncope, atrial fibrillation condition " . The patient's condition was listed as guarded and was admitted for cardio version. Based on the patient's clinical presentation and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(14) Patient #29 presented to the ED on December 1, 2011 per ambulance. The ambulance run sheet reported the patient's chief complaint of " difficulty breathing/respiratory distress " . The patient's initial oxygen saturations were 88% on 3 liters of oxygen. The patient was triaged at 5:18 am and assigned an Acuity level 3. The patient's chief complaint was respiratory distress. The patient vital signs were blood pressure 124/88, pulse 113, and respirations 18, 99% on aerosol mask and temperature 99 degrees. The ED Physician evaluated the patient " immediately upon arrival " , and the ED physician documented " presents with difficulty breathing, wheezing and respiratory problems " . The patient past medical history was listed as hypertension, cerebrovascular accident, osteoporosis, and carotid endarectomy. The Physicians diagnosis was Dyspnea, and COPD acute exacerbation. Based on the patient's clinical presentation, shortness of breath, elevated heart rate and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.
(15) Patient #30 presented to the ED on December 1, 2011 per private vehicle. The patient was triaged at 11:22 am and assigned an Acuity level 3. The patient was sent to the ED with daughter by physician for evaluation of (2) episodes of angina this week. The patient vital signs were blood pressure 169/100, pulse 80, respirations 18, and oxygen saturations 99%.The ED MD evaluated patient at 11:34 am and documented the patient presents with " chest pain onset 5 days ago, pt. feels funny and out of sorts " . Based on the patient's clinical presentation and vital signs and according to the facility's Emergency Severity Index (ESI) Triage Algorithm the patient should have been assigned an Acuity level of 2.


A review of the facility's policy, " Triage: Initial Emergency Department Assessment ", policy # T-025, revealed page 2 paragraph 6, Assign an initial acuity score (ESI severity index)-
? Acuity Level 1: the patient is unstable and requires immediate response by the Physician and nursing staff
? Acuity Level 2: the patient is unstable and requires a timely response by the Physician and nursing staff.
? Acuity Level 3: the patient is stable and requires two or more resources i.e., Laboratory, Intravenous access, imaging, medication.
? Acuity Level 4: the patient is stable and most likely requires only one resource
? Acuity Level 5: the patient is stable and does not require resources.
A review of the computerized " Emergency Severity Index " revealed selections for the nursing staff to enter.
? The ESI Level 1 screen revealed the following selections- Immediate life-saving intervention required; airway, emergency medications, or other hemodynamic interventions; and/or any of the following; intubated apneic, pulseless, severe respiratory distress, SpO2 less than 90%, acute mental status changes or unresponsive.
? The ESI Level 2 screen revealed the following; High Risk situation or patient confused, lethargic, disoriented or in severe pain or distress.
? The ESI Level 3 revealed the following selections; requires 2 or more resources; hospital services, tests, procedures, consults or interventions above and beyond the Physician History and Physical, or simple ED simple interventions such as applying a bandage.
? The Danger Zone screen reveled (Heart rate greater than 100, respirations greater than 20, oxygen saturations less than 92%)

A review of the " Appendix B. ESI Triage Algorithm, v.4 " revealed if a patient requires immediate life-saving interventions they are assigned Level 1 acuity. If the patient is assessed as high risk situation, confused, lethargic, disoriented or experiencing severe pain/distress they are assigned Level 2 acuity. If the patient is exhibiting vital signs that are listed in the " Danger Zone " they are to be considered as Level 2 acuity. If the patient requires more than 1 resource and are not in the " danger Zone "vital signs than they are assigned a Level 3 acuity.

An interview was conducted with an ED Triage/Staff Registered Nurse on 12/8/11 at 9:30 am. 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. The Triage nurses also have the ESI algorithm to reference located in triage. The nurse was given the scenario of patient's #1, #11 and #12. These patients had received an acuity level 3. When questioned on what acuity level based on the scenarios the nurse responded she would have assigned Level 2 acuity.

An interview with an ED staff nurse/ relief Charge Nurse was conducted on 12/8/11 at 10:00 am. The nurse was questioned on the Triage training process. The nurse stated the Triage ESI class is given prior to working in the Triage area. When the nurse questioned concerning the bedside triage process stated nurse 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, but she has been receiving " Triage Tips " in her email. The nurse was given the scenario of patient's #1, #11 and #12. These patients had received an acuity level 3. When questioned on what acuity level based on the scenarios the nurse responded she would have assigned Level 2 acuity.

An interview with the Clinical Nurse Manager of the ED was conducted on 12/8/11 at 2:20 pm. The Manager was questioned on the process for assigning acuity levels for patients at bedside. The Nurse Manager responded that the assessment of the patient is based on the patient's condition, not the acuity level. The Manager further added that the ED Physician selects their patients to be seen by order of arrival not acuity.

A telephone interview was conducted with an ED Physician on 12/8/11 at 1:20 pm. The Physician was questioned as to if patients are assigned to him or does he select the patients in the ED to evaluate and treat. The Physician responded that patients are not assigned. The Physician would look at the tracking screen and see the different Acuity Levels assigned to the Patients. If there are 1's or 2's on the tracking board those would be seen first. If there are 2-3 Level 3 patients than those are selected based on time of arrival? When questioned on the importance of the triage acuity level, the physician responded that the Physicians depend on the acuity level to determine who needs to be seen next or emergently.

Based on review of 1(#1) of 30 clinical records , facility policies and staff interviews it was determined the facility failed to integrate the ED with the facilities Quality Assurance Performance Improvement program to ensure a mechanism for consistent, systematic evaluation of outcomes, processes and structures related to emergency department (ED) triage process to optimize and maintain the safety of the ED.

Findings include:

A review of patient #1's clinical record revealed the events from the time the ambulance arrived at the scene to the time the patient left the emergency department. The patient expired on 12/3/11.
The ambulance vital signs at 3:08 pm were blood pressure 148/104, heart rate 100, sinus tachycardia, respirations 18 normal, at 3:23 pm vitals blood pressure 142/98, heart rate 102 sinus tachycardia and at 3:27 pm the patient arrived at the ER.
The patient was triaged at 4:03 pm on Jul 28, 2011 and assigned an Acuity Level 3.
The patients chief complaint abdominal pain and centralized chest pain with vomiting and her vital signs were blood pressure 95/49, heart rate 112, respirations. 22, temperature 96.8, oxygen saturations 100% on room air. The patients history of present illness was the abdominal pain started yesterday, describes the quality of pain as sharp and relates the location as generalized across abdomen. The patients pain level was 8 out of 10. the ED Technician performed 12-lead EKG at 4:16 pm and gave it to the physician to read. ED Technician drew blood and sent it to the lab at 4:34 pm
At 5:57 pm a review of the nursing progress notes, revealed " pt. brought to exam 5 from triage with 0 spontaneous respirations, 0 heartbeat, and unresponsive. CPR initiated and respirations assisted via bag valve mask BVM,
The patient was seen and evaluated by ED physician at 6:09 pm;the patients past medical history was hypertension and diabetes. The clinical impression was cardiac arrest, abdominal aortic dissection, sepsis.
( Course of care documentation )- ACLS was initiated upon entry to room 5, pt. was intubated, and bedside ultrasound obtained results consistent with a ruptured aneurysm. Medications given per ACLS protocol.
? 6:15 pm patient with spontaneous pulses with sinus tachycardia
? 6:22 pm 16 French nasogastric tube inserted in right nostril with difficulty
? 6:25 pm blood pressure 113/25, heart rate 124, sinus tachycardia respirations 20 assisted via BVM
? 6:26 pm Finger stick glucose 364, results shown to ED Physician
? 6:29 pm ultrasound at bedside
? 6:29 pm blood pressure 64/47 heart rate 128 and sinus tachycardia, respirations 20 assisted by BVM (pulses thread)
? 7:15 pm patient was transported to intensive care unit



An interview was conducted with the Quality Director on 12/8/11 at 1:15 pm. The Quality Director was questioned as to what kind of investigative 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.
An interview with the ED Director was conducted on 12/8/11 at 2:00 pm The ED Director was questioned on the event involving patient #1. The Ed Director looked into the patient flow but denies looking at the triage process.
An interview was conducted with an ED Triage/Staff Registered Nurse on 12/8/11 at 9:30 am. 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 am. The nurse was questioned on the Triage training process. The nurse stated the Triage ESI class is given prior to working in the Triage area. When the nurse questioned concerning the bedside triage process stated nurse 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, but she has been receiving " Triage Tips " in her email
A review of the "Quality Plan",policy # P1601, review 1/2011, revealed the facility's philosphophy. "Initiatives are intended to attain optimal patient out comes and patient/family experience, enhance appropriate utilization and minimize risks and hazards of care."