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Based on document review, policy review and staff interview it was determined the Emergency Department (ED) failed to ensure two (2) out of nine (9) ED patients were reassessed according to hospital policy (patient #3 and #7). This failure has the potential to miss a decline in the patient's condition that could ultimately lead to the patient's demise.

Findings include:

1. Patient #3 is a seventy-four (74) year old female that arrived at Charleston Area Medical Center (CAMC)-General Division via Emergency Medical Services (EMS) on 6/15/21 at 9:37 a.m. with complaints of altered mental status and seizure activity. Patient #3 was triaged at 9:37 a.m. and given an emergency severity index (ESI) level of three (3). The medical screening exam was completed at 10:01 a.m. The patient was not removed from the EMS bed until 1:54 p.m., four (4) hours and seventeen (17) minutes after her arrival in the ED. The patient was reassessed at 2:00 p.m. and was not reassessed until 8:20 p.m. on 6/15/21.

2. A review of the physician order for patient #3 dated 6/15/21 at 3:49 p.m. stated "vital signs q (every) 4 (four) hr. (hours)."

3. A review of the hospital document entitled 'Triage Categories' publication date March 26, 2021 states, "Reassess ESI level 2 (two) goes directly to a bed in the treatment area. The nurse can proceed with initiating Protocol orders; however, the ED physician must be notified of the patient's presence and status. (It would be unsafe for a Level 2 patient to remain in the waiting room for any length of time.) ESI level 3 (three) patients may go directly to a bed if one is available. However, they may proceed to the comprehensive Triage area for vital signs and more in-depth evaluation to determined number of resources. Reassess ESI level 3 (three) patients placed in the waiting room hourly with supporting documentation in Cerner."

4. An interview was conducted with the ED Clinical Manager on 7/7/21 at approximately 12:30 p.m. She concurred patient #3's vitals were not completed per ESI policy or by physician orders.

5. A review of the medical record for patient #7 revealed a one hundred four (104) year old female who arrived in the ED at CAMC-General Division via EMS with complaints of hip swelling after a fall on 6/15/21. She arrived in the ED at 9:56 a.m., was triaged at 9:58 a.m. and given an ESI level of three (3). She was removed from the EMS cot and placed in an ED bed at 2:04 p.m. and her medical screening exam was performed at 2:05 p.m. The patient did not receive a reassessment of her vital signs until 7:52 p.m.

6. A review of the physician order for patient #7 dated 6/15/21 at 2:07 p.m. stated "Vital Signs per ESI level."

7. An interview was conducted with the ED Clinical Manager on 7/7/21 at approximately 12:30 p.m. She concurred patient #7's vitals were not completed per ESI policy.