HospitalInspections.org

Based on a review of clinical records and facility documentation, a registered nurse failed to supervise and evaluate the nursing care for each patient, as ED patients were not seen in order of acuity, physician's orders were not carried out in a timely manner, and assessments/reassessments of patients were not performed according to facility policy.

Findings:

The clinical records for 10 emergency department patients were reviewed (patients #17 - #23, patient #160, and patient #162).

Patient #17 presented to the facility ED on 1-15-19 at 1:50 pm by private vehicle with a chief complaint of lung problems and shortness of breath. He was assigned an emergency severity index of 2. Online reference https://www.esitriage.com/esi-algorithm states "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."

Patient #17 saw the physician at 1:59 pm. The physician ordered lab work, a chest x-ray, an EKG [electrocardiogram] a Proventil nebulizer treatment, a Duo-Neb nebulizer treatment and Solu-Medrol 125 mg intravenously. Although intravenous access was established within minutes of the order, the ordered medications were not administered until 5:18 pm. No documentation was provided to explain the 3 hour, 19 minute delay in carrying out the physician's orders.

The patient's vital signs were assessed at the following times:
* 1:53 pm
* 3:40 pm
No other documentation of vital sign assessment was found.

After waiting in the waiting room for 6 hours and 31 minutes, Patient #17 was placed in ER room #A-06 at 8:30 pm. Additional medication was ordered at 8:56 pm and given at 9:06 pm.

Patient #17 was diagnosed and discharged from the emergency department at 9:49 pm. He was given prescriptions along with his discharge instructions.


A review of 2 additional clinical records revealed the following:

* Patient #160 arrived at the ED on 1-15-19 at 3:14 pm. The patient was assigned an emergency severity index of 5. The patient was placed in an ED room at 3:54 pm, seen by the physician at 4:38 pm and discharged at 5:20 pm.

* Patient #162 arrived at the ED on 1-15-19 at 4:28 pm. The patient was assigned an emergency severity index of 2. The patient was placed in an ED room at 4:35 pm, seen by the physician at 4:49 pm and discharged at 8:56 pm.


Facility policy titled "Discharge of Patient from Emergency Services - Emergency Department" states, in part:
"Policy
...
B. Vital signs including pain level will be assessed within one hour prior to discharge and any significant changes reported to provider."

Facility policy titled "Treatment Area Reassessment Guidelines - Emergency Department" states, in part:
"Procedures
...
2. Reassessments:

i. The frequency of reassessment is initially based on the patient's acuity and adjusted as the patient's condition improves or worsens.

ii. Reassessment parameters are based on the patient's presenting condition, and typically include but are not limited to pulse, respiratory rate, blood pressure, pulse oximetry and pain assessment minimally every four (4) hours."


Facility policy titled "Triage - Emergency Department" states, in part:

"Procedures

A. All patients arriving in Baylor St. Luke's Medical Center (BSLMC) Emergency Department (ED) or Community Emergency Centers (CECs) will be seen and evaluated by an RN for purposes of prioritizing patient care. The RN will assign the patient an appropriate triage acuity level based on the Emergency Severity Index (ESI)."