HospitalInspections.org

Based on medical record review, facility policies and procedures and staff interviews, the facility failed to follow their triage policy for reassessing patients at least every two (2) hours to determine any changes in triage level for one (1) (Patient #1) out of ten (10) patients reviewed. This failure has the potential to negatively affect all patients receiving services at the facility.

Findings are as follows:

A medical record review was completed on 4/21/25, for patient #1. Patient #1 arrived at the emergency department on 3/25/25, at 11:33 a.m., complaining of chest pain and elevated blood pressure. At 11:40 a.m., the patient was triaged and given an acuity level of 3. The patient was returned to the lobby area to wait to see a doctor. The patient remained in the lobby area until leaving against medical advice (AMA) and without seeing the doctor (LWOT) at 8:41 p.m. The medical record produced no documented evidence that reassessments were completed per the facility's triage policy and procedures.

Review of document titled, "Emergency Department, Triage Decision Algorithm" reveals the levels of acuity. Level 3 is labeled danger zone vitals.

Review of document titled, "ED Triage Adult and Peds Form" dated 3/25/25 at 11:40 a.m., completed by staff #5 states in part, "...ED Vital Signs, systolic blood pressure was 161 (one hundred sixty-one) mm Hg (milliliters of mercury), and diastolic blood pressure was 79 (seventy-nine) mm Hg. Objective Assessment, Alert and oriented x 3 [three]..."

Review of document titled, "Vital View" indicates the following: On 3/25/25 at 11:40 a.m. "Temperature Oral 99.1 N, Peripheral Pulse Rate H 108 N, Respiratory Rate 18 N, Systolic Blood Pressure NBP H161 N, Diastolic Blood Pressure NBP 79 N, SpO2 99 N." On 3/25/25 at 2:00 p.m. Vitals were as follows: "Peripheral Pulse Rate 81 N, Respiratory Rate 18 N, Systolic Blood Pressure NBP 111N, Diastolic Blood Pressure NBP 74 N, SpO2 98 N."

Review of the document titled, "Flowsheet, Vitals View" indicates that the patient's vitals were taken on 3/25/25 at 11:40 a.m., then again at 14:00 (2:00 p.m.). There is no documented evidence that within the nine (9) hours the patient was waiting in the lobby, that vitals were taken.

A review of "ED Nursing Narrative" completed by staff #4 states, "Patient reports low blood pressure [BP] on home BP monitor on wrist while in lobby. Patient brought back for new vitals at this time. Visual Snow Syndrome [VSS]."

Review of the policy titled, "Assessment of Patient" date unknown, states in part, "...V. Reassessment A. Patients will be reassessed as designated intervals throughout the course of his/her care to determine the patient's response to treatment/care; B. Reassessments are completed, as necessary, based on his/her plan of care or changes in his/her condition. Reassessments may also be based on the following: 1. Patient diagnosis 2. Desire for care, treatment, and services 3. Response to previous care, treatment, and services 4. Setting requirements; C. Additional reassessments will be completed when there is a significant change in a patient's condition, and/or when a patient's diagnosis warrants a reassessment; D. Time frames for reassessment are discipline/care setting specific and will depend upon the complexity of the patient's condition..."

Review of policy titled, "Triage 4 - Tier System" last reviewed 7/24, states in part, "...Procedure: The process of triage is used to establish priorities and determine urgency of need for emergency care of patients presenting to the Emergency Department. The goals of triage are to identify life-threatening conditions and determine acuity level for each patient. Patients presenting to Triage will be placed into 1 [one] of 4 [four] triage categories based upon the objective and subjective assessment findings of the triage nurse....3. URGENT: Conditions that involve a significant risk of significant complications or disabilities or impairment of bodily functions. Patient must be, but does not require rapid intervention, however, should be reassessed at least every hour to determine any change in triage level...The triage nurse will note in the triage assessment the assigned acuity of the patient. The triage nurse will complete and document a focused assessment on the patient in a clinical notes..."

Review of the policy titled, "Patient Rights" last reviewed 10/21, states in part, "...B. PATIENT RIGHTS: Patients have the right to: 1. Reasonable access to care; 2. considerate care, provided by competent staff, that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values, as these impact their care...20. expect that patients treated in the hospital will receive the most appropriate care within the scope of services available at this hospital. If it is determined that the patient needs services not available at this hospital arrangements will be made to transfer the patient to an appropriate facility which provides the needed services..."

An interview was conducted on 4/22/25, at 2:15 p.m., with staff #2. Staff #2 stated, in part, "I concur that the patient received no diagnosis. There is no medical screening or documentation in the medical record. There are only two sets of vitals recorded and no documentation in the medical record."

An interview was conducted on 4/22/25, at 1:05 p.m. with staff #5. Staff #5 stated, in part, "...If a patient is on the chest pain protocol, they could be in the lobby, but you can't do monitoring and reassessments every hour in the lobby. So, if patients self-report we have brought them back to reassess them. It could be around the corner or behind a curtain, not necessarily a triage bay. The chest pain protocol is standing orders we do if a patient is complaining of chest pain. You can't do everything that is marked on the protocol. If a patient needs nitro, you can't give that unless we can monitor. Protocol reassessments can be hourly or every ten [10] minutes. Documentation is part of the protocol process. You would expect charting on that."

An interview was conducted on 4/22/25, at 10:40 a.m., with staff #4. Staff #4 stated, in part, "...If the patient is stable and doesn't need immediate care, they would come back to the waiting room. They get labs and a full work up and go back to the waiting room. It's the triage nurse's responsibility to do reassessments and get vitals. We try to go back and forth. We use our best judgement. The providers review labs and test to determine where people should go. The physician's assistant [PA] can put orders in but most of the time we do protocols. The tech will pull patients back to get troponin levels and look at cardiac enzymes. That's a six [6]-hour process. We check every two [2] hours. Yes, in a perfect world there should be notes but that's health care now days. It's not how you want to run a hospital but that's how it's done. I probably did the 2:00 p.m. vitals but I didn't document them. You can't do cardiorespiratory monitoring in the triage waiting room. They would have to be in a room first before some of the things could be done...We try to have two [2] RNs [Registered Nurses] in triage. We may not be doing vitals, but we are reassessing the results of labs, specific cardiac troponins and diagnostic indicators. That's still a level of care..."

An interview was conducted on 4/22/25, at 2:00 p.m., with staff #3. Staff #3 stated, "I can't remember the patient. If I have time I will help in triage. I might do labs or vitals on a patient. Reassessments are done if we can get the patient back in a room. If a patient comes up to the window and tells us something is wrong, we can get them back for an assessment or try. We can do narrative notes now, so there should be notes in the chart."

An interview was conducted via telephone on 4/22/25, at 3:20 p.m. with staff #7. Staff #7 stated, in part, "Policy for reassessment is every two [2] hours. There should be evidence in the record that services were performed. There is potential for patients to fall through the cracks but that is not what we strive for. There are pit providers in the triage, and they can see the patients. No patient should be waiting for nine [9] hours to see a provider. The RN in triage should be doing vitals and reassessing the patients. There should be opportunities to pull the patients back and complete reassessments..."