HospitalInspections.org

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Based on interview and record review, the hospital failed to ensure implementation of the ED's P&P for the reassessment of two of 10 sampled patients (Patients 35 and 43) after triage while waiting in the ED lobby for treatment. This failure posed the risk of the patients to not receive medical and nursing services if a change in condition occurred while waiting in the lobby.

Findings:

Review of the hospital's P&P titled Triage and Treatment of Patients in the ED revised 11/15 showed each patient is classified by the triage nurse in to one of the classifications using the ESI (Emergency Severity Index). For all patients triaged as ESI level 3, the nurse should send the patient to the waiting area and instruct them to be seated until their name is called in the event a bed is not immediately available, update the vital signs and assessment on these patients every two hours or more frequently if necessary, and inform the patient to notify staff if they have a change in condition.

During a tour of the ED on 2/23/16 at 0918 hours, RN 17 was interviewed. RN 17 stated he was assigned as the triage nurse today. When asked how the patients who were sent back to the lobby after triage to wait for an available ED were monitored, RN 17 stated he would reassess the patient every two hours. When asked how he tracked the time since the last assessment, RN 17 stated an icon on the computer screen alerted him after two hours.

1. Medical record review for Patient 35 was initiated on 2/23/16. Patient 35 arrived in the ED on 2/21/16 at 1843 hours, and was discharged on 2/21/16 at 0115 hours (6 hours and 28 minutes later). Review of the ED disposition showed Patient 35 left without being seen by the physician after triage.

Review of the Emergency Flowsheets showed during triage, Patient 35 reported having back pain at a level of 10/10 on a pain scale of 0 to10 (with 0 being no pain and 10 the worst pain) on 2/21/16 at 1844 hours. Patient 35 was categorized as an ESI level 3 at 1845 hours and was sent back to the waiting room after the triage to wait for an ED bed.

Further review of the Flowsheet showed documentation at 1920 hours, Patient 35's vital signs were taken, the patient reported zero pain and showed no signs of apparent distress. However, there was no documented evidence to show the vital signs were obtained and a reassessment was done for Patient 35 after 1920 hours.

Review of the Arrival Documentation dated 2/21/16, showed Patient 35 was called at 2323 hours, but there was no answer in the ED lobby.

During an interview and concurrent medical record review with the Interim Director of the ED on 2/23/16 at 1500 hours, the Interim Director verified the triage nurse did not reassess Patient 35 two hours after triage as per the hospital's P&P.


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2. Review of medical record for Patient 43 was initiated on 2/23/16. Patient 43 presented to the ED on 2/13/16 at 1516 hours, with complaints of chest pain and generalized body pain. Further review of the form showed Patient 43 was discharged at 1904 hours (3 hours and 45 minutes later).

Review of the Health Information Management form under the section for ED Disposition dated 2/13/16, showed Patient 43 left without being seen by a physician after triage.

Review of the ED Flowsheets dated 2/13/16, showed during triage; a set of vital signs (temperature, pulse, heart rate, respiration, oxygen saturation, blood pressure, patient position, and pain assessment) was obtained at 1519 hours. However, there was no documentation to show Patient 43 was reassessed every two hours after triage as per the hospital's P&P.

During an interview with the Interim Director of the ED on 2/23/16 at 1500 hours, he confirmed the above findings.