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Based on interview and record review, the facility failed to ensure the Emergency department (ED) was directed in a manner to ensure complete assessments were performed prior to discharging 1 of 23 sampled patients (Patient #6).

Staff failed to obtain vital signs on Patient #6 prior to discharge.

This deficient practice had the likelihood to affect all patients presenting to the ED.

Findings include:



Review of the ED record on Patient #6 revealed she was a 90-year-old female who presented to the ED on 12/01/2024 at 11:05 a.m. via ambulance.

According to the record the physician's medical screening exam (MSE) started at 11:05 a.m. Patient #6 presented with complaints of epigastric abdominal pain with gradual worsening in severity for a week. According to the record Patient #6 had diagnoses which included diabetes mellitus Type II, hyperlipidemia, cerebral vascular accident, hypertension, and paroxysmal atrial fibrillation.


Patient #6 was triaged at 11:18 a.m. and given an emergency severity index (ESI) level of 3 (meaning urgent).

At 11:19 a.m., Patient #6 had a blood pressure of 151/60, heart rate of 60, respiration of 20, temperature of 98.4 degrees Fahrenheit, abdomen pain level of 3 and an oxygen saturation of 100 percent on 3 Liters of oxygen. There was documentation in the assessment of Patient #6 being oxygen dependent at home.

At 11:22 a.m., Patient #6 had a blood pressure of 151/60 and a heart rate of 59.

Lab reports revealed some of the following:

A Pro BNP (indicator of acute heart failure) which was collected at 11:26 a.m. was elevated at 18,800 with reference ranges being 0-300.

A urinalysis which was collected at 11:39 a.m. and showed a few white blood cells and many bacteria.

At 11:41 a.m., Patient #6 had a blood pressure of 194/118, heart rate of 58, respiration of 18 and an oxygen saturation of 100 percent.

At 11:46 a.m., Patient #6 had an oxygen saturation of 100 percent on 3 Liters of oxygen and epigastric pain at a level 8.

The results of the chest x-ray signed off at 11:46 a.m., showed no acute abnormality identified, chronic elevation of the left hemidiaphragm with adjacent left basilar atelectasis, normal heart size and prominent calcification of the mitral annulus

At 11:48 a.m., Patient #6 had a respiration rate of 16 and a pain level of 8. The pain medication morphine 4 milligrams was administered via intravenous.

At 11:49 a.m., Patient #6 had a blood pressure of 196/76, heart rate of 60, respiration of 16, and an oxygen saturation of 99 percent.

At 12:04 p.m., Patient Smith had a blood pressure of 159/62, heart rate of 58, respiration of 18 and an oxygen saturation of 94 percent.

The computed tomography scan signed off at 12:35 p.m. revealed there was patchy ground glass opacities in the lung bases, small left pleural effusion, diverticulosis without evidence of diverticulitis, and a small fat containing umbilical hernia.

At 12:52 p.m. the physician decided to discharge Patient #6 with diagnoses of urinary tract infection and bibasilar pneumonia. Patient #6 was discharged on the antibiotic Doxycycline.

A 1:37 p.m., a dose of doxycycline was administered by Staff #9 (Registered nurse).

At 1:52 p.m., there was documentation that Patient #6 was stable,on oxygen 3 liters per nasal cannula, without pain and was preparing to be discharged home.

The last set of vital signs on Patient #6 were almost 2 hours before discharge.

Review of another ED record on Patient #6 returned to the ED via ambulance at 4:27 p.m. on 12/01/2024 in cardiac arrest.

During an interview on 12/30/2024 after 1:27 p.m., Staff #4 (ED Director) confirmed there was no documented vitals signs in the chart after 12:04 p.m..Staff #4 (ED Director) said that vital signs were supposed to be obtained within 30 minutes of patients being discharged from the ED.

During an interview on 01/03/2024 after 10:30 a.m., Staff #9 (Registered nurse) confirmed that she was the nurse that discharged Patient #6 from the ED on the first visit. Staff #9 (Registered nurse) confirmed she gave Patient #6 a dose of antibiotic prior to discharge. Staff #9 (Registered nurse) said Patient #6 was awake, alert and took her medications without any problems. Patient #6 went home on 3 liters of oxygen. Patient #6 was assisted to the car between 1:53 p.m. and 2:15 p.m. Staff #9 (Registered nurse) checked Patient #6's chart and confirmed she could not find any documentation of vital signs. She stated they are supposed to take vital signs within 30 minutes of a patient's discharge.

Review of a facility's policy named "Title: Vital Signs Reassessment in the Emergency Department per ESI" dated 03/2021 revealed the following:

" ...C.ESI level 3:
...4. Vital sign assessment should be current within 30 minutes of discharge ..."

Based on observation and interview, the facility failed to ensure the required rights posting with respect to examination and treatment for emergency medical conditions and women in labor was conspicuously posted in 2 of 2 waiting areas in the Emergency Department (ED).

This deficient practice had the likelihood to affect all patients presenting to the ED.

Findings include:

During an observation of the ED on 12/30/2024 after 2:10 p.m., the Main waiting room area was noted to have patients sitting in the area. There were no required rights posting addressing examination and treatment for emergency medical conditions and women in labor.

During an observation of the ED on 12/30/2024 after 2:28 p.m., a smaller waiting room was noted to have family members waiting in it. There were no required rights posting addressing examination and treatment for emergency medical conditions and women in labor in the area.

Staff #4 confirmed there were no postings in the waiting areas.