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Based on observation, interview, record review and policy review, the hospital failed to fulfill its Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) obligation when they did not provide a timely complete and ongoing medical screening exam (MSE) for one patient (#23) out of 24 Emergency Department (ED) sampled cases reviewed from 02/05/23 through 07/05/23. Patient #23 presented to the ED with nausea and abdominal pain for three days. She was triaged, then placed in the ED waiting room. She remained there for 13 hours and six minutes before she was placed in a patient exam room. She suffered a medical emergency three minutes after entering the exam room. The hospital's average monthly census over the past six months was 6,103.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 03/30/23, showed that the hospital has a responsibility to provide any individual presenting to the hospital ED requesting examination or treatment for a medical condition, an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not a medical condition exists. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage (process of determining the priority of a patient's treatment based on the severity of their condition). Individuals authorized to perform initial MSE include: Physicians, Advance Practice Nurses, Physician Assistants, Emergency Department Registered Nurses, or Labor and Delivery Triage Registered Nurses.

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements," dated 08/24/21, showed that a MSE is a process required to determine whether or not an emergency medical condition (EMC) exists. The MSE must be completed within the capabilities of the hospital and determine if further medical examinations and/or treatments are required to stabilize the patient. The hospital shall not discharge a patient without completing an MSE, providing stabilizing treatment, or transferring the patient to another hospital with the necessary capabilities to treat the patient.

Review of the hospital's policy titled, "Patient Triage in the Emergency Trauma Center," dated 05/02/23, showed that a focused assessment would be initiated based on the patient's chief complaint within 30 minutes of arrival to the ED by the primary triage nurse. An initial set of vital signs (body temperature, blood pressure, heart rate, and breathing rate) would be obtained and the patient would be assigned an Emergency Severity Index (ESI, a numerical value of one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) level. During prolonged waiting periods, patients in the waiting room should be reassessed based on acuity, presentation, and nursing judgement. Vital signs and focused reassessment by a licensed staff member should be repeated every four hours. If a patient exhibits worsening symptoms upon reassessment, the nurse should escalate the findings to a provider to expedite the completion of the MSE.

Review of Patient #23's medical record, dated 06/23/23, showed:
- She was a 51 year-old female that presented to the ED with a chief complaint of vomiting for the last three days, unable to keep anything down.
- At 6:50 AM, her vital signs were obtained and were within normal limits.
- At 7:08 AM, her secondary triage assessment was completed by Staff DD, Registered Nurse (RN). Multiple laboratory tests were ordered based on ED protocols and the patient's chief complaint. Patient #23 was alert, oriented, and in no acute distress. She was placed in the waiting room and given instructions to return to the triage desk if symptoms worsened.
- Her past medical history included a previous bowel obstruction, a post-operative bile leak, and depression (extreme sadness that doesn't go away).
-At 9:10 AM, she complained of dizziness. Staff EE, Patient Care Technician (PCT), obtained vital signs and notified the primary triage nurse.
-At 2:10 PM, Patient #23's vital signs were obtained by Staff FF, PCT.
-At 4:19 PM, she approached the triage desk complaining of nausea and Staff L, Clinical Supervisor, administered anti-nausea medication.
-At 7:35 PM, Patient #23's visitor/family member notified the triage nurse that her abdominal pain had increased and her skin was cool to the touch. Staff AA, RN, documented that Patient #23's vital signs were rechecked and she was to be placed in the first available treatment room.
-At 7:35 PM, Staff CC, PCT, re-checked Patient #23's vital signs. He documented that her blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heart-beat, normal is approximately 90/60 to 120/80) was 59/30. He re-checked her BP multiple times obtaining the same results.
-At 7:52 PM, exam room seven opened and Patient #23 was escorted to the room.
-At 7:58 PM, Patient #23 experienced a medical emergency and Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was initiated.
-At 8:02 PM, Patient #23 was intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own).

Based on observation, interview, record review, policy review and video review, the hospital failed to provide a timely appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed within its capability, capacity, and the scope of its abilities for one patient (#23) of 24 Emergency Department (ED) records reviewed from 02/05/23 through 07/05/23. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 6,103.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 03/30/23, showed the hospital has a responsibility to provide any individual presenting to the hospital emergency department requesting examination or treatment for a medical condition, an appropriate MSE within the capability of the hospital's ED, including ancillary services, to determine whether or not an EMC exists. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage (process of determining the priority of a patient's treatment based on the severity of their condition).

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements," dated 08/24/21, showed that a MSE is a process required to determine whether or not an EMC exists. The MSE must be completed within the capabilities of the hospital and determine if further medical examinations and/or treatments are required to stabilize the patient. The hospital shall not discharge a patient without completing a MSE, providing stabilizing treatment, or transferring the patient to another hospital with the necessary capabilities to treat the patient.

Review of the hospital's policy titled, "Patient Triage in the Emergency Trauma Center," dated 05/02/23, showed that a focused assessment would be initiated based on the patient's chief complaint within 30 minutes of arrival to the ED by the primary triage nurse. An initial set of vital signs (body temperature, blood pressure, heart rate, and breathing rate) would be obtained and the patient would be assigned an Emergency Severity Index (ESI, a numerical value of one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) level. During prolonged waiting periods, patients in the waiting room should be reassessed based on acuity, presentation, and nursing judgement. Vital signs and focused reassessment by a licensed staff member should be repeated every four hours. If a patient exhibits worsening symptoms upon reassessment, the nurse should escalate the findings to a provider to expedite the completion of the MSE.

Review of the undated education document titled, "EMTALA for Emergency Department Co-Workers," showed all patients that present to the ED shall receive a MSE to determine whether or not an EMC exists and stabilizing treatment within the hospital's capacity and capabilities.

Review of the hospital's undated education document titled, "Reassessment and Vital Signs in the Emergency Trauma Center," directed staff to obtain and document vital signs and for licensed staff to complete a focused reassessment based on the patient's chief complaint, presenting conditions, and/or changes in the patient's condition every four hours.

Although requested, the hospital failed to provide a policy specific to assessment/reassessment of the patient specific to the Emergency Department.

Review of the hospital's undated document titled, "So, What Makes Emergency Trauma Center (ETC) Techs Special," indicated that ED Patient Care Technician (PCT) triage area responsibilities included vital signs, patient weights, electrocardiograms (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions), triage and procedure room cleaning, removal of trash and linens, stocking supplies, waiting room cleaning, assisting patients to assigned treatment rooms, rechecking patient vital signs every two hours, transporting patient to the Obstetrical (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) unit, and restocking of oxygen tanks.

Although requested, the hospital failed to provide a policy specific to Cardiac (having to do with the heart), Medical, or OB Alerts within the ED.

Review of Patient #23's medical record, dated 06/26/23, showed:
- She was a 51 year-old female that presented to the ED with a chief complaint of vomiting for last three days and unable to keep anything down.
- Her past medical history included a previous bowel obstruction, a post-operative bile leak, and depression (extreme sadness that doesn't go away).
- At 6:51 AM, her vital signs were obtained and her blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heart-beat, normal is approximately 90/60 to 120/80) was slightly elevated at 141/73.
- At 7:08 AM, her secondary triage assessment was completed by Staff DD, Registered Nurse (RN). Multiple laboratory tests were ordered based on ED protocols and the patient's chief complaint. She was assigned an ESI level of two. Patient #23 was alert, oriented, and in no acute distress. She was placed in the waiting room and given instructions to return to the triage desk if symptoms worsened.
-At 9:10 AM, she complained of dizziness. Staff EE, PCT, obtained her vital signs and notified the primary triage nurse. Her BP remained slightly elevated at 149/76.
-At 2:10 PM, Patient #23's vital signs were obtained by Staff FF, PCT. Her BP was within normal limits at 113/81.
-At 4:19 PM, she approached the triage desk complaining of nausea and Staff L, Clinical Supervisor, administered anti-nausea medication.
-At 7:35 PM, Patient #23's visitor/family member notified the triage nurse that her abdominal pain had increased and her skin was cool to the touch. Staff AA, RN, documented that Patient #23's vital signs were to be rechecked, then she was to be moved to the first available treatment room. Staff CC, PCT, re-checked Patient #23's vital signs. He documented that her BP was extremely low at 59/30.
-At 7:52 PM, Patient #23 was transported via wheelchair to exam room seven.
-At 7:58 PM, Patient #23 experienced a medical emergency and Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was initiated, and code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called.
-At 8:02 PM, Patient #23 was intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own).
- At 8:05 PM, Patient #23 was moved from exam room seven to room five, where CPR and the code blue continued.
- At 8:10 PM, return of spontaneous circulation was achieved.

Video review of the hospital's ED waiting room on 06/02/23 showed:
- At 6:48 AM, Patient #23 entered the ED, obtained a wheelchair, seated herself and approached the triage desk to sign in.
- At 6:51 AM, Patient #23's vital signs were obtained at the triage desk.
- At 6:53 AM, she relocated to near the chairs in the waiting area, a staff member provided her a trash can.
- At 7:08 AM, Staff DD, RN, spoke with Patient #23.
- At 9:10 AM, Patient #23 goes off camera to have her vital signs taken. She has a cup of ice chips in hand upon exit.
- At 9:23 AM, Patient #23 enters the triage room to have blood drawn.
- At 2:10 PM, Patient #23 goes off camera to have her vital signs taken.
- At 4:15 PM, Patient #23 approaches the triage desk. She speaks with Staff L, RN, Clinical Supervisor, complains of nausea. Medication administered per Staff L.
- At 7:33 PM, Staff CC, PCT, approaches Patient #23. She moves toward the vital signs room, accompanied by a friend/family member. Patient #23 appears alert and was conversing with the visitor. Staff CC obtains her blood pressure, re-checks the blood pressure, re-positions the blood pressure cuff, and applies a new blood pressure cuff. Staff CC attempts to obtain a pulse oximetry reading, monitor appears to alarm for pulse ox reading, not able to read exact numbers. Staff CC then switches the probe's location to obtain a better reading.
- At 7:40 PM, Staff CC, PCT, exits the vital signs room to speak with the primary triage nurse.
- At 7:43 PM, Patient #23 appears to spit into the cup, possible emesis, none visible. Staff CC takes Patient #23's BP again. Patient #23 appears alert.
- At 7:45 PM, Staff CC changes the blood pressure cuff to Patient #23's other arm. Monitor appears to alarm for blood pressure, unable to visualize exact numbers. Staff CC exits the room and enters to back area of the ED.
- At 7:52 PM, Patient #23 remains seated in the vital sign room with her visitor. She does not appear to be in distress, but calmly holding a conversation.
- At 7:53 PM, Staff CC returns to vital sign room and escorts Patient #23 and her visitor through the double doors to the exam rooms.
- At 7:54 PM, they enter exam room seven and are no longer visible on video.
- At 7:55 PM, Staff Y, Medical Doctor (MD), enters exam room seven.
- At 7:57 PM, Staff CC, PCT, exits exam room seven as a code blue was called.
- At 7:58 PM, numerous staff members respond to exam room seven.
- At 8:02 PM, the difficult airway cart arrived to exam room seven, along with a second ED physician.
- At 8:04 PM, numerous staff members exit exam room seven, move away from camera to exam room five, followed by a stretcher with Patient #23 lying and CPR in process. They move off camera into exam room five.

Patient #23 had been in the waiting room for 13 hours and seven minutes before she suffered a code blue. She had only had her vital signs taken four times. Patient #23's primary and secondary triage assessments were completed at 7:09 AM, she never received a reassessment. Her initial vital signs were taken then repeated at the two hour and 19 minute time. Her next set of vital signs were obtained five hours later. Her final set of vital signs were taken five hours and 25 minutes later.

Observation on 07/05/23 at 2:15 PM, showed only two RNs working the ED triage area, one primary triage nurse and one secondary triage nurse.

During an interview on 07/05/23 at 2:15 PM, Staff L, RN, Clinical Supervisor, stated that the primary triage nurse would obtains the patient's chief complaint and assign an ESI level. The patient would then be sent to the vital signs room. Once the patient's vital signs were obtained, a secondary triage nurse would perform the secondary assessment. During the secondary assessment, laboratory testing and radiological testing would be ordered according to established protocols. Vital signs and secondary assessments should be completed on patients in the waiting room every four hours.

During an interview on 07/05/23 at 2:30 PM, Staff N, RN, ED Clinical Nurse Educator, stated that all patients in the waiting room should have their vital signs retaken every four hours. The PCTs obtain repeat vital signs and assess for pain or any changes. They were to notify the primary or secondary triage nurse if any abnormal vital signs, complaints, or a change in status was identified. Every PCT that works in the ED completes hospital orientation and ED unit specific orientation.

During an interview on 07/05/23 at 2:30 PM, Staff R, PCT, stated that the primary triage nurse dictated what order patients were assigned and taken back to see the physician. He stated that the expectation of a PCT was to get a full set of vital signs and do EKG's if indicated, within ten minutes of the patient arrival time. He stated that a PCT was specifically assigned to do vital signs and EKG's on those patients that had been checked in by the primary nurse. He stated that if a patient had abnormal vital signs he would notify the primary triage nurse.

During an interview on 7/05/23 at 3:15 PM, Staff S, ED Nurse Manager, stated that the primary nurse has oversight of the ED waiting room. The secondary triage nurse determined the patient acuity, ordered laboratory and radiology tests, completed the triage assessment and would return the patient to the waiting room. He stated that the Charge Nurse and Clinical Supervisors would monitor the computer and assign rooms according to the acuity of the patient. There were routinely 16-20 nurses assigned to the ED per shift. The number of PCTs varied depending on the number of PCTs on staff.

During an interview on 07/06/23 at 11:15 AM, Staff K, Clinical Director Emergency Trauma Unit, stated the primary triage nurse should obtain the patient's presenting complaint and assign an ESI level. The patient then presents to the vital sign room where a PCT obtains their vital signs. Once the vital signs are documented, the secondary triage nurse would complete the triage assessment. During the secondary assessment, laboratory and radiological testing were ordered. The initial ESI level could be changed by the secondary nurse after assessment if necessary. The ED does not have a set or definitive time frame for rounding in the ED waiting area. Within the treatment rooms, rounding would be completed every two hours. If a PCT identified any abnormalities related to patient vital signs for patients in the ED waiting room, they were to notify the primary or secondary triage nurse and a reassessment would be completed. Abnormal laboratory values were monitored by the primary or secondary triage nurse. The values would be flagged within the electronic medical record (EMR). All nursing staff were able to see abnormal findings. Her expectation was that all patients within the ED waiting room should be reassessed minimally every four hours. Reassessments were completed based on the data collected. To avoid fatigue, the PCTs were rotated to different areas within the department every four hours.

During an interview on 07/06/23 at 12:00 PM, Staff L, RN, Clinical Supervisor, stated that she had been working on 06/26/23, the day that Patient #23 had presented to the ED. While she was rounding in the waiting room, Patient #23 had complained of nausea. She had administered some nausea medication to her. Patient #23 was alert, seated in a wheelchair, and had a cup in her hand for emesis. Staff L stated that she did not follow up on the effectiveness of the nausea medication. The PCTs would notify the nurses if a patient had any continued complaints or abnormal vital signs and place a note in the EMR identifying who was notified and when. Once laboratory values were reviewed by a nurse, they would enter a note or comment to indicate that they had been reviewed. No specific staff members were assigned to review laboratory or testing results. At times it was difficult for the primary or secondary to review any laboratory results or to complete reassessments, at times there could be over 70 new patients waiting to be signed in and triaged. Signing patients into the ED was the priority for the primary triage nurse. Ideally, there should be a third nurse stationed next to the primary triage nurse, who would monitor the waiting room and complete reassessments as needed. On the shift when Patient #23 presented, there had not been a third nurse in the waiting room. Staff L stated that when she returned for her next shift on 06/27/23, she found out that Patient #23 had expired. She reviewed Patient #23's EMR and wrote out a timeline for the patient to see if she could identify any issues. She did speak with other staff members regarding the code blue, but there was not a formal investigation or medical review completed on Patient #23.

During an interview on 07/06/23 at 12:55 PM, Staff S, ED Nurse Manager, stated that the hospital did not have a formal policy or maintain records for the Cardiac, Medical, or Obstetric Alerts (an overhead alert in the ED that informs the medical providers that a patient requires immediate assessment) used by the ED.

During an interview on 07/06/23 at 1:45 PM, Staff S, Nurse Manager (NM) ED, stated that reassessments for patients waiting in the waiting room was the responsibility of the secondary triage nurse. He expected this to be done on every patient waiting in the ED to be seen every four hours.

During an interview on 07/06/23 at 3:05 PM, Staff Y, ED Medical Doctor (MD), stated that he had been present when Patient #23 collapsed. When he entered exam room seven, she was sitting in a wheelchair and a visitor was next to her. They were talking. She was alert and breathing on her own. He proceeded to introduce himself and was asking about her complaints. She seemed to be "off" and was acting odd, like she didn't understand him. Staff CC, PCT, was transferring her from the wheelchair to the stretcher. When Patient #23 stood, she moaned and appeared to lean forward as if she were going to vomit. She did vomit a large volume of coffee ground emesis and simultaneously slid to the floor. Staff Y, MD stated that she most likely aspirated at that time. Patient #23 continued vomiting, there was a very large volume and the floor was completely covered. She was not responsive. They initiated a code blue. They had a difficult time moving her from the floor to the stretcher. Once on the stretcher, she was difficult to intubate. Once intubated, Patient #23 was moved to the larger exam room five to accommodate all the staff required to stabilize her. She was ultimately admitted to the ICU for care.

During an interview on 07/10/23 at 12:00 PM, Staff DD, Triage RN, stated that the ED triage area was unsafe. Staff members had voiced their concerns to management numerous times but their concerns had not been addressed. Each patient that presents to the ED encounters the primary triage nurse whom completes a brief initial assessment that includes their chief complaint. Patients then proceed to the vital signs room where a PCT obtains a full set of vital signs, including height and weight for every patient. From the vital signs area, patients proceed to the secondary triage nurse. The secondary triage nurse completes the first thorough assessment of each patient, initiating laboratory and radiological (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) testing based on their chief complaint, and assigning an ESI level. Staff DD had been assigned as the secondary triage nurse on the early morning of 06/26/23, the day that Patient #23 presented to the ED with abdominal pain. Patient #23 had shown no signs of acute distress, her vital signs had been stable, and she had voiced no other concerns. Staff DD ordered laboratory testing based on her complaint of abdominal pain and then provided the oncoming secondary triage nurse with report. When she returned to work on the evening of 06/26/23 she was assigned as the secondary triage nurse. Staff CC, PCT, notified her that Patient #23's BP had dropped and a physician needed to evaluate her. Staff DD stated that she looked through the door to observe the patient and was told by the primary triage nurse, Staff AA that the PCT was cleaning exam room seven, then moving Patient #23 to that room. She did not complete any type of assessment due to her workload and the fact that the patient was being moved to an exam room. She was unaware of a Medical Alert page being completed for Patient #23. Staff CC told her that Patient #23 had a medical emergency as soon as he placed her into exam room seven and a code blue had been initiated. At times, staff members were too busy logging and triaging patients to call any type of alerts. Staff frequently miss critical symptoms and/or laboratory values. At times there were over 70 patients waiting to be seen by a provider. Staff DD stated that as a secondary triage nurse she did not have time to do re-assessments for patients in the waiting room. She had been told that her priority was provide an initial assessment to the walk in patients as they logged in and to order any type of testing they may require. The PCTs taking vital signs were just as busy, they do not have time to re-assess the patients either. Staff try to re-check vital signs on some of the longest waiting patients. The PCTs were responsible for assessing the patients and notifying the triage nurses of any changes. PCTs receive training for their position, but some of them do not have enough clinical experience to recognize acute changes. At night, the secondary triage nurses are required to remain in their position to focus on initial assessments for the newly entered patients. The secondary nurse does not have time to review any of the laboratory results or to walk through the waiting room and complete reassessments. The ED Charge Nurses assist in the waiting room when they can, but they are responsible for keeping the patients flowing through the exam rooms. Frequently the primary triage nurse has had to go outside to assist patients from cars alone. Often, other patients waiting to be seen in the waiting room, or even security staff, assist the primary triage nurse with incoming patients. The triage area of the hospital has been "unsafe and short staffed".

During a phone interview on 7/10/23 at 6:18 PM, Staff CC, PCT, stated that he was very frustrated with this situation and that Patient #23 had not been re-assessed throughout the day nor had vital signs been obtained like they were supposed to be done. He stated that unfortunately this happens a lot. He stated that the triage nurses were expected to get the patients in, triage them and keep up with everyone that is waiting to be seen. He stated that when you have over 70 patients in the waiting room they were unable to complete the re-assessments of those patients that are waiting to be seen by a physician. Due to staffing shortages, there had had been multiple times that only one nurse was assigned to do triage at night. The PCTs try to help the nurses keep by monitoring the patients in the waiting room. The priority for triage staff was to check patients in, obtain initial vital signs and to re-check the vital signs every three to four hours. The re-checks were routinely missed. Staff CC, PCT, stated he was asked to re-check the vital signs on Patient #23. He assisted her to the vital sign room and noted that her BP was low when he took her vital signs. He checked it multiple times and then alerted the primary triage nurse. He had been instructed to place Patient #23 in exam room seven, but he had to clean the room first. Patient #23 did not look good and he tried to get her to the room quickly. Once she was in the exam room, she became unresponsive and he initiated CPR. The patient was intubated and then admitted into ICU. Prior to her code blue, Patient #23 had not been assessed by a nurse. The physician was at the bedside when she became unresponsive. Both of the triage nurses had been very busy and they had relied on him to monitor the waiting room patients. He felt that he was able to identify patients in distress and would notify a nurse when needed. Due to lack of staff, these types of situations continue to occur. There were not enough staff to thoroughly complete the reassessments and to re-check vital signs on all the patients waiting to be seen.

During a phone interview on 7/10/23 at 7:24 PM, Staff BB, RN, ED, stated that she was working on a team the evening that Patient #23 was brought back to ED room seven. She stated that she heard a PCT yelling for help and she entered room seven to find the patient on the floor, eyes were open but she was unresponsive. The physician was in the room and the patient was vomiting black emesis profusely. She stated she hit the code blue button as they were doing compressions. The patient was then intubated and other nursing staff took over this patient. She stated that typically she was assigned as one of the triage nurses. She stated that it was very busy and that it was not unusual to have 60 plus patients waiting to be seen at any given time. She stated that she does not always have time to do re-assessments of those patients that are waiting to be seen in the ED. On the average, patients are out there six to eight hours or more. She stated that there should always be one nurse who was assigned to be the re-assessment nurse and that was crucial because as a primary or secondary triage nurse you do not have the time to complete re-assessments of all the patients in the waiting room. She stated that she was not able to review lab results and that they depended on the lab to call them with the critical results. She stated that the primary nurse was to focus on getting the patients checked in and do a quick look of the patient. The secondary nurse was the one that was doing the official triage assessment and ordering lab tests to be done per the triage protocol. The PCTs were crucial and were often left in the waiting room to be the eyes for the nurses. She stated that at times on second shift, there may be only one triage nurse and that the Charge Nurse (CN) was expected to help cover. She stated that they do everything they can to keep things going smoothly but, the CN was over the entire ED and could not be counted on to help triage when there was only one nurse. There had been some occasions when they were short PCT's and that the main focus was to get the initial set of vital signs for the patients that were checked into the ED. She stated that the PCT's were not able to re-check vital signs as they should due to short staffing and the number of patients that come through the door wanting to be seen. She stated that they have talked to management about the ongoing problems in the triage area, but nothing has been done to fix the problem. She stated that it was often an unsafe work environment due to the shortage of staff and the number of patients that were seeking care in the ED. It was very overwhelming.

During a phone interview on 07/10/23 at 11:30 AM, Staff AA, RN, ED Triage, stated that she had been assigned as the primary triage nurse on 06/26/23 during second shift which started at 7:00 PM. When Patient #23's family member/friend came to the triage desk and stated that she was pale, sweaty, and had an increase in abdominal pain, she asked Staff CC, PCT, to re-check the patient's vital signs. He notified her that Patient #23's BP was extremely low. She told Staff CC, PCT, to get the patient to ED exam room seven but that it needed to be cleaned first. She was unable to assess the patient due to the line of people waiting to be checked in. Staff CC had notified the CN of the patient that needed to be seen immediately. She later learned that the patient coded when she was taken back to exam room seven. It was extremely difficult to check in patients and to be re-assessing patients waiting in the ED waiting room. The PCT's were the extra set of eyes in the waiting room for the nurses. The environment was unsafe for the patients and the nurses. Staff were expected to check people in, triage them, monitor the waiting area, and complete re-assessments for 50-60 patients waiting to be seen by the physician. Nursing staff rely on the PCT's to assess, identify and notify them of any medical issues that the waiting patients may have. Staff have voiced concerns to management and there have not been any changes in the ED triage department. There seems to always be a shortage of staff and the night shift relies heavily on the PCTs to monitor the waiting room, which creates an unsafe working environment.










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