HospitalInspections.org

Based on record review and interview, the facility failed to timely reassess patients triaged in the ED according to their policy in 1 of 5 triaged ED patients out of a total universe of 10 ED records reviewed (Pt. #1).

Findings include:

Review on 9/23/2014 at 1:45 p.m. of facility policy #4.0E "Triage of Patients Presenting to the Emergency Department" dated 5/14 states that patients presenting to the ED are prioritized into one of five ESI (Emergency Severity Index) levels (1-5) with '1' being the most critical and '5' being the most stable. ESI integrates acuity levels and utilization of resources. "ED patients waiting for evaluation/treatment are reassessed according to the following guidelines: ESI 1 = immediate treatment; ESI 2 = a few minutes; ESI 3 = every 30 minutes; ESI 4 = every 30 minutes; ESI 5 = every hour"

During a telephone interview with RN E on 9/23/2014 at 3:40 p.m., RN E stated that reassessment per the ESI rating includes documenting any changes from the baseline assessment and would "definitely" include vital sign documentation. If the patient is stable and there is no change in the patient's condition, then an entry of "patient visited" would be made in the computer.

ED Mgr C stated during an interview on 9/23/2014 at 2:50 p.m. that ED staff is expected to document electronically when entering a patient's room. This is time stamped as 'patient visited' on the patient's electronic medical record.

RN D visited Pt. #1 at 3:52 p.m. on 8/7/2014 and documented initial triage and screening information, vital signs and presenting complaint. Pt. #1's medical record lacks documentation of reassessment, vital signs or any indication that staff (RN or MD) was in Pt. #1's room (noted as 'patient visited') between 3:52 p.m. and 6:06 p.m. at the time of Pt. #1's departure. These finding were confirmed by Dir B during medical record review on 9/23/2014 at 1:48 p.m.

Based on record review and interview, the facility failed to maintain accurate time notations in the patient ED record in 5 of 5 (Pt. #1, 2, 3, 4, 10) triaged patients out of a total universe of 10 ED medical records reviewed.

Findings include:

Facility policy No. 5.0E "Guidelines for Assessment of the Patient in the Emergency Department" dated 5/14 states that documentation for patient presenting to the ED includes "Triage time, time in ER and time MD notified of patient ..." This policy was reviewed on 9/23/2014 at 3:30 p.m.

Pt. #1's ED record, reviewed on 9/23/2014 at 1:48 p.m., failed to include the time of MD notification.
Pt. #2's ED record, reviewed on 9/23/2014 at 1:30 p.m., failed to include the time of MD notification.
Pt. #3's ED record, reviewed on 9/23/2014 at 1:35 p.m., failed to include the time of MD notification.
Pt. #4's ED record, reviewed on 9/23/2014 at 1:55 p.m., failed to include the time of MD notification.


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A MR review of Pt. #10's closed ED record dated 8/7/2014 was reviewed on 9/23/2014 at 2:00 p.m. accompanied by ED Mgr C. There is no documentation of when the MD was notified that Pt. #10 was in the ED and needed a medical assessment.

Per interview with ED Mgr C during the MR review, Mgr C stated that the facility does not capture when the MD gets notified. Mgr C went on to say, "Because of the layout of the department they know right away when a new patient comes in during the day because they are right there with us."