HospitalInspections.org

Based on review of facility policies, standard of care, medical records and interview, the facility failed to ensure initial and ongoing/continuing assessment of the patient in the emergency department.

The findings included:

1. Review of the facility policy "Triage Guidelines" revealed, "Triage is an essential function of an Emergency Department (ED). Triage must be the first interaction a patient has in the Emergency Department. The aim is to ensure the patients are treated in order of clinical urgency... The goal of triage is to expedite patient care, by prompt and accurate assessment which prioritizes patients into levels, resulting in appropriate response levels for medical evaluation and treatment. The triage clinician is responsible for assessing, analyzing, planning, intervening and evaluating the care of patients admitted through the triage care... Utilizing Emergency Severity Index (ESI), patients will be triaged to the appropriate Emergency area... The triage nurse will facilitate the immediate transport of patients to the appropriate treatment area when beds are open and available... Patients categorized as (Level 3) remaining in the waiting room, will be reassessed every two (2) hours... Level 1: Resuscitation (RED)... The patient requires immediate life-saving intervention such as intubated, apneic, pulseless, unresponsive... Trauma patients will be triaged based on mechanism of injury and abnormal vital signs... Level 2: Emergent... These patients are in a high risk situation where there is a threat to life or limb, new onset (acute) altered mental status or is patient in severe pain or distress. This category is high risk for a patient waiting for treatment... Level 3: Urgent... This category is moderate risk for patient waiting to be seen. The patient's condition is stable, but treatment should be provided as soon as possible to relieve distress and pain... The patient should be reassessed every 2 hours while waiting..."

2. Review of the facility policy "Initial Physical Assessment and Reassessment" revealed, "The patient will receive an assessment and reassessment... [patients in the] Emergency Department... [will receive] initial physical assessment/Triage upon arrival Treatment area within 1 hour [and will be reassessed] every 2-4 hrs [hours] based on acuity..."

3. Review of the facility "Standard of Care: Emergency Department Frequency of Vital Signs/Assessments in the Emergency Department" revealed, "Standard of Care... Each patient will receive the appropriate level of vital sign monitoring while seated in the waiting area and during his/her stay in the Emergency Department. Standard of Practice... Obtain vital signs immediately upon triage and at least every two hours while seated in the waiting area and notify patient of bed availability and estimated wait time... Standard of Care... Each patient will receive the appropriate level of assessment during his/her stay in the Emergency Department. Standard of Practice... Perform and document a complete physical assessment of the newly admitted patient within thirty minutes of arrival and within one hour of each shift change. Reassess each assigned patient every two hours or more frequently, as patient status or physician order dictates..."

4. Medical record review for Patient #1 revealed an arrival date of 4/24/16 at 2:47 AM via ambulance with diagnoses of Bimalleolar Ankle Fracture, Motor Vehicle Crash and Acute Myofascial Strain. Patient #1's right leg was splinted. Patient #1 was transferred from an outlying hospital after being involved in motor vehicle crash (MVC). The patient was the driver of the vehicle, and was restrained with lap and shoulder harness. The vehicle was impacted on the front end. Patient #1 did not lose consciousness. The crash occurred in a neighboring state. The injury occurred 4/23/16 at 3:10 PM. The Acuity of Patient #1 was documented as ESI 3 Urgent.

Nurse's notes documented vital signs at 8:11 AM. An assessment was documented at 8:15 AM: pain "complains of pain right ankle Pain currently is 9 out of 10 on a pain scale... Ortho splint to right lower extremity..." At 9:35 AM documentation revealed the orthopedic team was at bedside and the patient was taken for re-splinting of a right ankle fracture.

The ED course summary documented patient interventions began at 8:15 AM and triage was completed at 9:11 AM. There was no documentation the patient received any assessment between the time arrival to the facility at 2:47 AM and 8:11 AM when vital signs were documented. Patient #1 was discharged home at 4:52 PM.

5. Medical record review for Patient #2 revealed an arrival date of 4/24/16 at 3:18 AM via ambulance with diagnoses of Closed Head Injury without Cranial Wound, Unspecified State Level of Consciousness, Hip Contusion, Chest Contusion, Acute Myofascial Strain, MVC. Patient #2 was transferred from the scene of the MVC to the facility. Patient #2 had a cervical collar in place and was placed on a backboard. Patient #2 was a front-seat passenger, restrained with lap and shoulder harness. The vehicle was impacted on the front end on the passenger side. The patient did not lose consciousness. The injury occurred 4/24/16 at 2:30 AM. The Acuity of Patient #2 was documented as ESI 3 Urgent.

Nurse's notes documented vital signs at 7:30 AM. A 7:30 AM "Reassessment" documented "First contact with pt [patient]... Pain is continuous. Complains of pain in right upper thigh and right quadriceps Pain currently 6 out of 10 on a pain scale. Range of motion limited in right hip..."

The ED course summary documented patient interventions began at 7:30 AM and triage was completed at 7:45 AM. There was no documentation the patient received any assessment between the time arrival to the facility at 3:18 AM and 7:30 AM when vital signs were documented. Patient #2 was discharged home at 2:29 PM.

6. During an interview in the Administrative conference room on 5/10/16 at 12:35 PM the Nurse Manager stated the staff "... try to get vital signs within 30 minutes [of arrival] whether the patient is off-loaded from stretcher or not..."

During an interview in the Administrative conference room on 5/10/16 at 4:10 PM, the Registered Nurse stated when patients come into the ED by ambulance, the assessment is started when they arrive.