HospitalInspections.org

28294

Based on interview and record review, the facility:

1. Failed to ensure data was collected, measured, analyzed, and tracked to monitor the effectiveness and safety of services, and quality of care provided by nursing staff in the Emergency Department (ED), resulting in missed opportunities to identify processes for improvement, and the potential for unsafe practices to go unnoticed and unchanged in the ED (Refer to A273).

This same deficiency was identified during the Complaint Validation Survey on January 27 through 30, 2015.

2. Leadership failed to ensure the Director Emergency Department (DED) completed training and implemented quality monitoring for Emergency Department (ED) nurses performing the triage process after the need to train and monitor was identified. This failed practice resulted in the potential for patients to be triaged inappropriately with potential for delays in treatment, harm or death (Refer to A309).

The cumulative effect of these systemic problems resulted in the facility's failure to ensure patients were receiving quality care in a safe and effective manner.

28294

Based on interview and record review, the facility failed to ensure data was collected, measured, analyzed, and tracked to monitor the effectiveness and safety of services and quality of care provided by nursing staff in the Emergency Department (ED). This resulted in missed opportunities to identity processes for improvement, and the potential for unsafe practices to go unnoticed and unchanged in the ED.

Findings:

The facility Performance Improvement (PI) Plan was reviewed on March 24, 2015. According to the plan, the ED PI Plan would ensure Patient Safety and outcomes in the ED through monitoring of the triage process to ensure patients were assessed and assigned the proper level.

During an interview with the Director Emergency Department (DED), on March 23, 2015, at 9:40 a.m., the DED stated he was not currently doing any monitoring of the triage system. The DED stated tools had been developed for use in the quality monitoring process, but he was not starting until April 1, 2015.


During an interview with the Director of Quality/Patient Safety (DQ), on March 24, 2015, at 1 p.m., she stated monitoring tools for the triage process and assigning the proper triage level in the ED had been developed as part of the facility's plan of correction for the Complaint Validation Survey on January 27 through 30, 2015. In addition, the DQ stated as part of the plan of correction, data was to be collected, analyzed, tracked, and trended weekly starting March 9, 2015. The DQ stated no data had been collected and no monitoring had occurred. The DQ stated data should have been collected and analyzed for the last two weeks to ensure the education provided to the ED staff had been effective in correcting the identified deficiencies.

Based on interview and record review, the facility leadership failed to ensure the Director Emergency Department (DED) completed training and implemented quality monitoring for Emergency Department (ED) nurses performing the triage process after the need to train and monitor was identified. This failed practice resulted in the potential for patients to be triaged inappropriately with potential for delays in treatment, harm or death.

Findings:

During an interview with the DED, on March 23, 2015, at 9:40 a.m., the DED stated the ED staff was told, "about a year ago," when a new computer program/system was put into place, they had to change from their previous three level triage system to a new five level ESI triage system. The DED stated there was no training for himself or any of the nurses at the time, and they were told they, "had to do it."

The DED stated a new triage policy was developed, but not yet been approved by all of the required committees, so the nurses did not have access to the policy to use as a resource when triaging patients. He stated there had been ongoing education regarding the ESI (Emergency Severity Index) level triage system (that was implemented a year earlier) over the previous three week period, but not all of the staff were trained. According to the DED, all nurses in the ED were assigned to triage, with the exception of two who had recently been hired. He stated if the nurses had questions regarding triage levels, they would have to ask each other or the charge nurses for assistance in making final determinations regarding the patient's assigned acuity level.

The facility policy titled, "Triage," was reviewed on March 23, 2015. The policy had a governing board approval date of February 26, 2015.

During an interview with the ED preceptor on March 23, 2015, at 9:45 a.m., the preceptor stated all ED nurses went through training prior to being assigned to triage, but there was not a current policy available to use for training purposes. He stated the training that had been done over the past three weeks was done by providing the nurses with an education packet with information that was taken out of the policy.

The facility education packet titled, "Triage/ESI Training," was received and reviewed on March 24, 2015. The packet indicated ED nursing staff was being taught from excerpts out of the recently approved policy.

The list of ED nurses who had received ESI level training was reviewed on March 24, 2015. According to the list, of 45 ED nurses, 25 (56%) received the training packet. There were no dates indicating when they received the training packets. There was no evidence any of the nurses completed the post test to determine their level of knowledge of the information (the column was blank). There was no evidence any of the nurses demonstrated competency in triaging ED patients using the five tiered ESI system.

During an interview with the Director of the ED (DED) on March 23, 2015, at 9:40 a.m., the DED stated he was not currently doing any monitoring of the triage system. The DED stated tools had been developed for use in the quality monitoring process, but he was not starting until April 1, 2015.

During an interview with the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Quality/Patient Safety (DQ), on March 24, 2015, at 9:35 a.m., the DQ stated monitoring tools for the triage process and assigning the proper triage level in the ED had been developed as part of the facility's plan of correction for the Complaint Validation Survey on January 27 through 30, 2015. In addition, the DQ stated as part of the plan of correction, data was to be collected, analyzed, tracked, and trended weekly starting March 9, 2015. The DQ stated she asked the DED about the collection and analysis of the data for the monitoring of the triage process, and he stated he would do it. The DQ stated she thought the DED was doing the quality monitoring for the triage process and did not know why the monitoring of the triage process had not occurred.

Based on interview and record review, the facility failed to:

1. Ensure narcotic medication orders were complete and followed as written and in accordance with the facility's policy and procedure for one sampled patient (Patient 1). This had the potential to result in oversedation or undersedation of the patient;

2. Ensure the Tetanus, Diphtheria and Pertussis (Tdap) vaccine was administered, per physician's order, to one sampled patient (Patient 12). This resulted in Patient 12 not being immunized against Tdap as ordered by the physician; and

3. Ensure an antibiotic ordered by the physician "STAT" was administered to one sampled patient (Patient 18) in a timely manner. This resulted in a delay in medication administration for Patient 18.

Findings:

1. The Richmond Agitation Sedation Scale (RASS) is a scale used to measure the agitation or sedation level of a patient ranging from +4 to -4.

(-2) light sedation, is defined as briefly (less than 10 seconds) awakens with eye contact to voice.

(-3) moderate sedation, is defined as movement or eye opening to voice (but no eye contact).

During a review of the electronic Medical Administration Record (eMAR) for Patient 1 on March 23, 2015, the following was noted:

There was a CPOE (Computerized Physician Order Entry) on March 8, 2015, at 11:04 a.m., for a Midazolam drip (continuous infusion of a medication used for sedation) to be started at 2 mg/hr (milligrams per hour) and titrated (increased and decreased) to keep the patient at a RASS of -3.

There was a CPOE on March 14, 2015, at 2:10 p.m., for a Fentanyl drip (for pain and anxiety) to be started at 1 mcg/kg/hr (microgram per kilogram per hour) and titrated to keep the patient at a RASS of....(the expected RASS was left blank [incomplete]).

During an interview on March 23, 2015, at 11 a.m., Pharmacist (Pharm)1 agreed the physician order for a Fentanyl drip was incomplete without the RASS score, and the pharmacist should have clarified the order with the physician or the nurse.

Review of the facility's Pre-Printed Order Form titled, "IV Medication Titration Drip Orders" indicated there were predetermined titration parameters based on RASS score for Fentanyl Drip as follows:

"Richmond Agitation Sedation Scale (Prescriber to indicate the desired level of sedation from +4 to -4)."

During an interview on March 23, 2015, at 11 a.m., Pharm 1 stated that the IV Medication Titration Drip Order for Fentanyl drip exactly mirrored the electronic CPOE for Fentanyl drip.

The RASS score, documented every 4 hours on the eMAR between March 13, 2015, at 1 a.m. and March 15, 2015, at 11 p.m., was consistently -2.

Pharm 1, the Director Critical Care (DCC), Registered Nurse (RN) 5, and the Clinical Systems Analyst (CSA) were not able to find in the patient's eMAR the reason for maintaining the RASS Score at -2 instead of -3 as ordered.

During an interview on March 24, 2015, at 11:30 a.m., Registered Nurse (RN) 5 stated the Fentanyl drip was being titrated based on the patient's pain assessment and not by a RASS score (not in accordance with the guidance on the facility pre-printed order form for Fentanyl).



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2. On March 23, 2015, the record for Patient 12 was reviewed. Patient 12 admitted to the facility on February 20, 2015, with the diagnosis of term pregnancy in active labor.

Patient 12 had a vaginal delivery of a Baby Girl on February 20, 2015, at 12:29 p.m.

The physician's order dated February 20, 2015, at 12:38 p.m., indicated Tdap 0.5 milliliter (ml) was to be given intramuscularly (IM) on the day of delivery at 9 p.m.

On February 20, 2015, at 9:03 p.m., the order for Tdap was "rescheduled," and entered and electronically signed by the nurse for the next day.

There was no indication the Tdap vaccine was administered to Patient 12 as ordered by the physician.

Patient 12 was discharged from the facility on February 21, 2015, at 2:03 p.m.

During an interview with the Director Perinatal Services (DPS), on March 23,2015, at 4 p.m., she reviewed the record and was unable to find documentation of Patient 12 being given the Tdap vaccine as ordered by the physician or contraindications as to why the patient should not receive the Tdap vaccine. The DPS stated Patient 12 should have been given the Tdap vaccine prior to discharge or there should be documentation in the record that the patient refused the Tdap vaccine.

The facility policy and procedure titled "Tetanus, Diphtheria, & Pertussis (Tdap) Vaccine Administration" dated March 2015, revealed "... Tdap vaccine will be offered to all postpartum women who do not have a contraindication to vaccination before discharge from the hospital with a written physician's order. ... If patient refuses ... If patient still refuses the vaccine notify the physician of refusal if indicated and document in the medical record. ..."

3. On March 24, 2015, the record for Patient 18 was reviewed. Patient 18 presented to the facility Emergency Department (ED), on March 20, 2015, with the chief complaint of difficulty urinating, flank pain, and a recent hospitalization for pyelonephritis (kidney infection) and sepsis (potentially life-threatening complication of an infection).

Patient 18 presented to the facility at 12:59 a.m., was seen by the triage nurse at 1:31 a.m., and was seen by the physician at 2:35 a.m. (1 hour and 36 minutes after the patient's arrival to the facility).

The physician ordered Levaquin (an antibiotic used to treat infections) 500 milligrams (mg) to be administered intravenous (IV - medication given directly into a vein) "STAT."

The electronic Medication Administration Record (eMAR) dated March 20, 2015, indicated the Levaquin 500 mg IV was given to Patient 18 at 5:21 a.m. (2 hours and 46 minutes after the antibiotic was ordered "STAT" by the physician).

There was no indication in the record as to why the Levaquin 500 mg ordered "STAT" by the physician was not given to Patient 18 within 30 to 60 minutes from the time the medication was ordered by the physician.

During an interview with Pharmacist (Pharm) 1, on March 24, 2015, at 1:30 p.m., she stated medications ordered "STAT" should be given within 30 to 60 minutes of the time ordered by the physician.

During an interview with Registered Nurse (RN) 2, on March 25, 2015, at 1:35 p.m., she reviewed the record and was unable to find documentation as to why the Levaquin 500 mg IV ordered "STAT" by the physician was not given until 2 hours and 46 minutes after the medication had been ordered by the physician. RN 2 stated medications ordered "STAT" should be given within 30 to 60 minutes of being ordered by the physician unless there was a reason why the medication could not be given and that reason should be documented in the record.

Based on observation, interview, and record review, the facility failed to ensure:

1. Patients were discharged in stable or improved condition when 3 patients (Patients 32, 29, and 16) did not have reassessments prior to discharge, resulting in the potential for unstable patients to be discharged or patients to deteriorate after discharge from the ED;

2. Emergency Department (ED) nurses were trained, and a new policy was made available to them, when they changed from a three level acuity system to a five level emergency severity index (ESI) system, resulting in lack of knowledge and lack of a reference for the triage nurses assigning ESI levels and determining the priority in which patients would be seen. This had the potential to result in a delay in necessary emergency care, harm, or death (A1104);

3. ED nurses triaged patients in accordance with the nationally recognized ESI standards, including consideration of both subjective and objective assessment information, resulting in the potential for delays in care, harm, or death (A1104);

4. The triage policy included time frames for reassessment of patients who were placed in the lobby to wait for medical evaluation and treatment, possibly resulting in deterioration in the condition of one patient (Patient 27) and the potential for deterioration in other patient's conditions, harm, or death (A1104);

5. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis, resulting in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them (A1112); and

6. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan, resulting in the potential for patient harm or death (A1112).

The cumulative effect of these systemic problems resulted in failure of the facility to provide emergency services in a safe and effective manner.

Findings:

1a. Patient 32, a 2 year old male, was taken to the ED by his parents on March 14, 2015, at 1:33 a.m., with complaints of diarrhea for five days, and fever since that afternoon. The triage note, completed at 2:06 a.m., indicated the child had a temperature of 102.4 degrees Fahrenheit (in the danger zone according to the ESI guidelines) and a heart rate of 147 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with diarrhea and fever. The patient was given Tylenol and Motrin while he was in the ED, and discharged home at 3:36 a.m. with a prescription for zofran (for nausea), and instructions for taking Tylenol and Motrin. There was no evidence the patient's temperature was taken prior to discharge. The last temperature in the record was 102.4 degrees Fahrenheit.

b. Patient 32 was taken back to the ED by his parents on March 15, 2015, at 2:24 a.m. (25 hours later), with complaints that his fever was not better. The triage note, completed at 2:27 a.m., indicated the child had a temperature of 102.9 (in the danger zone according to the ESI guidelines) and a heart rate of 144 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with viral syndrome, ear infection, and sinus infection, with a note "there is no fever at this point in time." The patient was discharged home with a prescription for an antibiotic, Tylenol, and Motrin. There was no evidence the fever was treated in the ED. There was no evidence the temperature was retaken. The last documented temperature was 102.9 degrees Fahrenheit.

c. Patient 29, a 65 year old female, presented to the ED on March 21, 2015, at 52 minutes after midnight, with complaints of an asthma attack with shortness of breath, wheezing, and productive cough. The triage note, completed at 54 minutes after midnight, indicated the patient had a blood pressure of 178/110 (normal 120/80).

The ED assessment indicated the patient had expiratory wheezes throughout all lung fields, and received a breathing treatment (which can increase the blood pressure) and steroids for her symptoms.

The record indicated Patient 29 was discharged home with prescriptions for her asthma. There was no evidence in the record her blood pressure was reviewed by the physician. There was no evidence her blood pressure was taken after the initial one in triage (although heart rate, respiratory rate, and oxygenation level were taken). There was no evidence Patient 29 had a safe blood pressure on discharge from the ED.



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d. On March 24, 2015, the record for Patient 16 was reviewed. Patient 16, a 15 month old child, presented to the facility ED on March 20, 2015, at 2:06 a.m., with the chief complaint of fever.

Patient 16's temporal temperature was 99.7° Fahrenheit (F) on March 20, 2015, at 2:07 a.m.

Patient 16 was "Triaged" at 2:42 a.m.; vital signs were taken at 2:45 a.m., to include a heart rate of 124 beats per minute, respiratory rate of 26 per minute, and a rectal temperature of 99.8°F; and an Emergency Severity Index (ESI) of 4 (less urgent).

The "Physician Documentation/Notes" dated March 20, 2015, indicated Patient 16 was seen by a physician at 3:28 a.m., and "Temperature is 103.9 Fahrenheit" with a review of systems to include "fever ... ear pain, ear pulling ... cough," and a physical examination which included "injected right TM (tympanic membrane - ear infection)."

Patient 16 was discharged home on March 20, 2015, at 3:59 a.m., with a prescription for antibiotics and instructions to see private physician in one to two days.

There was no indication Patient 16's temperature was taken after being documented by the physician as 103.9°F, at 3:28 a.m.

There was no indication Patient 16's vital signs were taken prior to discharge from the facility ED.

During an interview with Registered Nurse (RN) 2, on March 25, 2015, at 1:35 p.m., she reviewed the record and was unable to find documentation of Patient 16's temperature after the physician's documented temperature of 103.9°F at 3:28 a.m. RN 2 stated she was unable to determine from the record if the physician's documented temperature for Patient 16 was correct. In addition, RN 2 stated she would have assessed Patient 16 prior to discharge which would have included a discharge temperature.

Based on observation, interview, and record review, the facility failed to ensure:

1. Emergency Department (ED) nurses were trained, and a new policy was made available to them, when the ED changed from a three level acuity system to a five level emergency severity index (ESI) system, resulting in lack of knowledge and lack of a reference for the triage nurses assigning ESI levels and determining the priority in which patients would be seen. This had the potential to result in a delay in necessary emergency care, harm, and death;

2. ED nurses triaged patients in accordance with the nationally recognized ESI standards, including consideration of both subjective and objective assessment information, resulting in the potential for delays in care, harm, or death; and

3. The triage policy included time frames for reassessment of patients who were placed in the lobby to wait for medical evaluation and treatment, possibly resulting in deterioration in the condition of one patient (Patient 27) and the potential for deterioration in other patient's conditions, harm, or death.

Findings:

The ESI is a five level triage algorithm that categorizes ED patients by evaluating both acuity and resource needs (different from the older systems that considered only patient acuity). Initially, the triage nurse assess only the acuity level. If a patient does not meet the high acuity level (ESI level one or two), the triage nurse then evaluates expected resource needs to help determine a triage level (level three, four, or five). The ESI is intended for use by nurses with triage experience, or those who have attended a separate, comprehensive triage educational program.

ESI level one patients are patients who will die without immediate intervention, where the patient's vital signs or major organs are compromised (airway, breathing, or circulation to the heart or brain).

ESI level two patients are ill and at high risk for deteriorating, and placement in an ED bed should be initiated rapidly (Patients who are suicidal, homicidal, or psychotic are level two patients). The triage nurse will rely on a brief interview with the patient (subjective assessment information) as well as the patient's appearance, age, medical history, and current medications (objective assessment information) .

ESI level three patients are ill, but can wait in the lobby for medical evaluation and treatment. The triage nurse will consider the subjective and objective assessment information (chief complaint, appearance, behavior, past medical history, current medications), as well as the patient's vital signs. ESI level three patients have stable vital signs, and will require a workup using two or more resources (lab, radiology, intravenous therapy). Patients who's vital signs are outside of the normal ranges (example: a child 3 months to 3 years with a temperature greater than 102.2 degrees Fahrenheit with no obvious source of infection, an adult with a respiratory rate greater than 20) should be strongly considered for elevation to an ESI level two.

ESI level four patients are stable and will require only one resource in addition to the medical examination and treatment.

ESI level five patients are stable, and will not require any resources in addition to the medical evaluation and treatment.

To help ensure successful adoption of the ESI level triage system in the ED, a well thought out implementation plan is critical. Implementation takes time, careful planning, and a group of professionals dedicated to a successful transition.

All triage policies must be reviewed, and many policies may need to be rewritten. Decisions regarding reassessment times need to be incorporated into the triage policies.

Education is one of the critical tasks required for implementation of the ESI triage system. Triage nursing staff will need a full orientation to the system, as several key concepts need to be understood in order to maintain the reliability and validity of the process.

Emergency Severity Index (ESI), A Triage Tool for Emergency Department Care, Version 4, Implementation Handbook, 2012 Edition. (Agency for Healthcare Research and Quality [AHRQ]).

1. During an interview with the Director Emergency Department (DED) on March 23, 2015, at 9:40 a.m., the DED stated the ED staff was told, "about a year ago," when a new computer program/system was put into place, they had to change from their previous three level triage system to a new five level ESI triage system. The DED stated there was no training for himself or any of the nurses at the time, and they were told they "had to do it."

The DED stated a new triage policy was developed, but not yet been approved by all of the required committees, so the nurses did not have access to the policy to use as a resource when triaging patients. He stated there had been ongoing education regarding the ESI level triage system (that was implemented a year earlier) over the previous three week period, but not all of the staff had been trained. According to the DED, all nurses in the ED were assigned to triage, with the exception of two who had recently been hired. He stated if the nurses had questions regarding triage levels, they would have to ask each other or the charge nurses for assistance in making final determinations regarding the patient's assigned acuity level.

The facility policy titled, "Triage," was reviewed on March 23, 2015. The policy indicated the following:

a. Triage was the preliminary screening step that sorted ED patients into urgency categories to prioritize them for evaluation and treatment;

b. All patients presenting to the ED would be seen by a registered nurse (RN) who would prioritize them according to acuity based on a five tiered triage system;

c. The RN would conduct a brief triage and complete the triage documentation;

d. All patients waiting in the waiting room would be reassessed by the triage nurse or designee,"as per condition and ESI triage level."

There were no time frames for reassessment based on the acuity of the patient;

e. Examples of ESI level one and two patients were listed (including psychiatric patients requiring 1:1 sitters), with no examples of ESI level three, four, or five patients; and

f. Danger zone vital signs were included, with heart rate, respiratory rate, and oxygen saturation level. There were no danger zones identified for blood pressure or temperature, and no explanation of how to incorporate them into the triage level determination.

During an interview with the ED preceptor on March 23, 2015, at 9:45 a.m., the preceptor stated all ED nurses went through training prior to being assigned to triage, but there was not a current policy available to use for training purposes. He stated the training that had been done over the past three weeks was done by providing the nurses with an education packet with information that was taken out of the policy.

The facility education packet titled, "Triage/ESI Training," was received and reviewed on March 24, 2015. The packet indicated ED nursing staff was being taught the following:

A. The opening paragraph read, "In the ED we sort patients by acuity level. Since the implementation of (the computer system) we are using the 5 tiered Triage Systems. We use the (Emergency Severity Index) ESI system to rapidly screen and categorize patients based on the number of resources it will take to safely care for the pt (patient)....Once the triage nurse screens the pt he/she will assign an acuity level in the (computer system). Level 1 being the most acute and level 5 being the least acute;

B. Any patient that presented to the ED for treatment must have their vital signs taken as part of their assessment, except for patients who were there for medication refills (which could include medications for blood pressure [and possible extremely high blood pressure], heart problems [and possible irregular heart beating or heart failure], diabetes [with possible hydration problems], pain [with possible severe pain], and asthma/respiratory problems [with possible oxygenation problems]);

C. Level one through five patients were described based solely on chief complaint, with no information regarding the need to consider objective as well as subjective information (observations, age, past medical history, allergies, and current medications they were taking);

D. Danger zones were included for vital signs (heart rate, respiratory rate, and oxygenation level). There were no danger zones identified for blood pressure or temperature, and no explanation of how to incorporate them into the triage level determination; and,

E. The final statement read, "All ED patients must be reassessed by the triage nurse or their designee. Reassessments include vital signs, pain level assessment and status of the patient's complaint." There was no information regarding the frequency of reassessments depending on the acuity of the patient.

The list of ED nurses who had received ESI level training was reviewed on March 24, 2015. According to the list, of 45 ED nurses, 25 (56%) had received the training packet. There were no dates indicating when they received them. There was no evidence any of the nurses completed the post test to determine their level of knowledge of the information (the column was blank). There was no evidence any of the nurses had demonstrated competency in triaging ED patients using the five tiered ESI system.

2. During a tour of the ED on March 23, 2015, at 9:50 a.m., an ED RN was observed in the front entrance area of the ED lobby next to the registration window with a vital signs machine. During the observation, two patients (at separate times) approached the nurse asking to be seen in the ED. The RN asked the patients what they were there for and if they had ever been there before, and took a set of vital signs. There were no other questions asked.

For the first patient, the RN called the charge nurse to get an immediate bed based on the information she had gathered.

For the second patient, the RN told the patient to have a seat in the lobby based on the information she had gathered.

A review of ED records conducted March 23 and 24, 2015, indicated the following:

a. Patient 32, a 2 year old male, was taken to the ED by his parents on March 14, 2015, at 1:33 a.m., with complaints of diarrhea for five days, and fever since that afternoon. The triage note, completed at 2:06 a.m., indicated the child had a temperature of 102.4 degrees Fahrenheit (in the danger zone according to the ESI guidelines) and a heart rate of 147 (normal 80-110). There was no evidence of an objective assessment with observation of the child's appearance, past medical history, or current medications. Patient 32 was assigned an ESI level of four (semi urgent - not in accordance with the ESI guidelines).

The record indicated the patient was given Tylenol and Motrin while he was in the ED, and discharged home at 3:36 a.m. with a prescription for zofran (for nausea), and instructions for taking Tylenol and Motrin.

Patient 32 was taken back to the ED by his parents on March 15, 2015, at 2:24 a.m. (25 hours later), with complaints that his fever was not better. The triage note, completed at 2:27 a.m., indicated the child had a temperature of 102.9 degrees Fahrenheit (in the danger zone according to the ESI guidelines) and a heart rate of 144. There was no evidence of an objective assessment with observation of the child's appearance, past medical history, or current medications. Patient 32 was again assigned an ESI level of four (semi urgent - not in accordance with the ESI guidelines);

b. Patient 25, a 17 year old female, presented to the ED on March 15, 2015, at 1:02 a.m., after taking an intentional overdose of pills (Tylenol, Motrin, and possibly metoprolol [blood pressure pills]). The triage note, completed at 1:15 a.m., indicated the patient had a heart rate of 117 (normal 60-100). There was no evidence of an objective assessment with observation of the patient's appearance, past medical history (that included self mutilation), or current medications. Patient 25 was assigned an ESI level of three (urgent - not in accordance with the ESI guidelines or the facility policy);

c. Patient 29, a 65 year old female, presented to the ED on March 21, 2015, at 12:52 a.m., with complaints of an asthma attack with shortness of breath, wheezing, and productive cough. The triage note, completed at 12:54 a.m., indicated the patient had a blood pressure of 178/110 (normal 120/80). There was no evidence of an objective assessment with observation of the patient's appearance (she had wheezing throughout all lung fields on physician examination), past medical history (that included asthma), or current medications (including asthma medications that she had run out of). Patient 29 was assigned an ESI level of four (less urgent - not in accordance with the ESI guidelines);

d. Patient 30, a 29 year old male, presented to the ED on March 15, 2015, at 5:15 a.m., with depression and suicidal ideations (wanting to kill himself). The triage note, completed at 5:24 a.m., had no evidence of an objective assessment with observation of the patient's appearance, past medical history (that included schizophrenia and past suicide attempts), or current medications. Patient 30 was assigned an ESI level of three (urgent - not in accordance with the ESI guidelines or the facility policy). The patient was not seen by the physician until 6:43 a.m. (one hour and 19 minutes later);

e. Patient 31, a 72 year old female, presented to the ED on March 15, 2015, at 11 a.m., with complaints of an increased heart rate. The triage note, completed at 11:25 a.m., indicated the patient had a blood pressure of 208/111 (normal 120/80), and a respiratory rate of 25 (in the danger zone according to the ESI guidelines). There was no evidence of an objective assessment with observation of the patient's appearance, past medical history, or current medications. Patient 31 was assigned an ESI level of three (urgent - not in accordance with the ESI guidelines);

f. Patient 27, a 76 year old male, presented to the ED on March 21, 2015, at 11:43 a.m., with complaints of a drain in his lung not working and shortness of breath. The triage note, completed at 11:49 a.m., indicated the patient had a blood pressure of 97/69 (normal 120/80), a low grade fever with a temperature of 99.1 degrees Fahrenheit (normal 98.6), and sudden onset of acute pain of 10/10. There was no evidence of an objective assessment with observation of the patient's appearance, past medical history, or current medications. Patient 27 was assigned an ESI level of three (urgent - not in accordance with the ESI guidelines);

g. Patient 17, a 55 year old male, presented to the ED on March 20, 2015, at 12:39 a.m., with a complaint of chest pain that was possibly cardiac in nature. The triage note, completed at 1:33 a.m., indicated the patient had chest pain which was a "heavy, pressure" and pain of 8/10 (on a pain scale of 0 to 10 with 10 being the worst pain. Patient 17 was assigned an ESI level of three (urgent - not in accordance with the ESI guidelines); and

h. Patient 18, a 65 year old female, presented to the ED on March 20, 2015, 12:59 a.m., with a complaint of difficulty urinating, flank pain, and a recent hospitalization for pyelonephritis (kidney infection) and sepsis (potentially life-threatening complication of an infection). The triage note, completed at 1:31 a.m., indicated the patient had a heart rate of 111 beats per minute (normal 60 to 100), a low grade fever with a temperature of 99.1 degrees Fahrenheit (normal 98.6), and lower abdominal pain of 5/10. Patient 18 was assigned an ESI level of four (less urgent - not in accordance with the ESI guidelines).

Failure of the triage nurses to complete an adequate assessment of the patient before assigning an ESI level, without evidence of rationale for assigning ESI levels lower than recommended by the ESI guidelines, had the potential to result in patients being placed in the lobby and suffering a deterioration in their condition, harm, or death.

3. The facility policy titled, "triage," was reviewed on March 23, 2015. The policy indicated all patients waiting in the waiting room would be reassessed by the triage nurse or designee," as per condition and ESI triage level."

There were no time frames for reassessment based on the acuity of the patient.

The record for Patient 27 was reviewed on March 23, and 24, 2015. Patient 27, a 76 year old male, presented to the ED on March 21, 2015, at 11:43 a.m., with complaints of a drain in his lung not working and shortness of breath. The triage note, completed at 11:49 a.m., indicated the patient had a blood pressure of 97/69 (normal 120/80), a low grade fever with a temperature of 99.1 degrees Fahrenheit (normal 98.6), and sudden onset of acute pain of 10/10.

According to the record, a critical lab value with an INR (International Normalized Ratio - time for the blood to clot) of 8.09 (normal 0.8 - 1.2) was reported by the lab at 12:14 p.m. (this critical value placed the patient at risk for internal bleeding). There was no reassessment by the nurse.

The record indicated the ED physician examined Patient 27 at 3:23 p.m. (three hours and 40 minutes after arrival), and ordered x-rays and labs to be done. The physician electronically pulled the triage vital signs into his record.

No repeat vital signs were done. No nursing reassessment was done. There was no evidence the critical lab values were reviewed.

The ED nurse's reassessment notes, completed at 5:50 p.m. (six hours after triage, five hours and 36 minutes after receiving critical lab results, and two hours and 17 minutes after the physician examination), indicated the patient's son called the RN to the waiting room (lobby - where the patient was still/again located) to assess the patient. Patient 27 was found to be aphasic (unable to speak) and lethargic (difficult to arouse) in the waiting room. Patient 27 was taken into the main ED and placed in a bed, a code stroke was called, and after stabilizing treatment, he was transferred to another acute care facility for a higher level of care with a diagnosis of stroke caused by a blockage in his middle cerebral artery (artery in his brain).



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Based on observation, interview, and record review, the facility failed to ensure;

1. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis; and

2. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan.

These failed practices resulted in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them.

Findings:

1. During a tour of the ED on March 23, 2015, at 9:50 a.m., accompanied by the Director Emergency Department (DED), an ED RN was observed in the front entrance area of the ED lobby next to the registration window with a vital signs machine.

The DED stated the RN in the front area was known as the, "pivot" nurse. The DED stated the "pivot" nurse assigned an ESI level to patients on arrival, the level one and two patients would go straight back to a bed, and the level three, four, and five patients would be directed to the lobby to wait for a different nurse (a triage nurse) to call them in. The director stated the triage nurse would complete a "focus" assessment on the patient.

During the observation, two patients (at separate times) approached the nurse asking to be seen in the ED. The RN asked the patients what they were there for and if they had ever been there before, and took a set of vital signs. There were no other questions asked.

For the first patient, the RN called the charge nurse to get an immediate bed based on the information she had gathered.

For the second patient, the RN told the patient to have a seat in the lobby based on the information she had gathered.

Upon entering the triage area, there was one RN present with one provider assigned to the area. The DED explained the area acted as a "combination" (secondary) triage/rapid medical screening exam/fast track (RME) area. The room contained multiple chairs with multiple patients sitting in them. The DED stated the patients were all in various stages of triage, examination, and/or treatment.

The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated the ED staffing would include one charge nurse and six RNs 24 hours a day, with four RNs for "mid shift overlap."

A review of the ED daily staffing assignment template indicated the overlap shifts included one RN at 10 a.m., two RNs at 12 noon, and one RN at 3 p.m.

During an interview with the DED on March 24, 2015, at 9 a.m., he stated when every shift was filled, the morning staffing (one charge nurse and six RNs) would cover one nurse in charge, four nurses for the 16 ED beds, one pivot nurse, and one triage nurse. He stated the 10 a.m. nurse would be assigned as a second triage nurse, the 12 noon nurses would provide lunch coverage for other staff, and the 3 p.m. nurse would assist in triage/RME. According to the DED, when all shifts were covered, the triage/RME area would have one RN at 7 a.m., two RNs at 10 a.m., and three RNs at 3 p.m.

During a concurrent interview with RN 1 and RN 2 on March 24, 2015, at 2 p.m., the RNs explained after level three, four, and five patients were sent to the lobby by the pivot nurse, the role of the triage nurse was to call them in and complete a "focus" assessment, then send them back to the lobby. The nurses explained the patients would then go "back and forth" between the RME room and the lobby, receiving their examination by the provider, having tests done, receiving treatments, and eventually being discharged or sent to a bed in the ED if necessary.

RN 2 stated the nurses assigned to triage were doing secondary triage on some patients, and assisting with treatments and procedures on other patients, within the same period of time. RN 2 stated there was "no physical way" they could keep up on charting on all of the patients being seen and treated in that area. RN 2 stated there were currently 43 patients "on the board" (in some stage of treatment in the ED). RN 2 stated with 16 ED beds, that left 27 patients in the process of treatment in the RME area (many of who were located in the lobby), with two or three nurses assigned there. She stated there was not enough staff to assign patients to nurses to manage their care/flow, so it was very difficult to keep up with what was being done on what patients, what was pending on what patients, what had been ordered on what patients, and what patients were waiting for dispositions.

2. The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated nursing care was delivered in a modified team approach, and was provided by RNs and ERTs.

A review of the ED daily staffing assignment template indicated the following staff was needed to meet the anticipated needs of the patients:

7a - 7p: One charge RN, six RNs, two ERTs;
9a - 9p: Two ERTs;
10a - 10p: One RN;
12 noon - 12 midnight: Three RNs and one ERT;
3p - 3a: One RN and one ERT; and
7p - 7a: One charge RN, six RNs, and two ERTs.

A review of the actual staffing for the week of March 16 through 22, 2015, indicated the following:

a. Monday, March 16, 2015:

- short one 7a-7p RN, assigned an RN to RME area, and an ERT to the pivot (ESI level) assignment (an assignment that requires an RN for assessment and acuity level);
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

b. Tuesday, March 17, 2015:

- short one 7a-7p RN, assigned an RN to triage area, and an ERT to the pivot (ESI level) assignment;
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short both 7p-7a ERTs.

c. Wednesday, March 18, 2015:

- short one 7a-7p RN and one 7a-7p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

d. Thursday, March 19, 2015:

- short two 7a-7p RNs and one 7a-7p ERT;
- short one 9a-9p ERT; and
- short one 7p-7a ERT.

e. Friday, March 20, 2015:

- short one 7a-7p RN;
- short one 9a-9p ERT;
- short one 12p-12a RN; and
- short one 7p-7a RN.

f. Saturday, March 21, 2015:

- short one 9a-9p ERT;
- short two 12p-12a RNs; and
- short the 3p-3a RN and the 3p-3a ERT.

g. Sunday, March 22, 2015:

- short two 7a-7p RNs;
- short two 12p-12a RNs;
- short the 3p-3a RN and the 3p-3a ERT; and
- short one 7p-7a RN and both 7p-7a ERTs.

At 3 p.m. on March 22, 2015, the ED was short by five RNs.

During an interview with the DED on March 24, 2015, at 9 a.m., the DED stated he was aware of the staffing problems in the ED, but he had employees out on leave, and he was "doing the best I can."


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