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Based on record review and interview the facility failed to promote and provide care in a safe setting by failing to treat pain per policy for 4 of 4 patients (Patients #1, 7, 8, 10) reporting severe pain in the Emergency Department (ED), facility failed to assess patients for suicide risk when presenting to the ED with suicidal ideation for 2 of 2 patients (Patients # 2, 11) presenting with suicidal ideation, and facility failed to reassess patients in the ED waiting room per facility guidelines for 10 of 13 patients (Patients # 1, 3, 4, 5, 8, 9, 10, 11, 12, 13) in a sample of 14 ED medical records reviewed.


Findings include:

The facility failed to treat a report of severe pain per facility policy in a patient presenting to the ED. See Tag 0144.

The facility failed to assess patients for suicide risk when they presented to the ED with complaints of suicidal ideation. See Tag 0144.

The facility failed to reassess patients in the ED waiting room per guidelines and accepted standards of practice. See Tag 0392.

Based on record review and interview Emergency Department (ED) staff failed to appropriately address pain for 4 of 4 ED patients (Patients #1, 7, 8, 10) in the waiting room, and failed to assess suicide risk for 2 of 2 patients (Patients # 2, 11) who presented with suicidal ideation in the ED in a sample of 14 ED medical records reviewed.

Findings include:

Record review of the facility policy titled, Patient Rights and Responsibilities, AW" last dated 03/14/2020 revealed, under "Procedure...#11. Receive compassionate, personal care, consistent with sound medical and nursing practice, in a clean, safe and secure environment.... 16. Effective, clinically appropriate management of pain."

Record review of the facility's policy titled, "Pain Management Resource, AW" last revised 11/09/2021 revealed, "...Reassess more frequently for patients experiencing severe, rapidly changing pain..."

Record review of the facility policy titled, "Surge Triage Process" last dated 02/22/2022 revealed, "The surge triage process will be used when there is a surplus of patients in the waiting room and a limited number of beds in the department to bring patients back to a bed. This should decrease the number of patients that have LWBS [left without being seen], while starting the diagnostic process before a room is available...A designated triage nurse will be responsible for the movement of patients. The provider will be in communication with the triage nurse to facilitate movement. After triaging the patient, the triage nurse will explain to the patient that the department is very busy but to decrease the amount of time spent in back, the provider will come assess the patient and get orders started. The 10 am tech will be dedicated to the triage area. They will be responsible for EKG's, assisting the triage nurse, and revitalizing the patients in the waiting room. -A level 2 ESI [triage acuity level], requires vitals every 2 hours. -A level 3 ESI, requires vitals every 3 hours while waiting for a room. -A level 4 ESI, requires vitals every 4 hours while waiting for a room. -A level 5 ESI, does not require reassessment..."

Record review of the facility policy titled, "Assessment-Reassessment-Patient" last revised on 08/12/2020 revealed, "...Emergency Department...4. Reassessment is performed at regular intervals related to the patient's course of treatment: A. To determine the patient's response to interventions. B. When a significant change occurs in the patient's condition. C. When a significant change occurs in the patient's diagnosis. D. When the patient is hemodynamically stable. E. Reassessment will be determined by nursing judgement and in collaboration with LIP [licensed independent practitioner] based on patient's status/condition with considerations given to: 1. Vital signs. 2. pain level. 3. Response to medication. 4. Response to interventions directed at resolving the presenting complaint..."

Review of Patient (Pt.) #1's medical record revealed presentation to the Milwaukee campus ED on 07/06/22 at 9:06 PM with complaint of abdominal pain. The ED Timeline revealed that triage was completed at 9:40 PM by ED RN G with pain assessment that revealed, "Pain Score: 8-Severe, Pain, Location: Abdomen" with an triage acuity of 3 assigned. The next documentation of reassessment in the Pt's record was on 07/07/2022 at 6:30 AM when a ED provider (Nurse Practitioner N) was assigned and Pt was evaluated. There was no documentation of reassessment or treatment of pain, the time in the waiting room without reassessment was 8 hours and 50 minutes.

On 8/3/2022 at 7:52 AM in an interview with ED Director D, Director D stated that "care was less than standard" for Pt. #1. When asked the process if a patient arrives in the ED and triaged with a pain level of 8-Severe, Director D states, "I would have asked a provider for like Tylenol if they had to wait." When asked if he/she spoke with Pt. #1 regarding long wait time, Director D stated, "I spoke with patient in the morning right away, it was busy that night-we had no tech sitting up front to keep eyes on patients."

On 08/03/2022 at 11:44 AM in an interview with ED Registration I, when asked if he/she recalled Pt. #1 in the waiting room the night of 07/06/2022 when working the Registration desk, Registration I stated "I came in on my shift that night at 11:00 PM, the wife came up complaining about the wait time. I let the Triage Nurse know, Triage said 'there are no beds available and it will be a couple of hours.' The second time [his/her] wife came up to the desk asking for a blanket and said that [he/she] was in pain; I let the Triage Nurse know [he/she] was in pain-a Tech came out to talk to the patient and [his/her] wife." When asked about the ED waiting room rounding log, Registration I stated, "I was told the log is there, but I have not been trained what to do."

Review of Pt. #7's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 11:04 AM with complaints of chest pain, shortness of breath and fatigue. The ED Timeline revealed triage was completed at 11:13 AM, a heart tracing was done and a triage acuity of 2 assigned. The patient was directed back to the waiting room. Pain score is documented as 8 out of 10. The next documentation at 1:04 revealed, "Pt. dismissed - LWBS [left without being seen] after triage." There is no documentation of reassessment or treatment of pain. The time in the waiting room without reassessment was 1 hours 51 minutes.

Review of Pt. # 8's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 4:14 PM with complaints of left sided abdominal pain. The ED Timeline revealed triage was completed at 4:23 PM blood and urine obtained and an acuity of 3 assigned. The patient was directed back to the waiting room. Pain score is documented as 8 out of 10. There is no documentation of reassessment or treatment of pain. The next documentation is at 8:49 PM, "Call 1x". The timeline at 1:52 AM revealed, "LWBS after triage." The time in the waiting room without reassessment from triage to first call was 4 hours 26 minutes.

Review of Pt. #10's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 8:52 PM with complaints of palpitations (heart irregular). The ED Timeline revealed triage was completed at 9:02 PM, a heart tracing and blood work was done and an acuity of 2 assigned. Pain score is documented as 8 out of 10. There is no documentation of reassessment or treatment of pain. The next documentation at 7:20 AM revealed, "Pt. dismissed - LWBS after triage." The time in the waiting room without reassessment was 10 hours 18 minutes.

On 8/3/2022 at 7:50 AM in an interview with ED Director D, Director D stated that the ED does not have any written guidelines for reassessment of patients in the ED waiting room but instead, "Leaves it up to the nurses discretion. I would expect an acuity level of 2 to be reassessed at least every 2 hours. We have a dedicated triage nurse and a ED Tech up front, reassessments can be done by the triage nurse or Techs."

Record review of the facility policy titled, Care of the Patient with Suicidal Ideation Policy, AW # 12102036 dated 7/25/2022 revealed, "Procedure: "...A. All inpatients and patients who present to the emergency department age 12 and older, and younger patients displaying behaviors or using language that may indicate risk of self-harm, will be screened to identify their risk for suicide using the designated validated tool...C. The RN (registered Nurse) will initiate appropriate suicide precautions based on the result of the suicide risk screen or whenever a patient expresses suicidal ideation, verbalizes, threatens, or engages in self-destructive behavior."

Review of Pt. #2's medical record revealed presentation to the Milwaukee campus ED on 6/7/2022 at 5:58 PM with chief complaint of suicidal. Pt. was accompanied by law enforcement and place on a protective hold. ED Timeline reveals triage completed at 6:01 PM with triage note revealing...Pt. verbalizes wanting to leave..." Blood work is obtained. There is no documentation of a Suicide Risk assessment being performed and no documentation of any suicide precautions placed. The patient did receive a MSE (medical screening exam) by the provider on 6/7/2022 at 6:34 PM. The record reveals the patient was transferred to another facility at 9:41 PM.




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Review of Pt. #11's medical record revealed presentation to the Ozaukee campus ED on 06/25/2022 at 6:01 PM with chief complaint of suicidal ideation (SI) and anxiety. The next documentation in the Pt's record at 9:14 PM by ED Registration revealed, "Pt. dismissed - LWBS" before triage. The time in the ED waiting room without triage assessment and suicide risk assessment was 3 hours 13 minutes. Pt. #11 presented back to the Ozaukee campus ED on 06/25/2022 at 9:50 PM with chief complaint of suicidal ideation (SI) and anxiety. Patient's triage was started at 11:01 PM by ED Registered Nurse (RN) L with a triage acuity of level 2 assigned and revealed, "Pt here for suicidal thoughts. States having auditory hallucinations telling pt to harm self...Pt admits to attempting suicide about 1 week ago by taking about 30 tabs [tablets] of hydrocodone [pain medication] which was prescribed for dental pain along with drinking alcohol. Pt was not seen for this." Pt was roomed in the ED at 11:13 PM and Provider Evaluation note by ED Physician M at 11:46 PM revealed, "...states that [he/she] had a period of time when [he/she] was in the waiting room and then [he/she] blacked out and woke up in another wing of the hospital...Pt is medically cleared at this time and will be transferred to behavioral health." There is no documentation of a Suicide Risk assessment being performed and no documentation of any suicide precautions placed when Pt returned back to the ED; the patient did receive a MSE (medical screening exam) by the ED provider M on 06/25/2022 at 11:28 PM.

On 08/02/2022 at 10:20 AM in an interview with ED Manager K during record review, Manager K stated, "Patients are triaged in a timely manner, 3 hours is too long to wait for for SI diagnosis/complaint." Manager K confirmed there was no triage/assessments done for Pt. #11, "Registration took [him/her] off the track board and was marked as left without being seen." When asked if Pt #11 should have had a suicide risk assessment for suicidal ideation when Pt came back again to the ED at 9:50 PM, Manager K stated, "I would expect there to be a C-SSRS [Columbia-Suicide Severity Rating Scale] done, it was done when [he/she] was transferred to the behavioral health unit."

On 08/03/2022 at 8:21 AM in an interview with ED Supervisor of Patient Services E, when asked about hourly rounding in the ED waiting room, Supervisor E stated, "There's a checklist between security, registration and Techs; they should be asking "Can I get you anything?"-it's more of a check-in to offer anything for comfort." When asked what happens if a patient in the ED waiting room complains of worsening pain or requests pain medication, Supervisor E stated, "Registration would call back to the nurse to report, Registration is available 24/7 [24 hours/day, 7 days/week]."

On 08/03/2022 at 11:20 AM in an interview with ED Registration H, when asked about the ED waiting room rounding log, Registration H stated "I work 3rd shift and have not done rounding, I have not been trained to do it; 3rd shift Registration is typically sits by themselves." When asked the process if a patient comes up to ED Registration desk complaining of pain and requesting pain medication, Registration H stated "I would get the Triage Nurse who sits in a room next to Registration, or I would track down the Charge Nurse to let them know."

Based on interview and record review the facility failed to ensure that patient needs are met by ongoing assessments for 10 of 13 patients (Patients # 1, 3, 4, 5, 8, 9, 10, 11, 12, 13) with extended ED wait times.

Findings include:

Record review of the facility policy titled, "Surge Triage Process" last dated 02/22/2022 revealed, "The surge triage process will be used when there is a surplus of patients in the waiting room and a limited number of beds in the department to bring patients back to a bed. This should decrease the number of patients that have LWBS [left without being seen], while starting the diagnostic process before a room is available...A designated triage nurse will be responsible for the movement of patients. The provider will be in communication with the triage nurse to facilitate movement. After triaging the patient, the triage nurse will explain to the patient that the department is very busy but to decrease the amount of time spent in back, the provider will come assess the patient and get orders started. The 10 am tech will be dedicated to the triage area. They will be responsible for EKG's, assisting the triage nurse, and revitalizing the patients in the waiting room. -A level 2 ESI [triage acuity level], requires vitals every 2 hours. -A level 3 ESI, requires vitals every 3 hours while waiting for a room. -A level 4 ESI, requires vitals every 4 hours while waiting for a room. -A level 5 ESI, does not require reassessment..."

Record review of the facility policy titled, "Assessment-Reassessment-Patient" last revised on 08/12/2020 revealed, "...Emergency Department...4. Reassessment is performed at regular intervals related to the patient's course of treatment: A. To determine the patient's response to interventions. B. When a significant change occurs in the patient's condition. C. When a significant change occurs in the patient's diagnosis. D. When the patient is hemodynamically stable. E. Reassessment will be determined by nursing judgement and in collaboration with LIP [licensed independent practitioner] based on patient's status/condition with considerations given to: 1. Vital signs. 2. pain level. 3. Response to medication. 4. Response to interventions directed at resolving the presenting complaint..."

Review of Pt. #1's medical record revealed presentation to the Milwaukee campus ED on 07/06/22 at 9:06 PM with complaint of abdominal pain. The ED Timeline revealed that triage was completed at 9:40 PM by ED RN G with pain assessment that revealed, "Pain Score: 8-Severe, Pain, Location: Abdomen" with an triage acuity of 3 assigned. Labs and a urinalysis was ordered by ED RN G at 9:43 PM, urinalysis was resulted by Lab at 10:00 PM that revealed a "Large" amount of occult blood; there was no documentation that urinalysis results were communicated to the ED provider. The next documentation in the Pt's record was on 07/07/2022 at 6:30 AM when a ED provider (Nurse Practitioner N) was assigned and Pt was roomed to a bed in the ED. The record revealed that the time Pt #1 was in the waiting room without reassessments done from triage was 8 hours and 50 minutes.

Review of Pt. #3's medical record revealed presentation to the Ozaukee campus ED on 7/12/2022 at 11:15 AM with complaints of abdominal pain. The ED Timeline revealed triage was completed at 12:34 PM, blood and urine obtained with an acuity of 3 assigned. The patient was directed back to the waiting room. The next set of vital signs is recorded at 5:08 PM, 4 hours 34 minutes hours after triage. The record revealed the patient left without being seen by a medical provider at 5:28 PM.

Review of Pt. #4's medical record revealed presentation to the Milwaukee campus ED on 7/13/2022 at 4:08 PM with complaints of hip pain. The ED Timeline revealed triage was completed at 4:15 PM with an acuity of 3 assigned. The patient was directed back to the waiting room. There is no documentation until 10:51 PM which revealed, "ED Disposition set to LWBS (left without being seen) after triage." The time in the waiting room without reassessment was 6 hours 36 minutes.

Review of Pt. #5's medical record revealed presentation to the Ozaukee campus ED on 7/7/2022 at 1:05 PM with complaints of abdominal pain having been seen at a local urgent care and sent to the ED for further workup. The ED Timeline revealed triage was completed at 1:40 PM with an acuity of 3 assigned. The patient was directed back to the waiting room. There is no documentation until 11:24 PM which revealed, "ED Disposition set to LWBS (left without being seen) after triage." The time in the waiting room without reassessment was 9 hours 44 minutes.

Review of Pt. # 8's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 4:14 PM with complaints of left sided abdominal pain. The ED Timeline revealed triage was completed at 4:23 PM blood and urine obtained and an acuity of 3 assigned. The patient was directed back to the waiting room. The next documentation is at 8:49 PM, "Call 1x". The timeline at 1:52 AM revealed, "LWBS after triage." The time in the waiting room without reassessment from triage to first call was 4 hours 26 minutes.

Review of Pt. # 9's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 4:20 PM with complaints of shortness of breath, chest tightness and headache. The ED Timeline revealed triage was completed at 4:31 PM with a heart tracing completed. No pain assessment is documented. The patient was directed back to the waiting room. There is no documentation until 1:52 AM which revealed, "ED Disposition set to LWBS (left without being seen) after triage." The time in the waiting room without reassessment was 9 hours 21 minutes.

Review of Pt. #10's medical record revealed presentation to the Milwaukee campus ED on 7/6/2022 at 8:52 PM with complaints of palpitations (heart irregular). The ED Timeline revealed triage was completed at 9:02 PM, a heart tracing and blood work was done and an acuity of 2 assigned. The next documentation at 7:20 AM revealed, "Pt. dismissed - LWBS after triage." The time in the waiting room without reassessment was 10 hours 18 minutes.


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Review of Pt. #11's medical record revealed presentation to the Ozaukee campus ED on 06/25/2022 at 6:01 PM with chief complaint of suicidal ideation (SI) and anxiety. The next documentation in the Pt's record at 9:14 PM by ED Registration revealed, "Pt. dismissed - LWBS" before triage. The time in the ED waiting room without triage assessment and suicide risk assessment was 3 hours 13 minutes.

On 08/02/2022 at 10:20 AM in an interview with ED Manager K during record review, Manager K stated, "Patients are triaged in a timely manner, 3 hours is too long to wait for for SI diagnosis/complaint." Manager K confirmed there was no triage/assessments done for Pt. #11, "Registration took [him/her] off the track board and was marked as left without being seen."

Review of Pt. #12's medical record revealed presentation to the Ozaukee campus ED on 06/27/2022 at 12:12 PM with complaint of "Chest pain x3 weeks." The ED Timeline revealed triage was started at 12:24 PM and ended at 12:25 PM by ED RN O with a triage acuity of 3 assigned and "Pt here for eval [evaluation] of intermittent chest pain X3 weeks. Pt is not currently having pain. Pt reports each episode lasting only seconds, less than 1 min [minute]." The next documentation at 4:39 PM revealed, "LWBS after triage." The time in the waiting room without reassessment from time of initial triage was 4 hours and 15 minutes.

During an interview on 08/02/2022 at 10:42 AM with ED Manager K, when asked about reassessment of Patient #12, Manager K stated "[He/she] should have had vitals checked/re-assessed at 3 hours." Manager K confirmed that vitals were not re-checked again before the Pt left the ED.

Review of Pt. #13's medical record revealed presentation to the Ozaukee campus ED on 06/08/2022 at 8:13 PM with arrival complaint of "Heart Problems." The ED Timeline revealed, triage was started at 8:23 PM and ended at 8:28 PM by ED RN R with a triage acuity of 3 assigned and "Pt arrives c/o [complaining of] racing heart and palpitations throughout the day. Denies pain." The next documentation at 12:43 AM on 06/09/2022 revealed, "LWBS after Triage." The time in the waiting room without reassessment from time of initial triage was 4 hours and 15 minutes.

During an interview on 08/02/2022 at 9:00 AM with ED Manager K, when asked if vitals/reassessment should be done again after 3 hours on a patient triaged at an acuity of 3, Manager K stated "Correct."

During an interview on 08/02/2022 at 11:47 AM with ED RN L, when asked how often vitals/reassessments should be done on patients waiting in the ED waiting room, RN L stated "It varies due to their triage acuity level, its every 2 hours if you are the triage nurse."

During an interview on 08/03/2022 at 9:32 AM with ED Triage RN G, when asked about rounding in the ED waiting room, RN G stated "It should be done every couple of hours, I have asked the Tech to do vital signs; I am suppose to round, but if I'm the only triage nurse-I don't have time."When asked if there are guidelines when to reassess patients, RN G stated, "There is a time frame to check them, but I'm not sure what it is."