HospitalInspections.org

Based on review of facility documents, policies and procedures, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure emergency treatment and reassessment was completed as required by facility policy for seven of 18 emergency medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR12, and MR15).

Findings include:

Review on February 7, 2013, of facility policy "Subject: Triage," dated June 1, 2012, revealed "... Purpose: To identify and prioritize the patient's needs for care and treatment. ... C. Operation...1. Triage Nurse ... b. Responsibilities and duties: 1. Assess patients upon arrival and determine the urgency of care needed using rapid triage assessment and designate appropriate care area. ... 5. Observe for changes in condition of waiting room patients, reassess/reprioritize as necessary. Reassessment recommendation of acuity level 2 should not exceed one hour and level 3 two hours. ..."

1) Review on February 7, 2013, of MR1 revealed that the patient presented to the Emergency Department (ED) on February 4, 2013. The patient was triaged at 6:10 PM and assigned an Emergency Severity Index (ESI) acuity level 3. Further review of MR1 revealed "No Answer 1st call- Pt called to ED Location, No answer Perimeter check made by triage tech, Pt not present..." at 9:13 PM. There was no documented evidence that MR1 was reassessed after the patient had been triaged at 6:10 PM.

2) Review on February 7, 2013, of MR2 revealed that the patient presented to the ED on February 4, 2013. The patient was triaged at 6:47 PM and assigned an ESI acuity level 3. Further review of MR2 revealed "No Answer 1st call- Pt called to ED Location, No answer Perimeter check made by triage tech, Pt not present..." at 9:18 PM. There was no documented evidence that MR2 was reassessed after the patient had been triaged at 6:47 PM.

An interview on February 7, 2013, at approximately 3:00 PM, with EMP1 confirmed that there was no documented evidence that MR1 and MR2 had been reassessed after they had been triaged.

3) Review on February 7, 2013, of MR3 revealed that the patient presented to the ED on February 4, 2013. The patient was triaged at 6:25 PM and assigned an ESI acuity level 3. Further review of MR3 revealed that the patient was reassessed at 9:17 PM, which exceeded the two hour reassessment recommendation per facility policy.

An interview on February 7, 2013, at approximately 3:00 PM, with EMP1 confirmed that that MR3 had a reassessment completed which exceeded the the two hour reassessment recommendation per facility policy.

4) Review on February 7, 2013, of MR4 revealed that the patient presented to the ED on February 4, 2013. The patient was triaged at 5:46 PM and assigned an ESI acuity level 2. Further review of MR4 revealed that the patient was reassessed at 7:36 PM.

An interview on February 7, 2013, at approximately 3:00 PM, with EMP1 confirmed that the patient listed in MR4 was triaged at 5:46 PM with an ESI acuity score of 2. EMP1 confirmed that the patient was reassessed at 7:36 PM, which exceeded the one hour reassessment recommendation per facility policy.

5) Review on February 7, 2013, of MR5 revealed that the patient presented to the ED on February 4, 2013. The patient was triaged at 10:41 PM and assigned an ESI acuity level 2. Further review of MR5 revealed that the patient was reassessed at 2:14 AM.

An interview on February 7, 2013, at approximately 3:00 PM, with EMP1 confirmed that the patient listed in MR5 was triaged at 10:42 PM with an ESI acuity score of 2. EMP1 confirmed that the patient was reassessed at 2:14 AM, which exceeded the one hour reassessment recommendation per facility policy.

6) Review on February 7, 2013, of MR12 revealed that the patient presented to the ED on February 4, 2013. The patient was triaged at 6:55 PM and assigned an ESI acuity level 2. Further review of MR12 revealed that the patient was reassessed at 8:16 PM.

An interview on February 7, 2013, at approximately 3:00 PM, with EMP1 confirmed that the patient listed in MR12 was triaged at 6:55 PM with an ESI acuity score of 2. EMP1 confirmed that the patient was reassessed at 8:16 PM, which exceeded the one hour reassessment recommendation per facility policy.

7) Review on February 7, 2013, of MR15 revealed that the patient presented to the ED on February 5, 2013. The patient was triaged at 4:03 PM and assigned an ESI acuity level 3. Further review of MR14 revealed that the patient was reassessed at 8:33 PM.

An interview on February 7, 2013, with EMP1 confirmed that the patient was triaged at 4:03 PM with an ESI acuity score of 3. EMP1 confirmed that the patient was reassessed at 8:33 PM, which exceeded the two hour reassessment recommendation per facility policy.