HospitalInspections.org

Based on a review of facility documents, medical records (MR) and interview with staff it was determined the facility failed to perform hourly assessments by triage nurse for patients not yet assigned a room in the Emergency Department for three of elevens patients reviewed (MR1, MR4 and MR11).

Findings include:

A review on November 30, 2015, of the "F. J. Dixon Foundation Emergency Center Policy Procedure Manual" entitled "Nursing Assessment" last reviewed on Feb. 3, 2015, revealed, " ... C. Ongoing Assessments 1. Patients in the department longer than one (1) hour should have an assessment documented a minimum of every one (1) hour. ... Vital signs are to be done on every patient in the ED on arrival and at a minimum every hour thereafter. ... "

A review on Nov. 30, 2015, of MR1, MR4 and MR11 revealed that the patients remained in the Emergency Department for longer than an hour and up to three hours and had no vital signs or assessment documented.

An interview on Nov. 30, 2015, at 1:25 PM with EMP1 confirmed there was no documentation of ongoing triage assessment for MR1.

An interview on Nov. 30, 2015, at 2:00 PM with EMP2 confirmed there was no documentation of ongoing triage assessment for MR4 and MR11.