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A. Based on review of Emergency Department (ED) records, policy and staff interview it was determined nursing services failed to ensure ED patients are assessed and reassessed per policy/expectation. This failure impacted three (3) of ten (10) ED patients reviewed and creates the potential for the care and condition of all ED patients to be adversely impacted.

Findings include:

1. Review of the ED record for patient #7 revealed the patient presented to the ED at 2024 on 9/3/13 with a complaint of left flank pain. The patient was triaged at 2031 and the patient's pain level was assessed as a six (6) on a scale of zero (0) to ten (10). The nurse documented the patient's triage classification as urgent. The record revealed the patient's vital signs were not reassessed by nursing until two (2) hours later at 2205. The patient's pain level was not re-evaluated even though documentation reflects the patient continued to experience pain. After waiting three (3) and a half hours, the patient left the ED at 2356, without being seen by the physician. The patient's vital signs were not rechecked by nursing after 2205.

2. Review of the ED record for patient #8 revealed the patient presented to the ED at 1517 on 8/29/13 with a complaint of hurting in back between shoulder blades which comes around left side under breast to upper chest. The patient was triaged at 1531 and the patient's pain level was assessed as six (6) on a scale of zero (0) to ten (10). The nurse documented the patient's triage classification as urgent. After waiting three (3) hours, the patient left the ED at 1831, without being seen by the physician. The patient's vital signs and pain level were not re-evaluated by nursing after the initial triage.

3. Review of the ED record for patient #10 revealed the patient presented to the ED at 2143 on 7/28/13 with possible spider bites. The patient was triaged at 2148. The patient's triage classification was documented by the nurse as urgent. The patient was seen by the physician three (3) hours later at 0045. Review of nursing documentation for the three hour period, following triage, revealed the patient's vital signs were not re-evaluated by nursing until 0049.

4. The policy "Triage," reviewed 6/12, was provided for review. The policy states in part: "Patients are reassessed every hour with vital signs and other observations performed as indicated by condition and complaint."

5. These records were reviewed and discussed with the ED Nurse Manager on 1/23/14 at 1400. She agreed with these findings.



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B. Based on review of Emergency Department (ED) records and staff interview it was determined nursing services failed to ensure ED patients are triaged in a timely manner per expectation. This failure impacted three (3) of ten (10) ED patients reviewed and creates the potential for the care and condition of all ED patients to be adversely impacted. Findings are:

1. Review of the ED record for patient #1 revealed the patient presented to the ED by ambulance at 1520 on 11/30/13 with a complaint of abdominal pain from a basketball sized hernia, and severe pain. The patient signed out of the hospital against medical advise at 1622, no nursing triage had occurred for this patient.

2. Review of the ED record for patient #3 revealed the patient presented to the ED by ambulance at 1444 on 11/30/13 with a complaint falling and hitting head, neck, back and right leg with numbness. The patient was triaged at 1535.

3. Review of the ED record for patient #4 revealed the patient presented to the ED by car at 1300 on 11/30/13 with a complaint of severe abdominal cramping, nausea and diarrhea. The patient was triaged at 1357.

These records were reviewed and discussed with the ED Nurse Manager on 01/23/14. She agreed with these findings.

C. Based on review of ED records and policy and staff interview it was determined nursing services failed to ensure ED patients are triaged with a classification of either non-urgent, urgent or emergent on five (5) of ten (10) records reviewed.

1. Review of the Ed records for patients #2, #3, #4, #5 and #6 on the identifier list revealed these patients were not classified as non-urgent, urgent or emergent on the triage assessment.

2. Review of the policy "Triage" dated 06/12, was provided for review. The policy states in part: "Based on triage assessment, the patient will be considered Emergent, Urgent or Non-urgent."

3. These records and the triage policy were reviewed and discussed with the ED Nurse Manager on 01/23/14. She agreed with these findings.