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Based on review of policies and procedures, interviews with Emergency Room Registered Nurses #1-#2, it was determined that Patient #2, who was classified as urgent, (Level 3 of 5), due to chest pain, spent a total of five hours and seventeen minutes between time of arrival and admission to an Emergency Room bed due to inadequate nursing and physician staffing on September 17, 2011.

The findings included:

1. Patient #2 was a twenty year old, who arrived at the Emergency Room (ER ) on September 17, 2011, with complaints of left arm, shoulder and back pain that began the day before, at 08:17 p.m. Classification for Patient #3 at that time was urgent. Patient #2 was diagnosed, on the next day as having had a Left Moderate Spontaneous Pneumothorax (A collapsed lung.), on September 18, 2011, at 08:00 a.m., after the Radiologist read the chest X-ray. Patient #2 was subsequently admitted to the hospital on September 18, 2011.

The Emergency Room Triage RN #1 documented that Patient stated that it hurts to take a deep breath while in the Emergency Room, on September 17, 2011, at 8:17 p.m., upon entering the ER. Pain assessment was documented initially as 10/10 on the pain scale with 1 being little pain, and 10 being the worst pain, at 08:17 p.m., by the ER Triage RN #1. Patient #2 was taken to an exam room in the Emergency Room, at 08:22, on September 17, 2011. Vital Signs and an EKG was performed at 08:29 p.m., on September 17, 2011.

Triage Emergency Room #1, stated during interview, that if there is no room in the Emergency Room, all patients are sent back to the waiting room. This interview occurred in the conference room, on December 14, 2010, at 10:10 a.m. The Emergency Room Director stated that the busiest time in the ER" is between 7:00 p.m. until 11:00 p.m., each day." This interview occurred in the conference room, on September 13, 2011, between 12;15 p.m. until 12:52 p.m., The hospital failed to ensure that the ER had adequate physician and nursing staff coverage on September 17, 2011. The hospital failed to adequately anticipate the needs of the ER patients during it's peak hours of operation.

Emergency Room Registered Nurse #2 ordered a chest X-ray, both PA (Posterior and Anterior, front to back view.), and Lateral (Side X-ray) at 00:16 a.m.; on September 18, 2011. St. Francis Emergency Room policy under Chest Paint Triage, stated, "Per rapid EKG Protocol and CXR (Chest X-ray) in Radiology, Transport by wheelchair) Patient #2 ambulated to the Radiology Department for the Chest X-ray. The staff failed to ensure that Patient #2 was taken to radiology per it's policy via a wheelchair.

On September 18, 2011, at 01:23 a.m., Patient #2 was admitted to ER room #5. During this time, Patient #2 stated that he was pain free, but had pain off and on, in his left shoulder with movement. The ER Physician #1 saw Patient #2, at 2:47 a.m., on September 18, 2011. A diagnosis of Muscle Spasm was entered for Patient #3 ER record. Flexeril (A muscle relaxant .) was ordered at 03:14 a.m., on September 18, 2011, during discharge from the ER.

2. The Bon Secours Richmond Health System of St. Francis Medical Center Policy/Procedure under Triage Process in the Emergency Room stated, "Category 3 (Urgent) "These patient require 2 or more recourses for a disposition decision to be reached. 'The Patient is stable for the interim but requires emergency department resources including, diagnostics, treatments, interventions or consultations. Reassessment will occur as often as needed. These patients will be advised they may have an extended wait and to inform the triage nurse should their condition change or worsen in any way."

The Bon Secours Richmond Health System of St. Francis Medical Center Policy/Procedure under Assessment of Patients in the Emergency Department stated, "Assessment and reassessment intervals will be determined by an acuity designation using the ESI 5-level Triage System as defined under the triage process Vital Signs: Every 2 hours after any intervention, Reassessment: Every 2 hours or after any intervention." Patient #2 had documented vital signs obtained ay 08:22 p.m., on September 17, 2011 and 03:22 a.m., on September 18, 2011, at discharge. The hospital failed to have adequate staff to assess Patient #2 at least every four hours due to lack of room in the Emergency Department.

3. The Safety Officer verified during interview that one nurse versus two nurses was assigned to ER Triage, on September 17, 2011, for four hours. This interview occurred in the conference room, on September 14, 2011 , at 2:20 p.m.