HospitalInspections.org

Based on document review, medical record review and interview, the facility did not ensure abnormal findings on patients presenting to the Emergency Department (ED) are communicated to the provider and that patients are re-assessed in a timely manner for 1 of 14 patients (Patient #5).

Findings include:

Review of policy # ED 05 titled: Emergency Department standards of care (effective date 1 - 20 -19) revealed that any abnormalities identified during triage assessment and/or reassessment should be communicated to the emergency room provider. Frequency of reassessment of vital signs for triage levels 1,2 or 3 will be every 2 hours. Triage categories are numbered 1- 5 with #1 being Resuscitation, 2 - Emergent, 3 - Urgent, 4 - Semi Urgent and 5 - Non - Urgent. H or V is assigned to determine if patient can sit (horizontal) or needs to lie down (vertical).

Review of Patient #5's ED medical record dated 7/27/19 revealed the patient presented to the ED at 4:07 PM with complaints of fall and confusion. The patient was alert with some confusion and a blood pressure of 170/91. The patient was assigned a triage level of 3H (Horizontal) - Urgent and placed in the waiting room. On 7/28/19 at 12:04 AM the patient was placed in a room, where a blood pressure of 202/115 was noted. A CT scan of the head was obtained, which revealed a lobular aneurysm with subarachnoid hematoma. There was no evidence to indicate the physician was informed of the patient's elevated blood pressure on arrival to the ED or that the patient received a re-assessment during the eight hour wait in the waiting room.

Interview with Staff (E) on 9/5/19 at 10:00 AM revealed that on 7/27/19 and 7/28/19, the ED was short by 2-4 registered nurses, while at the same time, the ED census was approximately 35 patients greater than average. Staff (E) stated that the provider should have been notified of the patient's elevated blood pressure on arrival and that the patient should have been re-assessed every two hours.