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3400 MINISTRY PARKWAY

WESTON, WI 54476

STAFFING AND DELIVERY OF CARE

Tag No.: A0392

Based on record review and interview, the facility failed to ensure a complete nursing assessment and reassessments were completed in 8 of 10 Emergency Department patients (Patient #1, #3, #4, #5, #6, #8, #9 and #10) in a total of 10 Emergency Department medical records reviewed.

Findings include:

Review of policy "Triage in the Emergency Department Policy" #KT2N6QC5SZE5-3-2275 last reviewed 6/28/2022 under policy revealed patient's presenting to the ED will receive a "triage assessment, focused nursing assessment to include the chief complaint and history of present illness, and vital sign measurements as applicable."

Review of policy "Standards of Nursing Practice Policy-Emergency/Urgent Care Department" #KT2N6QC5SZE5-3-2854 last reviewed 11/09/2022 under Triage revealed "The nurse should collect and document" data to ensue completeness of assessment and concise communication of findings."

Patient #1's medical record review revealed patient #1 was a 2 year-old who presented to the Emergency Department 11/22/2022 at 8:22 AM with a cough, fatigue and a history of testing positive for respiratory syncytial virus infection (RSV) at daycare 4 days ago and was discharged 11/22/2022 at 11:34 AM. There was no nursing documentation of patient #1's cardiac assessment or complete respiratory assessment documented. There were no breath sounds documented.

Patient #3's medical record review revealed patient #3 was a 6- year-old who presented to the Emergency Department 12/06/2022 at 8:05 PM with fever and sore throat and was discharged home 12/06/2022 at 9:30 PM. There was no nursing documentation of patient #3's cardiac assessment or breath sounds documented.

Patient #4's medical record review revealed patient #4 was a 3-month-old who presented to the Emergency Department 11/28/2022 at 3:06 PM with a cough and rhinorrhea and was discharged home 11/28/2022 at 7:24 PM. There was no nursing documentation of patient #4's cardiac assessment or breath sounds documented.

Patient #5's medical record review revealed patient #5 was a 4- year-old who presented to the Emergency Department 11/21/2022 at 6:23 PM, tested positive for RSV yesterday, and his parent stated his/her breathing was worse. Patient #5 was transferred to another acute facility on 11/22/2022 at 6:40 AM. There was no nursing documentation of patient #1's cardiac assessment or nursing re-assessments of patient #5 condition from 8:01 PM to transfer on 11/22/2022 at 6:40 AM (>10 hours later). There were no breath sounds documented by nursing during this visit.

Patient #6's medical record review revealed patient #6 was a 7-month-old who presented to the Emergency Department 11/27/2022 at 10:26 PM with a cough and upper respiratory symptoms for 3 days, and was discharged home 11/28/2022 at 1:05 AM. There was no nursing documentation of breath sounds in patient #6's medical record.

Patient #8's medical record review revealed patient #8 was a 19-year-old who presented to the Emergency Department 11/22/2022 at 5:18 AM with abdominal pain and vomiting and was discharged 11/22/2022 at 8:40 AM. There was no nursing assessment of Patient #8's abdominal, gastrointestinal system, or bowel sounds documented during this visit.

Patient #9's medical record review revealed patient #9 was a 13-month-old who presented to the Emergency Department 11/21/2022 at 2:30 AM, diagnosed with RSV 3 days ago, and parent states s/he is not improving. Patient #9 was discharged home 11/21/2022 at 5:28 AM. There was no nursing assessment of patient 9's cardiac assessment or breath sounds documented.

Patient #10's medical record review revealed patient #10 was a 2-year-old who presented to the Emergency Department 12/26/2022 at 8:59 AM with a cough, congestion, and fever and was transferred to another acute care children's hospital 12/26/2022 at 12:19 PM. There was no nursing assessment of patient #1's cardiac or neurologic systems, or breath sounds documented. The first nursing respiratory assessment was completed 12/26/2022 at 9:50 AM (49 minutes after presentation). There were no nursing reassessments documented prior to transfer on 12/26/2022 at 12:19 PM.

On 1/04/2023 during interview with Emergency Department (ED) Manager H, while reviewing emergency department medical records from 10:57 AM to 2:30 PM, when asked what the expectations were for documentation of a nursing assessment, ED Manager H stated "my practice" at a minimum is a focused assessment; on a respiratory patient would be to do a lung, heart, and skin assessment with vital signs. When asked if the medical record nursing documentation met his expectations, Manager H stated, "I don't have an answer." ED Manager H confirmed the findings in patient #1, #3, #4, #5, #6, #8, #9 and #10's ED records.

On 1/04/2023 at 1:54 PM during interview with Chief Nursing Officer (CNO) B, CNO B stated that "triage is based on vital signs" and agreed, ED nursing assessments should be focused on the chief complaint, which were not assessed by nursing in Patient # #1, #3, #4, #5, #6, #8, #9 and #10's medical record reviews.