HospitalInspections.org

Based on staff interview and record review, the hospital failed to assure that the Emergency Department took appropriate action aimed at performance improvement after identifying an improvement need regarding nurse's proficiency of the triage process. Findings include:

As a result of a complaint investigation regarding a patient's treatment in the Emergency Department (ED) during June, 2011, the Registered Nurse (RN) Manager of ED Services identified a lack of triage proficiency for one of it's RNs regarding this patient. Although the RN Manager stated that he had verbally counseled the RN and had made a note regarding triage time issues in the annual evaluation done in October, 2011, he had not documented any quality improvement plan, nor any subsequent follow up audits to assure proficiency in triage levels. The RN Manager also confirmed that he had identified an educational need for several RNs after administering a triage rating test to RNs in late 2009 and early 2010. The results of these tests were reviewed with the ED Nurse Manager and the Director of Risk Management/Compliance on 7/31/12 at 1:20 PM. The results showed a need for an improvement process to re-educate and re-evaluate RN knowledge/triage proficiency on an on-going basis and the Manager confirmed that he had not formally developed a quality improvement process to address this identified need.