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Based on interview and record review, the hospital failed to follow the triage P & P which resulted in a delay in the provision of an MSE (Medical Screening Exam) to determine if an emergency medical condition existed for two of 54 sampled patients (Patients 2 and 50) which could potentially result in the failure to stabilize an emergency medical condition.

Findings:

On 5/13/10, review of the hospital's policy and procedure showed an MSE "means the process required to reach within a reasonable clinical confidence the point at which it can be determined whether or not an emergency medical condition exists."

On 5/13/10, the hospital's P&P #3; subject Triage, page 1, stated the purpose of triage was to categorize patients based on the severity of their injuries or illness, and to prioritize their need for treatment. The triage nurse would classify the patient into one of five categories using the Emergency Severity Index (ESI). Level 2 acuity patients were defined as high risk situations and included as a symptom, confusion.

For patients categorized with an acuity Level 3, vital signs should be obtained at a minimum of every two hours. Patients triaged as a level greater than 3 would be reassessed on an ongoing basis. Acuity Level 3 were patients with danger zone vitals such as heart rate greater than 100-180, respiratory rate greater than 20-50 and oxygen saturation (oxygen in the blood) less than 92%.

1. During an observation of the ED Adult Waiting Room Six on 5/13/10 at 1110 hours, Patient 50 was interviewed. The patient stated she had "brain surgery" last week and passed out this morning. The patient stated she had arrived in the ED by ambulance at 0430 hours and was triaged by the RN quickly. The patient stated she had not been told how long it would be before she saw a physician, but stated she "almost wanted to leave."

The patient's record was reviewed on 5/17/10 and showed Patient 50 arrived in the ED at 0427 hours and was triaged at 0429 hours as an acuity Level 3. The nursing reassessments were at 1308 hours and 1754 hours. The nurse's notes from the 0802 triage showed the patient complained of feeling weak and confused. The patient did not receive an MSE to determine if there was an emergency medical condition until 1940 hours on 5/17/10, more than 15 hours since arrival in the ED.

Further review of Patient 50's history in the medical record showed, on 5/5/10, the patient had a ventricular shunt placed (a tube that is surgically placed in one of the fluid-filled chambers inside the brain (ventricles) to drain it and thereby relieve excess pressure and had been brought into the ED on 5/13/10 by ambulance after "passing out" in her parents' arms.

2. The medical record for Patient 2 was reviewed on 5/14/10. Documentation showed the patient arrived in the ED on 5/4/10 at 0832 hours. Triage by the RN was documented as completed at 0807 hours. The patient stated she had been diagnosed with a cerebral vascular accident (stroke) on 4/30/10, and had been referred to this hospital for further follow-up and neurology consult. On arrival in the ED the patient complained of a headache with "ringing" in her right ear. Documentation showed the patient had left sided weakness to the upper and lower extremities. The triage RN assessed the patient as acuity Level 3. Documentation showed the patient was not called for further assessment of her condition until 1518 hours, almost seven hours after arrival in the ED.

During an interview with RN I on 5/17/10 at 1125 hours, the medical record for Patient 2 was reviewed. The RN provided documentation of an electronic screen shot which showed the patient had been called for further reassessment on 5/14/10 at 1518 hours but was not available. The RN was asked when a patient should be reassessed by the nurse if presenting with a history of a stroke and an onset of a headache and ringing in the ear. RN I stated she was not able to state in this case, however vital signs should have been checked every two hours for any deterioration of the medical condition following the triage assessment, as the patient was an acuity Level 3. Documentation showed the patient left the ED without being seen for an MSE.