HospitalInspections.org

Based on review of the hospital policies and procedures, medical record reviews, and staff interviews, the hospital staff failed to reassess patients vital signs while waiting for treatment in the Emergency department (ED) waiting room for 5 of 31 sampled ED patients. (#19, #35, #37, #1, #5)

The findings include:

Review on 06/24/2021 of the hospital policy titled, "Vital Sign/Pain Assessment" revised on 04/2015 revealed, " ... 6. Reassessment of vital signs should occur based on patient acuity and condition and documented appropriately. ESI (Emergency Service Index - criteria used to assign acuity. 1 being most severe and 5 not being as severe) level 1: minimum of every 15 minutes. ESI level 2: Minimum of every 30 minutes. ESI level 3: minimum of every 2 hours. ESI level 4 or 5: minimum of every 4 hours ..."

Review of the updated policy "Vital Sign/Pain Assessment", effective April 2021, revealed "...All patients who come into the Emergency Department will have vital signs....upon arrival and reassessed based on patient's acuity....6. Reassessment of vital signs (excluding temperature) should occur based on patient acuity and condition and documented appropriately....ESI level 2: minimum of every 30 minutes ESI level 3: minimum of every 2 hours... ."

1. Review of the medical record for Patient #19 revealed a 65-year-old female presented to the hospital Emergency Department (ED) via private owned vehicle (pov) on 06/23/2021 at 1217 with a chief complaint of "chest pain." Review of the EKG (electrocardiogram - image of the electrical activity of the heart) performed at 1226 revealed "Interpretation: Sinus tachycardia Right bundle branch block T wave abnormality, consider inferior ischemia Abnormal ECG ..." Review revealed at 1236 Patient #19 was assigned "Patient Acuity: 2." Review of the vital signs at 1236 revealed "Temp (temperature): 98.3 degrees F (Fahrenheit); Pulse Rate: 106; BP (blood pressure) 184/84; Oxygen Therapy: SpO2: 98%." Review revealed Patient #19 was transferred from triage to the waiting room at 1243.
Review of Patient #19's vital signs at 1407 (1 hour 51 minutes after initial assessment.) revealed "Temp: 98.5 degrees Fahrenheit; Pulse rate: 95; Resp: 15; BP: 137/68 ... SpO2: 98% O2 Device: Room Air ..." Review of Patient #19's vital signs at 1714 (3 hours 7 minutes after last assessment) revealed "Temp: 98.2 degrees Fahrenheit; Pulse rate: 100; Resp: 16; BP: 161/86 ... SpO2: 100% O2 Device: Room Air ..." Review of the ED timeline revealed Patient #19 was transferred to room 015C at 1742 (5 hours 25 minutes after presenting to the ED).

Interview on 06/24/2021 at 1143 with an ED Technician (ED Tech )#17 revealed the vital signs are reassessed based on the acuity. Interview revealed vital signs are assessed every 2 hours in the ED lobby (waiting room) and if a patient has an acuity level 2, the vital signs are assessed every 30 minutes. Interview revealed it is "hard to circle back to get vital signs." Interview revealed it "depends on the volume" in the lobby and if there is only 1 ED Tech and if the "Sort RN (Registered Nurse) [Nurse in the lobby to assist with patient flow] goes to help the triage" depending on the volume in the ED.

Interview on 06/25/2021 at 0935 with the President of (Hospital Name) #18 and the Executive Director of Nursing #19 revealed the hospital had identified in November 2020 the Emergency Department (ED) non-COVID patient volumes was increasing. Interview revealed the ED is holding more patients that are to be admitted due to the hospital not having enough beds available for the patients. Interview revealed the holding of the patient in the ED has led to an increase in the amount of time patients are having to wait in the waiting room and the increase in patients LWOBS (left without being seen).

2. Review of the medical record for Patient #35 revealed a 50-year-old male presented to the hospital ED via pov on 05/26/2021 at 1107 with a chief complaint of "SOB (shortness of breath)." Review of the vital signs at 1119 revealed "Temp: 97.8 degrees F; Pulse Rate: 90; BP 117/82; Oxygen Therapy: SpO2: 99%. O2 Device: Room Air." Review of the Triage note at 1130 revealed "patient complains of increased SOB and chest pressure since Monday. Reports had covid 4 weeks ago. Alert and oriented,". Review revealed at 1133 Patient #35 was assigned a "Patient Acuity: 2" and was transferred to the waiting room at 1134. Review revealed Patient #35 was transferred to ED room "029C" at 1659. Review of Patient #35's vital signs at 1711 (5 hours 19 minutes after initial assessment) revealed "Temp: 97.5 degrees Fahrenheit; Pulse rate: 63; Resp: 15; BP: 152/89 ... SpO2: 100% O2 Device: Room Air ..."

Interview on 06/24/2021 at 1143 with an ED Technician (ED Tech) #17 revealed the vital signs are reassessed based on the acuity. Interview revealed vital signs are assessed every 2 hours in the ED lobby (waiting room) and if a patient has an acuity level 2, the vital signs are assessed every 30 minutes. Interview revealed it is "hard to circle back to get vital signs." Interview revealed it "depends on the volume" in the lobby and if there is only 1 ED Tech and if the "Sort RN (Registered Nurse) [Nurse in the lobby to assist with patient flow] goes to help the triage" depending on the volume in the ED.

Interview on 06/25/2021 at 0935 with the President of (Hospital Name) #18 and the Executive Director of Nursing #19 revealed the hospital had identified in November 2020 the Emergency Department (ED) non-COVID patient volumes was increasing. Interview revealed the ED is holding more patients that are to be admitted due to the hospital not having enough beds available for the patients. Interview revealed the holding of the patient in the ED has led to an increase in the amount of time patients are having to wait in the waiting room and the increase in patients LWOBS (left without being seen).

3. Review of the medical record for Patient #37 revealed a 71-year-old female presented to the hospital ED via pov on 06/15/2021 at 1124 with a chief complaint of "SOB (shortness of breath)." Review revealed Patient #37 had an EKG which showed normal sinus rhythm at 1125. Review of the vital signs at 1128 revealed "Pulse Rate: 90; Resp: 18; BP 183/112; Oxygen Therapy: SpO2: 100%. O2 Device: Room Air." Review revealed at 1137 Patient #35 was assigned a "Patient Acuity: 3" and was transferred to the waiting room. Review of Patient #37's vital signs at 1810 (6 hours and 42 minutes after initial assessment) revealed "Temp: 97.7 degrees Fahrenheit; Pulse rate: 83; Resp: 16; BP: 186/88 ... SpO2: 100% O2 Device: Room Air ..." Review revealed at 1841 Patient #37 was roomed in the ED room 032C.

Interview on 06/24/2021 at 1143 with an ED Technician (ED Tech) #17 revealed the vital signs are reassessed based on the acuity. Interview revealed vital signs are assessed every 2 hours in the ED lobby (waiting room) and if a patient has an acuity level 3, the vital signs are assessed every two hours. Interview revealed it is "hard to circle back to get vital signs." Interview revealed it "depends on the volume" in the lobby and if there is only 1 ED Tech and if the "Sort RN (Registered Nurse) [Nurse in the lobby to assist with patient flow] goes to help the triage" depending on the volume in the ED.

Interview on 06/25/2021 at 0935 with the President of (Hospital Name) #18 and the Executive Director of Nursing #19 revealed the hospital had identified in November 2020 the Emergency Department (ED) non-COVID patient volumes was increasing. Interview revealed the ED is holding more patients that are to be admitted due to the hospital not having enough beds available for the patients. Interview revealed the holding of the patient in the ED has led to an increase in the amount of time patients are having to wait in the waiting room and the increase in patients LWOBS (left without being seen).



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4. Emergency Department (ED) record review, on 06/23-24/2021, revealed Patient #1 arrived by private vehicle to the ED at Campus B on 04/26/2021 at 2055. Review of "ED Triage Notes", date of service 04/26/2021 at 2117, revealed "Pt (Patient) presents with headache and all over body rash after removing a tick from her Left hip Thursday." Vital Signs (VS) at 2120 were Temperature (T) 98.1, Pulse Rate (P) 108, Respirations (R) 16, Blood Pressure (BP) 118/85 and SpO2 (Pulse oximetry - monitors a person's oxygen saturation) was 100% on room air. Patient #1 was assigned an ESI acuity of 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). VS were rechecked on 04/27/2021 at 0124 (4 hours, 4 minutes after first vital signs) and were T 98, P 61, R 15, BP 153/74 [elevated] and SpO2 99%. Review of the ED Timeline revealed Patient #1 left the ED at 0455 without being seen by a provider. Record review indicated the patient was "advised" to stay but did not indicate VS were rechecked or the patient was reassessed by a nurse prior to Patient #1 departing the ED (3 ½ hours after last vital signs and 8 hours after arrival).

Telephone interview on 06/23/2021 at 1330 with Nurse Tech #10 revealed vital signs needed to be checked in the waiting room every two hours but sometimes when they were very busy it would go over 2 hours.

Interview with the Triage Nurse, RN #9, on 06/23/2021 at 1440, revealed every two hour vital signs "is good, but with 60 people it is hard to get back around."

5. ED medical record review, on 06/23/2021, revealed Patient #5, a 40 year old, arrived to the Campus C ED on 04/27/2021 at 0130 via private vehicle. Review of Triage Notes, at 0206 revealed "Patient arrived stating for about a week he has had a headache on the left side of his head that radiates to the back of his head. Reporting no nausea or vomiting. Endorces sensitivity to light." VS at 0154 were T 98.2, P 83, R 19, BP 133/85, and SpO2 99% on room air. A Pain Assessment was completed at 0207 with a pain score of 8 (on a scale of 0-10 with 0 being no pain and 10 being the worst pain). Patient #5 was assigned an ESI acuity of 3. At 0619 Timeline review revealed "Called for Triage x1" and at 0704 review revealed "...Called for Triage, Treatment, or Rooming x3..." and noted "...ED Disposition set to LWBS (left without being seen) after Triage. ..." Review did not reveal any further vital signs between 0154 and 0619 (4 hours 25 minutes) and did not reveal any additional pain assessment. ED record review revealed Patient #5 returned on 04/27/2021 at 0721 (1 hour 2 minutes after the first Triage call). A Triage Note at 0743 revealed "Patient reports left side of head and neck has been hurting for one week. ..." VS at 0744 were T 97.9, P 69, R 16, BP 140/69 and SpO2 100% on room air. At 0746, Timeline review revealed a pain assessment with a score of 6 documented and at 0747 Patient #5 was assigned an acuity of 3. At 1151 (4 hours 7 minutes after VS obtained) documentation noted "...Called for Triage, Treatment, or Rooming x 1." Record review did not reveal any evidence VS were rechecked for Patient #5 per policy on either visit.

Telephone interview on 06/23/2021 with the Nurse Tech, NT #13, revealed a patient's VS should be checked every two hours in the lobby or based on request. NT #13 stated if a patient was in the ED lobby as long as this patient was, VS should have been rechecked.

Telephone interview on 06/24/2021 at 1000 with RN #14 revealed that in regards to reassessment/vital signs the staff did the best they could, but sometimes due to how busy they were they could not get them done.

NC00177125, NC00177951