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Based on record review and interview the facility failed to ensure patients in the emergency room received a complete nursing assessment and reassessment per facility policy in 2 of 11 patients seen in the emergency room 2/16/2022. (Patient ID#s 15 an 21 )

Findings include:

Record review of facility policy titled ER Triage/Assessment/Reassessment, dated 2/2022 showed the following:

POLICY
All patients presenting to the emergency room will be assessed using a triage methodology to determine the severity of the presenting chief complaint. The triage acuity level is assigned to each patient using a 5-
Level Triage Acuity Scale (ESI) during the initial assessment.

The triage acuity level determines time the patient can safely wait to be seen by a primary nurse and physician when no beds or caregivers are immediately available, anticipated treatment and resources are required.

Patients awaiting an initial medical screening exam (MSE), regardless of where the patient is waiting , should be reassessed hourly.

DEFINITIONS
1. Rapid Initial Assessment- Triage is a dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN at the time of presentation and before registration. The triage Rapid Initial Assessment should be initiated within ten minutes of arrival to the emergency department. This assessment consists of information, which is obtained, the would enable the triage RN to determine a minimal acuity. This assessment is composed of a chief complaint, subjective, objective neurovascular, cardiovascular, respiratory status, first point of contact, mode of arrival, pain assessment, allergies, vital signs (if needed).

PROCEDURE
All patients presenting to the emergency department shall receive a Initial Rapid Assessment (Triage) by a Registered Nurse based on the severity of presenting symptoms. Assessments in the ED should be completed and documented as follows:
1. Rapid Initial Assessment (Triage) may include, but is not limited to:
...
2. Triage Reassessment
Prior to the Medical Screening Exam (MSE), the patient should be reassessed on an hourly basis at a minimum.

3. Detailed Assessment...

4. Reassessment Guidelines
Reassessment guidelines are provided as follows. The rapid initial assessment should be performed within 10 minutes of arrival. Reassessments should be performed at a minimum of hourly until the medical screening exam is initiated. Following the MSE, reassessments should be completed based on the acuity and/or status of the patient, regardless of the patient's location.

A. Level 2/ Emergent
Conditions that are a potential life threat...
2. Reassessments- Hourly

C. Level 3 / Urgent
Conditions that could potentially progress to a serious problem requiring emergent interventions
2. Reassessments- Every 2 hours or as patient condition requires.

Medical record review on 2/16/2022 at 1217 PM for patient (ID 15 ) showed the patient arrived in the emergency department (ED) on 2/16/2022 at 0207. The patient received a Rapid Initial Assessment at 0209. No other nursing assessments were documented. The patient was discharged from the facility 02 2/16/2022 at 0246.

ED manager (ID 53) at this time confirmed the above findings and stated that all patients should receive a full nursing assessment and it should be documented.

Medical record review for patient (ID 21 ) on 2/16/2022 at 12:51 showed that patients arrived at 0822. The patient was assigned acuity level of 3 (urgent) and rapid initial assessment was completed at 0821. There was no other nursing assessments documented for the patient at this time.

ED manager (ID 53 ) confirmed the above findings and stated that the arrival time may be documented after the initial rapid assessment due to the registration process. She went on to say that the patient should have had a complete assessment and reassessment performed and documented.