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Based on interview, and record review, the facility failed to ensure Patient 11 was consistently assessed in the Emergency Department (ED) while awaiting an available bed on an inpatient unit. This failure had the potential for a negative health outcome for Patient 11 .

Findings:

A review was made of a facility policy titled, "Triage," revised 5/2022, which indicated that triage involved a rapid, directed patient assessment, and provided the assignment of an acuity or priority level for each patient based on the industry standardized Emergency Severity Index (ESI) algorithm. According to the acuity level definition outlined in the policy, a triage ESI level 3 indicated a potentially unstable patient that required two or more resources.

A review was made of a facility policy titled, "Assessment/Reassessment of Patients," revised 4/2021, which outlined that patients with ESI Level 3 required, at a minimum, reassessments and vital signs (VS: temperature, heart rate, respiratory rate, blood pressure, and the saturation of oxygen in blood) to be performed every 30 to 60 minutes.

During an interview 7/18/24 10:16 am, Patient 11 recalled the events that led to her filing a complaint with California Department of Public Health and stated she was placed on a gurney late at night on 7/27/22 in a darkened room in the ED, the glass door shut, and unable to see a call bell button. Patient 11 stated she felt in a stupor from strong pain medications she had been given earlier in the evening. She stated, I was afraid of falling off the gurney if I tried to get off it, I looked around and didn't see a way to get hold of a nurse. I can't say I was in pain, but I was uncomfortable, there was pressure and I hurt. During the night I wet myself and was soaked from the neck down. I called out 2 or 3 different times at nurses passing by, but they didn't notice me.

A review of Patient 11's medical record found that Patient 11 came to the ED with severe right flank pain, increased urinary frequency and burning with urination. In an Emergency Room Provider note dated 7/27/22, Physician's Assistant (PA) 1 documented Patient 11 had a known history of chronic kidney disease and kidney stones (a mineral build-up that causes formation of stone-like material that accumulates in the kidney). After he reviewed the results of a CT (computed tomography, a scan that takes detailed images of bodily structures and organs), which indicated an ureteropelvic junction obstruction (a blockage preventing urine from releasing from the kidney into the bladder), PA 1 consulted Medical Doctor (MD) 1 at 7:42 pm, and admitted Patient 11 for intravenous (IV, 'in the vein') antibiotics (medications that destroy harmful bacteria that cause illness) due to the obstructing stone and a urinary tract infection.

A review was made of a nursing triage note dated 7/27/22 12:17 pm, by Registered Nurse (RN) 12 who made a comment in the triage notes that Patient 11 was complaining of aching sharp pain in the right flank radiating to the right lower quadrant of the abdomen along with urinary frequency, burning and urgency and that she had a history of kidney stones. RN 12 documented that Patient 11 had a pain level of nine, with 10 being the maximum amount of pain conceivable on this pain scale. ESI was determined to be a level 3.

A review was made of Patient 11's ED Visit Summary. On 7/27/22 at 5:30 pm, Medic 1 documented a pain assessment of right flank pain, level four.

A review was made of Patient 11's History and Physical dated 7/27/22 8:30 pm, by Physician Assistant (PA) 1, who documented a kidney stone on the right side, and planned for IV antibiotics, an evaluation with urology (physicians who specialize in problems involving the urinary system), a medication to relax urinary bladder muscles, and nothing given to eat/drink by mouth.

In Patient 11's ED Visit Summary dated 7/27/22 at 8:47 pm, Patient 11 was designated an admit hold, then listed at 9:11 pm as an inpatient, awaiting an available bed. She remained in ED overnight and was admitted to a nursing unit on 7/28/22 at 4:26 pm.

A review was made of Patient 11's provider orders for medications and fluids dated 7/27/22 5:35 pm, by PA 1 who ordered:
- Normal saline (a solution of sterile water and 0.9% salt, used for hydration) 1000 milliliters (mL, a unit of measure) IV, once;
- Toradol (a pain reliever) inj (injectable - medication injected into the body via needle and syringe) 15 milligrams (mg, a unit of measure) IV, once;
- Morphine (a potent narcotic pain reliever) inj 4 mg IV, once, for severe pain; and,
- Zofran (an medication for nausea) inj 4 mg, IV, once.
At 6:35 pm, MD 1 ordered a dose of an antibiotic, Rocephin, 2 grams (g, a unit of measure) in 50 mL of D5W (a solution in which medications are mixed and diluted) IV, once.

A review was made of Patient 11's medication administration record dated 7/27/22, for the administration of the medications ordered: the normal saline, Toradol, morphine, and Zofran were given as ordered by Medic 1 at 5:35 pm; the Rocephin was given as ordered by RN 13 at 6:35 pm.

A review was made of Patient 11's provider orders for medication and fluids dated 7/27/22 8:21 pm; MD 2 ordered morphine 1-2 mg IV every four hours as needed, normal saline 1000 mL IV, and Flomax (a medication to relax the bladder muscles) 0.4 mg by mouth at bedtime.

In Patient 11's ED Visit Summary on 7/27/22 at 10:06 pm, RN 6 documented a general assessment, a fall risk assessment, and VS. At 10:08 pm, RN 6 documented in the nursing note section that this was her first encounter with Patient 11 who was in the ED for flank pain and awaiting an inpatient bed and that Patient 11 was aware she was to eat or drink nothing after midnight. The next nursing note entry was made 11 hours later, on 7/28/22 at 9 am by RN 7, who documented, "Patient has been resting on stretcher with cardiac monitor (medical equipment that remains on patients to monitor/record VS) in place, and call bell within reach." The last nursing note entries are by RN 7 and are in regard to Patient 11 being admitted to a nursing unit, at 2:29 pm and 3:53 pm. Between 7/27/22 at 10:06 pm, until her transfer out of the ED on 7/28/22 at 4:26 pm, over 18 hours later, there were no further nursing assessments or reassessments, no pain assessments, no documentation of urinary output. Vital signs were documented on 7/28/22 at 12:06 am, 2:30 am, 4:34 am, 6:25 am, 6:57 am, 8:32 am, 10 am, 11:46 am, 2:23 pm. The VS taken at 10 am and 11:46 am both include temperature readings, indicting these VS involve staff going into the room as temperatures, for a patient in this situation, would not be taken remotely.

During a concurrent interview and record review conducted on 7/10/24 at 9:20 am, the Emergency Department Director (EDD) stated that a triage Level 3 patient should have been assessed with hourly vital signs, per policy in place in 2022. She stated a full general assessment is done upon arrival and thereafter a focused assessment, in this case a genitourinary-focused (sexual organs and urinary system) assessment, should have been done. EDD stated her concern is that Patient 11 was left alone all night; she could see in the medical record that vital signs were being reviewed but may have been done remotely with cardiac monitoring/automated blood pressure cuff; she could not determine whether or not Patient 11 went to the restroom, or urinated, or that pain was reassessed.