HospitalInspections.org

Based on a review of medical records (MR), facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies to ensure that patients triaged as Emergency Severity Index (ESI) 3, received hourly vital signs as per their policy, in nine of 17 medical records. (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, and MR9).

Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 2463892 ... Last Reviewed: May 2016 ... Policy Area: Emergency Department ... Department of Emergency Services Triage Process ... "Purpose: To provide guidelines for a quick, initial assessment of every patient who presents to the Emergency Department and to assume early identification of those who are eligible for Fast Track and allows the RN to begin advanced Triage protocols. Process: 1. All patients who come to the Emergency Department for care are triaged, either at bedside or in he [sic] triage area. At times, ambulance patients will be directed to Triage based on Medical Command report. 2. Triage responsibilities are: a) completing the reason for visit and assigning a Triage acuity level b) obtaining vital signs ... f) initiate the advanced Triage protocols as appropriate. 3. The Triage nurse is responsible for monitoring patient condition and updating them on delays while in the Waiting Room, working with the Triage Tech and Pt Advocate to keep patients and families informed regarding delays. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 2747232 ... Last Reviewed: August 2016 ... Policy Area: Emergency Department ... DEM Vital Sign Assessment ... Documentation of of Vital Signs/Patient Assessment Protocol: 1. Temperature, pulse, heart rate, respirations, blood pressure and pulse oximetry are taken on all patients upon arrival to the Department of Emergency Medicine (DEM). ... 4. Emergency Severity Index (ESI) Level 1 patients should have vital signs monitored and documented at least every 15 minutes or more frequently based on patient condition or provider request. This includes a documented set of vital signs within 15 minutes of departing the DEM to inpatient bed, special procedure are (cath lab, GI lab, IR), OR, or transfer to another facility. 5. ESI Level 2 and 3 patients should have vital signs monitored and documented at least every 60 minutes. The last set of vital signs before patient departure should be captured within 30 minutes of leaving the DEM. ... ."

1) MR1 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival 1310 ... Chief Complaint: Fall, back, knee injury ... Triage Priority: 3 ... Time: 1310 ... Temp: 36.9 Pulse: 77 RR: 18 BP: 170/72 ... Additional Orders ... Time: 1410 36.6 69 88 136/64 ... 1510 36.4 78 94 124/59 1610 36.2 72 90 130/62 ... Time Seen by Provider: [blank] ... Diagnosis: [blank] ... Check out time: 1755 ... Disposition: ... LWOT [box marked with x] ... ." EMP3 confirmed that MR1 failed to reveal documented evidence that the patient had additional vital signs taken at 1710 while in the ED Waiting Room prior to leaving before being examined by a provider.

2) MR2 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1914 ... Time in Room: 0020 ... Chief Complaint: Cough, Hx Lung Transplant ... Triage Priority: 3 ... Time: 1914 ... Temp: 37.1 Pulse: 103 RR: 18 BP: 108/65 ... Time Seen by Provider: 0025 ... Diagnosis: PNA ... Check out time: 0845 ... Disposition ... Transfer ... ." EMP3 confirmed that MR2 failed to reveal documented evidence that the patient had any additional vital signs taken while in the ED Waiting Room prior to being examined by a provider.

3) MR3 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1504 ... Time in Room: 1958 ... Chief Complaint: R Facial Droop since 10/2 ... Triage Priority: 3 ... Time: 1504 ... Temp: 36.4 Pulse: 109 RR: 16 BP: 188/99 ... Additional Orders ... Time: 1604 36.8 94 90% 158/71 ... Time Seen by Provider: 2004 ... Diagnosis Facial Droop R/O CVA ... Check out time: 0150 ... Disposition ... Admit ... ." EMP3 confirmed that MR3 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider.

4) MR4 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1508 ... Time in Room: 1959 ... Chief Complaint: RLE Pain ... Triage Priority: 3 ... Time: 1508 ... Temp: 36.5 Pulse: 75 RR: 18 BP: 131/89 ... Additional Orders ... Time: 1608 36.7 110/72 71 100% 20 ... 1709 36.5 112/75 90 100% 20 ... Time Seen by Provider: 2003 ... Diagnosis Suspect DVT ... Check out time: 2323 ... Disposition ...Discharge ... ." EMP3 confirmed that MR4 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider.

5) MR5 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1533 ... Time in Room: 2015 ... Chief Complaint: Weakness BLLE Swelling ... Triage Priority: 3 ... Time: 1533 ... Temp: 36.5 Pulse: 57 RR: 18 BP: 104/52 ... Additional Orders ... Time: 1633 Not in waiting room ... 1733 36.4 60 98% 18 100/61 ... 2000 36.6 59 99% 20 111/59 ... Time Seen by Provider: 2022 ... Diagnosis: [blank] ... Check out time: 2200 ... Disposition: [blank] ... ." EMP3 confirmed that MR5 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider.

6) MR6 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1632 ... Time in Room: [blank] ... Chief Complaint: Abd injury ... Triage Priority: 3 ... Time: 1632 ... Temp: 36.7 Pulse: 106 RR: 16 BP: 118/77 ... Time Seen by Provider: [blank] ... Diagnosis: [blank] ... Check out time: 1935 ... Disposition: LWOT [box marked with x] ... ." EMP3 confirmed that MR6 failed to reveal documented evidence that the patient had any additional vital signs taken at 1730 and 1830 hours while in the ED Waiting Room prior leaving the facility before being examined by a provider.

7) MR7 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1705 ... Time in Room: 2257 ... Chief Complaint: Shaky ... Triage Priority: 3 ... Time: 1705 ... Temp: 36.8 Pulse: 106 RR: 16 BP: 141/93 ... Additional Orders ... 1805 36.9 111 140/87 99% 18 ... 2000 37.0 105 139/96 98% 18 ... P 93 BP 137/83 O2 100 RA 2325 ... Time Seen by Provider: 2306 ... Diagnosis: dizziness anxiety ... Check out time: 0300 ... Disposition: Discharged ... ." EMP3 confirmed that MR7 failed to reveal documented evidence that the patient had additional vital signs taken at 1900, 2100 and 2200 hours while in the ED Waiting Room prior to being examined by a provider.

8) MR8 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1836 ... Time in Room: 2305 ... Chief Complaint: R Leg Swollen Pain ... Triage Priority: 3 ... Time: 1836 ... Temp: 37.0 Pulse: 86 RR: 16 BP: 126/81 ... Additional Orders ... 2015 36.7 88 18 146/77 95% ... 2130 36.7 80 18 141/75 93% ... Time Seen by Provider: 2310 ... Diagnosis: PE DVT Hx of SAH ... Check out time: 0236 ... Disposition: Admit ... ." EMP3 confirmed that MR8 failed to reveal documented evidence that the patient had additional vital signs taken at 1930 and 2230 hours while in the ED Waiting Room prior to being examined by a provider.

9) MR9 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival:1857 ... Time in Room: 0011 ... Chief Complaint: Abd Pain ... Triage Priority: 3 ... Time: 1857 ... Temp: 37.1 Pulse: 100 RR: 16 BP: 108/67 ... Additional Orders ... 2030 37.0 85 18 106/65 100% ... Time Seen by Provider: 0015 ... Diagnosis: Colitis Nausea ... Check out time: 0329 ... Disposition: Discharge ... ." EMP3 confirmed that MR9 failed to reveal documented evidence that the patient had additional vital signs taken at 2100, 2200 and 2300 hours while in the ED Waiting Room prior to being examined by a provider.