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Based on interview and record review, the facility failed to provide an appropriate Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment when vital signs were not monitored and reassessed, and medical condition assessed and monitored for change of condition for one of 24 sampled patients (Patient 1) who presented to Emergency Department (ED) for a clotted dialysis vascular access (an access to remove patient blood so it can be filtered).

This failure resulted in Patient 1 remaining in the ED waiting room for more than 12 hours without any vital signs and medical conditions reevaluated and reassessed on 11/14/2020 from 8:26 am to 9:20 pm.

Findings:

A review of Patient 1's nursing emergency department (ED) Triage note dated 11/14/2020 at 8:29 AM, indicated Patient 1 was brought to the Emergency room with a chief complaint unable to receive dialysis( treatment for kidney failure to remove toxins from the body) on 11/14/2020 due to clotted vascular access site.( Patient1 was triaged as Emergency Severity Index Level 3 (ESI Level 3 - Serious condition that requires emergency intervention), and Pain level was at zero (no pain). Patient 1's vital sign on 11/14/2020 at 8:29am, indicated: temperature was at 99.1 F( normal is 97F to 99F), pulse was at 82 beat per minute (normal 60 to 100), respiration rate (RR) was at 18 breaths per minute (normal RR is 12 to 20/minute), blood pressure was at BP105/77( normal BP 120/80), pulse oximetry (amount oxygen in the blood) was at 96% on room air (RA). Pain scale was zero

A review of Patient 1's Emergency Room Report dated 11/14/2020 at 08:36 AM, indicated Patient 1 had history of Congestive Heart Failure (failure of the heart to pump adequate amount of blood), Liver failure and Chronic Kidney Disease (Kidney damage resulting in less filtration of toxins from the body through the kidney). During a regular scheduled dialysis, on 11/14/2020, Patient 1 was noted to have a clot in vascular access site and was sent to the ED for evaluation and treatment. A review of impression and plan section of the medical record indicated Patient 1 was assessed "stable at the time of exam able to return to WR [waiting room] while awaiting results. Patient was instructed to advise triage or greet RN with any change of condition."

A review of Patient 1's medical record dated 11/14/2020 at 8:36 am included: doctor's orders, laboratory studies, and EKG (Electrocardiograph used to determine heart rate, heart rhythm) Patient 1 completed ordered tests and remained in the waiting room. There were no orders for a consult to evaluatePatient1 clotted vascular access and delay in dialysis.

A review of Patient1 Medical record, dated 11/14/2020 there was no documentation of Patient 1's VS or medical condition was reassessed including evaluation for dehydration or complications from delay in dialysis while Patient1 was waiting in the ED waiting room. From 8:29 am until 9:20 pm on 11/14/2020 for over 12 hours.

During an interview with the ED Manager on 12/11/2020 at 8:05am indicated when patients are in the waiting room, vital signs of patients are checked every 2 hours. When asked for documentation of vital signs or reassessment documentation for Patient 1 on 11/14/2020 between 8:29 am and 9:20 pm for there were none. On12/11/2020 at 12:30 pm the ED Director stated the vital signs should be checked every two hours on patients in the waiting room.

During an interview with ED Manager on 12/11/2020 at5:05pm when asked if there was a staffing shortage on 11/14/2020 in the ED resulting in VS not being checked for Patient1 in the ED Manager indicated she was not aware of any staffing problems. The ED Manager provided a daily report used to evaluate nurse staffing and bed availability titled" Daily Shift report" dated 11/14/2020, indicated night shift ED was short 4 RNs and 1 EMT( Emergency Medical Technology) and had "multiple ER Holds (20)"and day shift included" Holds and entire hospital staffing problems."

A review of the nursing emergency department notes dated 11/14/2020 at 9:25 pm Patient1 had VS taken Including temperature was at 37.4 C (normal is 36.1C to 37.2C), pulse was 90 beats per minute (normal is 60 to 100/minute), respiration rate18 breaths per minute (normal 12 to 20 breaths per minute), blood pressure was at 92/60 (normal BP 120/80), and pulse oximetry was 94% on room air (RA). Patient 1's pain scale was three and pain location was on the abdomen. In addition, Patient 1 was documented as "fatigued."

During an interview with the Chief of ED on 12/11/2020 at 3:55 pm, stated vital signs for Patient 1 should be completed every 2 hours while waiting to be seen. The Chief of ED explained Midlevel provider completed rapid Medical Exam (RME). The Chief of ED explained Depending on Triage, level Patients with Triage 1 and 2 are brought to the back sooner to be examined by ED physician. Chief of ED indicated once Patient 1 was examined by the ED MD orders and nephrology consults were written, and Patient 1 was admitted to inpatient Hospital care. Emergency Physician (EDMD4) examined a review of Patient 1's medical record titled ED Physician Record dated 11/14/2020 at 9:42 pm. Patient 1 was transferred to Inpatient Care on 11/14/2020 at 10:00 pm.

A review of the policy, "Emergency Medical Treatment and Active Labor Act", approved 11/17/2015 indicated "Medical Screening Exam is the process requiring determining with reasonable clinical confidence whether or not an emergency medical condition exists or a woman is in labor. This is documented in the patient's medical record. Qualified Provider to perform a medical screen at ...includes doctor of medicine or osteopathy"

A review of Assessment and Re-assessment of Patients policy, dated May 2018, indicated the following:
1. Each patient's physical, psychological and social status is assessed in order to determine the need for care, the type of care to be provided and the need for further assessment.
2. Care decisions and planning will be based on identified patient needs and care priorities.
3. Reassessments may be done more frequently depending on the complexity of the patient, duration of their care and the dynamics of conditions surrounding their care.
4. A registered nurse assesses the patient's need for nursing care in all settings where nursing care is provided.
5. Vital signs are important to obtain a reliable assessment of the patient's health status.
6. Vital signs will be taken more frequently if there is any significant variation from the previous reading.
7. Vital signs will be taken at the nurse's discretion according to medications, interventions, and patient's symptoms.