HospitalInspections.org

Based on policy review, closed medical record review, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to reassess 4 of 13 patients, that awaited treatment in the Emergency Room lobby and then left the hospital without being seen by a physician, per policy (#43, #26, #25 and #28).

The findings include:

Review of current hospital policy entitled "Triage Policy - Adult" dated 04/11/2005 and last reviewed on 02/25/2011 revealed, "PROCEDURE: Patients presenting to the Adult Entrance of the Emergency Department (ED) are assessed by a Registered Nurse...B. Initial Intake Process:...3. When ED beds are not available, Frontline Triage Nurse performs Primary Triage. Frontline Primary Triage includes:...Chief Complaint....Initial Acuity according to ESI (Emergency Severity Index)....Initial Pain assessment...Subjective note related to patient complaint....Brief complaint focused objective assessment (vital signs...at the discretion of the nurse)....Assigns patient to the triage area....4. The Triage Nurse or delegate escorts the patient to assigned room. a. ESI level 1 (highest acuity level) is directly placed in the Resuscitation room or any available ED room. ESI level 2 - Secondary Triage Nurse is notified to take patient directly to triage room to complete secondary triage and initiate protocols as indicated....c. ED Lead Charge Nurse is notified for ESI level 2 bed assignment. Secondary triage for all other patients is completed according to ESI acuity level. Secondary Triage includes:...Focused Assessment....Treatment Area Assignment...Review of primary triage acuity....Vital Signs....Pertinent past medical history....C. Patient Reassessment (Waiting Room) - The frequency of reassessment is based on the patient's acuity, condition, history, and complaint. ESI level 2 (yellow) patients will be reassessed every two (2) hours. ESI level 3 (green), level 4 (light blue), level 5 (blue - lowest acuity) will be reassessed every four (4) hours. Reassessment includes vital signs and pain level. Physical assessments will be completed as needed...."

1. Medical record review for Patient # 43 revealed a 61 year old female that presented to the ED on 02/21/2011 at 2005 via EMS (Emergency Medical Services ambulance) after she sustained a fall at home. Review of the triage nurse's documentation at 2032 revealed, "Primary Triage Info....Chief Complaint: Fall injury....Initial Triage Acuity: 3 - Green. Note: Pt (patient) presents to triage after slipping on wet floor and fell backwards onto floor around 1900 tonight and struck back of head. knot on back of head noted. Pt also complaining of left shoulder and arm pain - good pulses with no deformities. no LOC (loss of consciousness)...." Further review of the triage note at 2032 revealed the nurse assessed the patient's vital signs and documented the patient's past medical history. Record review revealed at 2033 the nurse documented the patient complained of pain in her head, back, and shoulder that the patient rated to be at a severity level of "10/10 - severe" (on a scale of 0 to 10, with 10 being the most severe pain)." Record review revealed documentation at 2034 of "Provider ED Protocol" orders for the patient to have x-ray studies of her left shoulder and forearm and a CT (computed tomography) scan of her head. Record review revealed documentation at 2035 the patient was placed in the Waiting Room (in the ED lobby). Review of radiology results reports revealed documentation the x-ray studies were done at 2110 and the CT scan was done at 2140. Record review revealed the next documentation by nursing staff was on 02/22/2011 at 0307 (6 hours and 32 minutes after the triage assessment was completed and the patient was placed in the Waiting Room). Review of nursing documentation at 0307 revealed, "UTLP - Unable to Locate Patient." Review of nursing documentation at 0555 revealed, "Reassessment: Patient cannot be found." Review of nursing documentation at 0707 revealed, "Note: pt called from lobby two more times with no answer." Review of nursing documentation at 0708 revealed, "Eloped - W/out being seen....Charting is Complete." Record review revealed no documented evidence a nurse reassessed (or attempted to reassess) the patient between 2035 on 02/21/2011 and 0307 on 02/22/2011 (6 hours and 32 minutes), when the patient was found to be missing from the ED Waiting Room.

Interview on 03/02/2011 at 1540 with the Interim Director/Nurse Manager of the ED revealed patients with an ESI level of 3 that awaited treatment in the ED Waiting Room must be reassessed at least every 4 hours by nursing staff. Interview revealed the Frontline and Secondary triage nurses shared the responsibility to ensure reassessments were completed. Interview revealed all reassessments must be documented. Interview revealed nursing staff should have reassessed Patient #43 within 4 hours of the triage assessment that was completed at 2035. Interview confirmed there was no available documentation that a nurse reassessed (or attempted to reassess) the patient between 2035 on 02/21/2011 and 0307 on 02/22/2011 (6 hours and 32 minutes), when the patient was found to be missing from the ED Waiting Room.



22798

2. Medical record review for Patient #26 revealed 24 year-old female that presented to the ED on 02/18/2011 at 1151 with chief complaint of right side abdominal pain. Review of the triage nurse's documentation at 1158 revealed the nurse assessed the patient's vital signs and documented the patient's past medical history. Review of the traige nurse's note revealed "pt ambulatory , c/o (complaining of) right sided abdominal pain x (times) 2 weeks, sharp in nature, nonradiating. Pt states she was given muscle relaxant yesterday by PCP (primary care provider) but no relief. Pt unable to recall any recent injury. Denies n/v/d (nausea, vomiting, diarrhea) or urinary/vaginal symptoms". Record review revealed the patient was given an acuity level of 3, a urine pregnancy test and urinalysis were obtained, and the patient was placed in the waiting room at 1203. Further record review revealed a negative pregnancy test and urinalysis was documented at 1610. Record review revealed the next documentation by nursing staff was on 02/18/2011 at 1812 (6 hours and 9 minutes after the triage assessment was completed and the patient was placed in the Waiting Room). Review of nursing documentation at 1812 revealed, "UTLP - Unable to Locate Patient." Review of nursing documentation at 1812 revealed, "Note: pt called to triage for reassessment, no answer." Review of nursing documentation at 1825 revealed, "Reassessment: Patient cannot be found." Review of nursing documentation at 1854 revealed, "Eloped - W/out being seen....Charting is Complete." Record review revealed no documented evidence a nurse reassessed (or attempted to reassess) the patient between 1203 on 02/18/2011 and 1812 on 02/18/2011 (6 hours and 9 minutes), when the patient was found to be missing from the ED Waiting Room.

Interview on 03/02/2011 at 1540 with the Interim Director/Nurse Manager of the ED revealed patients with an ESI level of 3 that awaited treatment in the ED Waiting Room must be reassessed at least every 4 hours by nursing staff. Interview revealed the Frontline and Secondary triage nurses shared the responsibility to ensure reassessments were completed. Interview revealed all reassessments must be documented. Interview revealed nursing staff should have reassessed Patient #26 within 4 hours of the triage assessment that was completed at 1203. Interview confirmed there was no available documentation that a nurse reassessed (or attempted to reassess) the patient between 1203 on 02/18/2011 and 1812 on 02/18/2011 (6 hours and 9 minutes), when the patient was found to be missing from the ED Waiting Room.

3. Medical record review for Patient # 25 revealed a 24 year old female that presented to the ED on 02/18/2011 at 1007 with chief complaint of headache. Review of the triage nurse's documentation at 1022 revealed, "Primary Triage Info....Chief Complaint: Headache...Initial Triage Acuity: 3 - Green. Note: Pt c/o (complaining of all over headpain which began this am. Pt states she's been having headaches on and off for about 1 month. Pt's mother recently passed from hemorrhagic stroke." Further review of the triage note at 1022 revealed the nurse assessed the patient's vital signs and documented the patient's past medical history. Record review revealed at 1022 the nurse documented the patient complained of pain in her head that the patient rated to be at a severity level of "9/10 - severe" (on a scale of 0 to 10, with 10 being the most severe pain)." Record review revealed the patient was placed in the waiting room at 1025. Record review revealed the next documentation by nursing staff was on 02/18/2011 at 1637 (6 hours and 12 minutes after the triage assessment was completed and the patient was placed in the Waiting Room). Review of nursing documentation at 1637 revealed, "UTLP - Unable to Locate Patient." Review of nursing documentation at 1656 revealed, "Reassessment: Patient cannot be found." Review of nursing documentation at 1719 revealed, , "Reassessment: Patient cannot be found." Review of nursing documentation at 1637 revealed, "Eloped - W/out being seen....Charting is Complete." Record review revealed no documented evidence a nurse reassessed (or attempted to reassess) the patient between 1025 on 02/18/2011 and 1637 on 02/18/2011 (6 hours and 12 minutes), when the patient was found to be missing from the ED Waiting Room.

Interview on 03/02/2011 at 1540 with the Interim Director/Nurse Manager of the ED revealed patients with an ESI level of 3 that awaited treatment in the ED Waiting Room must be reassessed at least every 4 hours by nursing staff. Interview revealed the Frontline and Secondary triage nurses shared the responsibility to ensure reassessments were completed. Interview revealed all reassessments must be documented. Interview revealed nursing staff should have reassessed Patient #25 within 4 hours of the triage assessment that was completed at 1025. Interview confirmed there was no available documentation that a nurse reassessed (or attempted to reassess) the patient between 1025 on 02/18/2011 and 1637 on 02/18/2011 (6 hours and 12 minutes), when the patient was found to be missing from the ED Waiting Room.

4. Medical record review for Patient # 28 revealed a 50 year old male that presented to the ED on 02/15/2011 at 1044 with chief complaint of severe groin pain. Review of the triage nurse's documentation at 1105 revealed, "Primary Triage Info....Chief Complaint: Leg injury...Initial Triage Acuity: 3 - Green. Note: Pt slipped and legs went into split position, pt c/o (complaining of) severe groin pain, swelling noted to right groin area. pt had testicle on right side removed less than a year ago due to cancer." Further review of the triage note at 1105 revealed the nurse assessed the patient's vital signs and documented the patient's past medical history. Record review revealed the patient's blood pressure was 214/112 (high) at 1105. Record review revealed at 1105 the nurse documented the patient complained of pain in his groin that the patient rated to be at a severity level of "10/10 - severe" (on a scale of 0 to 10, with 10 being the most severe pain)." Record review revealed the patient was placed in the waiting room at 1106. Record review revealed the next documentation by nursing staff was on 02/15/2011 at 1605 (4 hours and 59 minutes after the triage assessment was completed and the patient was placed in the Waiting Room). Review of nursing documentation at 1605 revealed, "UTLP - Unable to Locate Patient." Review of nursing documentation at 1622 revealed, "Reassessment: Patient cannot be found." Review of nursing documentation at 1854 revealed, , "Reassessment: Patient cannot be found." Review of nursing documentation at 1605 revealed, "Eloped - W/out being seen....Charting is Complete." Record review revealed no documented evidence a nurse reassessed (or attempted to reassess) the patient between 1106 on 02/15/2011 and 1605 on 02/15/2011 (4 hours and 59 minutes), when the patient was found to be missing from the ED Waiting Room.

Interview on 03/02/2011 at 1540 with the Interim Director/Nurse Manager of the ED revealed patients with an ESI level of 3 that awaited treatment in the ED Waiting Room must be reassessed at least every 4 hours by nursing staff. Interview revealed the Frontline and Secondary triage nurses shared the responsibility to ensure reassessments were completed. Interview revealed all reassessments must be documented. Interview revealed nursing staff should have reassessed Patient #28 within 4 hours of the triage assessment that was completed at 1106. Interview confirmed there was no available documentation that a nurse reassessed (or attempted to reassess) the patient between 1106 on 02/15/2011 and 1605 on 02/15/2011 (4 hours and 59 minutes), when the patient was found to be missing from the ED Waiting Room.


NC00070531
NC00071016