HospitalInspections.org

Based on policy review, medical record review and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to reassess 5 of 12 sampled Emergency Department patients per policy (#10, #7, #6, #5 and #3).

The findings include:

Review of current hospital policy entitled "Triage" dated 12/2008 revealed, "Purpose: To establish system for prioritizing patient care in the Emergency Care Center (Emergency Department - ED)....All patients who present to the Emergency Department will be assessed promptly to ascertain their condition....The priorities are as follow...Emergent - Immediate Care, Life Threatening Condition....Urgent - Major injury or illness, stable....Non-Urgent - Minor injury or illness....Assessment:...The Registered Nurse (RN) will evaluate and categorize each patient upon arrival to the Emergency Care Center as either Emergent, Urgent, or Non-Urgent....stable patients are directed to the waiting area to complete the registration process....Patients will be placed based on their triage category....Patients placed in the waiting room will be re-evaluated by the triage nurse based on condition, as needed...."

Review of current hospital policy entitled "Initial Assessment of the Emergency Care Center Patient" dated 12/2008 revealed, "Purpose: Establish assessment criteria for all Emergency Care Center patients as a key factor in safe, effective care....After triage patients will have continued assessment based on patient condition....All patients admitted to the Emergency Care Center will have the following documentation:....Vital Signs: Initial vital signs during triage. Additional vital signs shall be obtained dependant on the patient's condition...Critical patients every 5-15 minutes, as needed. Intermediate/urgent patients every 1 hour. All other patients every 2 hours or prior to discharge...."

1. Closed medical record review for Patient #10 revealed a 78 year old female that presented to the ED on 06/03/2010 at 1640 with complaints of abdominal pain. Record review revealed a triage assessment was performed by the triage nurse at 1645. Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record revealed the patient was taken to an ED treatment room at 1700. Record review revealed no documentation of a nursing assessment between 1916 and 2200 (2 hours and 44 minutes). Record review revealed the patient was discharged to home at 2200.

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed patients that are categorized as Acuity Level 2 - Urgent should be reassessed a minimum of every 1-2 hours. Interview revealed after a patient has been evaluated in the ED treatment area, the frequency of reassessments depend on the nurse's assessment of the patient's condition. Interview revealed, "All patients must be assessed at least every 2 hours per policy." Interview confirmed there was no available documentation that Patient #10 was reassessed on 06/03/2010 between 1916 and 2200 (2 hours and 44 minutes).

2. Closed medical record review for Patient #7 revealed a 30 year old female that presented to the ED on 03/21/10 at 1539 with complaints of abdominal pain, nausea/vomiting and blood in her stools. Record review revealed a triage assessment was performed by the triage nurse (RN #1) at 1549. Review of the triage assessment revealed the patient rated her abdominal pain as a 10 out of 10 (on a scale of 1-10 with 10 being the most severe pain). Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record review revealed no documentation the patient was taken to the ED treatment area. Record review revealed, "Disposition: D/C (discharge) Time: 2345 Date: 03/21/10." Record review revealed no documentation that the nurse attempted to locate the patient to reassess her before 2345. Record review revealed the patient left the ED without being seen by a physician (LWBS). Further record review revealed no documentation the patient was reassessed by a nurse before she left the hospital without being seen by a physician (7 hours and 56 minutes after the triage assessment).

Interview on 06/10/2010 at 0930 with RN #1 revealed the nurse worked from 0700 until 1900 on 03/21/2010. Interview revealed the nurse didn't remember Patient #7, but she did remember that 03/21/2010 had been a busy day in the ED and most patients had to wait for long periods of time in the waiting room after they were triaged. Interview revealed, "I probably didn't reassess her (Patient #7). I don't reassess patients in the waiting room unless they start to complain of a change in their condition....I wish I could go to every patient in the waiting room and reassess them, but on days like that I can't do it."

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed patients that are categorized as Acuity Level 2 - Urgent should be reassessed a minimum of every 1-2 hours. Interview revealed, "Triage nurses are trained to eye-ball patients in the waiting room frequently, but they may not document unless there was a change in the patient's condition." Interview revealed Patient #7 should have been reassessed within 1-2 hours of the triage assessment and every 1-2 hours until she was taken to the ED treatment area for a more comprehensive assessment. Further interview revealed nursing staff must document unanswered attempts to call waiting room patients for treatment. Interview revealed staff must document the time that patients were first found to be missing from the waiting room (LWBS). Interview revealed Patient #7's disposition time of 2345 was probably documented by a secretary and there was "no way to know" when the patient actually left. Interview confirmed there was no available documentation that the nurse attempted to locate the patient to reassess her before 2345. Interview confirmed there was no available documentation the patient was reassessed by a nurse before she left the hospital without being seen by a physician (7 hours and 56 minutes after the triage assessment).

3. Closed medical record review for Patient #6 revealed a 76 year old male that presented to the ED on 03/21/10 at 1909 with complaints of fever. Record review revealed a triage assessment was performed by the triage nurse at 1915. Review of the triage assessment revealed the patient's temperature was 101.5 degrees Fahrenheit. Record review revealed the triage nurse did not categorize the patient's Acuity Level. Record review revealed the nurse administered Tylenol (antipyretic medication) 650 milligrams by mouth to the patient in triage. Record review revealed no documentation the patient was taken to the ED treatment area. Record review revealed, "Disposition: D/C (discharge) Time: 2345 Date: 03/21/10." Record review revealed no documentation that the nurse attempted to locate the patient to reassess him before 2345. Record review revealed the patient left the ED without being seen by a physician (LWBS). Further record review revealed no documentation the patient was reassessed by a nurse before he left the hospital without being seen by a physician (4 hours and 30 minutes after the triage assessment).

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed "Triage nurses are trained to eye-ball patients in the waiting room frequently, but they may not document unless there was a change in the patient's condition." Interview revealed Patient #6 should have been reassessed within 1 hour of the administration of Tylenol for his fever and then reassessed every 1-2 hours until he was taken to the ED treatment area for a more comprehensive assessment. Further interview revealed nursing staff must document unanswered attempts to call waiting room patients for treatment. Interview revealed staff must document the time that patients were first found to be missing from the waiting room (LWBS). Interview revealed Patient #6's disposition time of 2345 was probably documented by a secretary and there was "no way to know" when the patient actually left. Interview confirmed there was no available documentation that the nurse attempted to locate the patient to reassess him before 2345. Interview confirmed there was no available documentation the patient was reassessed by a nurse before he left the hospital without being seen by a physician (7 hours and 56 minutes after the triage assessment and administration of Tylenol for a fever).

4. Closed medical record review for Patient #5 revealed a 66 year old female that presented to the ED on 03/21/10 at 1601 with complaints of bilateral leg pain. Record review revealed the patient had a history of breast cancer with metastasis to the brain, lungs, liver and bone. Record review revealed a triage assessment was performed by the triage nurse (RN #1) at 1629. Review of the triage assessment revealed the patient rated her abdominal pain as a 10 out of 10 (on a scale of 1-10 with 10 being the most severe pain). Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record review revealed no documentation the patient was taken to the ED treatment area. Record review revealed the next documentation of a nursing assessment at 1755 (1 hour and 26 minutes after the triage assessment). Review of nurse's note at 1755 revealed, "Pt (patient) states pain worsened. VS (vital signs) obtained. Charge nurse notified. No available beds at this time." Review of nurse's note at 1759 revealed, "Pt liason reports pt has left with family." Record review revealed the patient left the ED without being seen by a physician (LWBS).

Further medical record review for Patient #5 revealed the patient returned to the ED on 03/21/2010 at 1830 with complaints of bilateral leg pain. Record review revealed a triage assessment was performed by the triage nurse (RN #1) at 1833. Review of the triage assessment revealed the patient rated her abdominal pain as a 10 out of 10. Record review revealed the triage nurse did not categorize the patient's Acuity Level. Record review revealed the next documentation of a nursing assessment at 2020, when the patient was taken to an ED treatment room (1 hour and 47 minutes after the triage assessment). Record review revealed the patient was transferred to an inpatient unit on 03/22/2010 at 0055 and expired on 04/02/2010.

Interview on 06/10/2010 at 0930 with RN #1 revealed the nurse worked from 0700 until 1900 on 03/21/2010. Interview revealed 03/21/2010 had been a busy day in the ED and most patients had to wait for long periods of time in the waiting room after they were triaged. Interview revealed the nurse recalled Patient #5 had a lot of pain when she came into the ED. Interview revealed, "She looked uncomfortable, but everybody in triage looked uncomfortable." Further interview revealed there was no protocol for treating chronic pain in the triage area. Interview revealed the patient had to wait until she could go to a treatment room to be evaluated by a physician before she received treatment. Interview revealed, "We had no beds in the back (treatment area) to take her to....I saw her as I went back and forth to give registration charts. She looked pitiful. I felt worse for her than anyone in the waiting room....I called the charge nurse and she told me there was nowhere to put her." Interview confirmed the nurse reassessed the patient at 1755 (1 hour and 26 minutes after the first triage assessment) because the patient's daughter kept telling her the patient was in pain. Further interview revealed, "She came back in within about 15 minutes (after she left without being seen by a physician at 1759). I don't know if they even got out of the parking lot. They went back to the registration desk. I triaged her again. She looked about the same as when she left....She went back into the waiting room....I probably didn't see her as much that time because I went home around 7 (pm)." Interview confirmed the next available documentation of a nursing assessment was at 2020 (1 hour and 47 minutes after the triage assessment). Interview revealed the nurse thought a patient categorized as an Acuity Level 2 should be reassessed every 4 hours. Interview revealed, "I don't reassess patients in the waiting room unless they start to complain of a change in their condition....I wish I could go to every patient in the waiting room and reassess them, but on days like that I can't do it."

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed patients that are categorized as Acuity Level 2 - Urgent should be reassessed a minimum of every 1-2 hours. Interview revealed, "Triage nurses are trained to eye-ball patients in the waiting room frequently, but they may not document unless there was a change in the patient's condition." Interview revealed Patient #5 should have been reassessed within 1 hour of the time she was triaged during both ED visits on 03/21/2010. Interview confirmed there was no available documentation of a nursing assessment within 1 hour of either ED visit on 03/21/2010.

5. Closed medical record review for Patient #3 revealed a 61 year old female that presented to the ED on 01/06/2010 at 1405 with complaints of heart failure and "needs Lasix (diuretic medication)". Record review revealed the patient had a history of Congestive Heart Failure and schizophrenia. Record review revealed a triage assessment was performed by the triage nurse 1420. Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record revealed the patient was taken to an ED treatment room at 1430. Record review revealed no documentation of nursing assessments between 1600 and 1940 (3 hours and 40 minutes), 2044 and 2330 (2 hours and 46 minutes) and 2330 and 0203 on 01/07/2010 (2 hours and 33 minutes). Record review revealed the physician diagnosed the patient as having diabetes mellitus and renal insufficiency. Record review revealed the patient was transferred to an inpatient unit on 01/07/2010 at 0300. Record review revealed the patient was discharged to home on 01/09/2010.

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed patients that are categorized as Acuity Level 2 - Urgent should be reassessed a minimum of every 1-2 hours. Interview revealed after a patient has been evaluated in the ED treatment area, the frequency of reassessments depended on the nurse's assessment of the patient's condition. Interview revealed, "All patients must be assessed at least every 2 hours per policy." Interview confirmed the was no available documentation that Patient #3 was reassessed on 01/06/2010 between 1600 and 1940 (3 hours and 40 minutes), 2044 and 2330 (2 hours and 46 minutes) and 2330 and 0203 on 01/07/2010 (2 hours and 33 minutes).

Based on policy review, staff interview, personnel file review and medical record review, the hospital failed to ensure 2 of 3 sampled Emergency Department Triage Nurses were trained and qualified in triage assessment/reassessment per policy (RN #1 and RN #2).

The findings include:

Review of current hospital policy entitled "Triage" dated 12/2008 revealed, "Purpose: To establish system for prioritizing patient care in the Emergency Care Center (Emergency Department - ED)....All patients who present to the Emergency Department will be assessed promptly to ascertain their condition....The priorities are as follow...Emergent - Immediate Care, Life Threatening Condition....Urgent - Major injury or illness, stable....Non-Urgent - Minor injury or illness....Assessment:...The Registered Nurse (RN) will evaluate and categorize each patient upon arrival to the Emergency Care Center as either Emergent, Urgent, or Non-Urgent....stable patients are directed to the waiting area to complete the registration process....Patients will be placed based on their triage category....Patients placed in the waiting room will be re-evaluated by the triage nurse based on condition, as needed...."

Review of current hospital policy entitled "Initial Assessment of the Emergency Care Center Patient" dated 12/2008 revealed, "Purpose: Establish assessment criteria for all Emergency Care Center patients as a key factor in safe, effective care....After triage patients will have continued assessment based on patient condition....All patients admitted to the Emergency Care Center will have the following documentation:....Vital Signs: Initial vital signs during triage. Additional vital signs shall be obtained dependant on the patient's condition...Critical patients every 5-15 minutes, as needed. Intermediate/urgent patients every 1 hour. All other patients every 2 hours or prior to discharge...."

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed new nurses complete orientation with a preceptor prior to independently staffing in the ED. Interview revealed, "The preceptor takes the orientee through all sides of the department, including triage and assesses their skills....They are assigned to triage together using the triage policy." Further interview revealed ED nurses staff independently in triage after they have demonstrated competency and after one year of employment.

1. Personnel file review on 06/10/2010 for RN #1 revealed the nurse began to work in the ED as a registered nurse on 05/26/2008. File review revealed a competency entitled "Triage Responsibilities" was completed on 08/26/2009 and was signed by the preceptor on 09/08/2009 and by RN #1 on 09/09/2009.

Closed medical record review for Patient #5 revealed a 66 year old female that presented to the ED on 03/21/10 at 1601 with complaints of bilateral leg pain. Record review revealed the patient had a history of breast cancer with metastasis to the brain, lungs, liver and bone. Record review revealed a triage assessment was performed by the triage nurse (RN #1) at 1629. Review of the triage assessment revealed the patient rated her abdominal pain as a 10 out of 10 (on a scale of 1-10 with 10 being the most severe pain). Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record review revealed no documentation the patient was taken to the ED treatment area. Record review revealed the next documentation of a nursing assessment at 1755 (1 hour and 26 minutes after the triage assessment).

Closed medical record review for Patient #7 revealed a 30 year old female that presented to the ED on 03/21/10 at 1539 with complaints of abdominal pain, nausea/vomiting and blood in her stools. Record review revealed a triage assessment was performed by the triage nurse (RN #1) at 1549. Review of the triage assessment revealed the patient rated her abdominal pain as a 10 out of 10 (on a scale of 1-10 with 10 being the most severe pain). Record review revealed the triage nurse categorized the patient's acuity level as a Level 2 (Urgent). Record review revealed no documentation the patient was taken to the ED treatment area. Record review revealed, "Disposition: D/C (discharge) Time: 2345 Date: 03/21/10." Record review revealed no documentation that nursing staff attempted to locate the patient to reassess her before 2345. Record review revealed the patient left the ED without being seen by a physician (LWBS). Further record review revealed no documentation the patient was reassessed by a nurse before she left the hospital without being seen by a physician (7 hours and 56 minutes after the triage assessment).

Interview on 06/10/2010 at 0930 with RN #1 revealed the nurse had been employed as a RN in the ED for about 2 years. Interview revealed the nurse routinely worked in all areas of the ED, including triage. Interview revealed Acuity Level 1 meant urgent, needs immediate attention and reassessments should be done in 2 hours. Interview revealed, "I'm not sure. I've never seen that part in writing." Interview revealed Acuity Level 2 meant urgent, needs attention today and reassessments should be done every 4 hours. Interview revealed Acuity Level 3 meant a problem that could be handled at a regular physician's office visit. Interview revealed, "As far as I know they (Level 3 Acuity patients) are reassessed every 8 hours, but don't hold me to that." Interview revealed the nurse was not sure the frequency of reassessment required by the triage policy. Interview revealed, "I've asked a couple of people to explain this to me. One of the charge nurses explained it. Everybody might do it differently." Further interview revealed, "I would like to see more in depth training with (triage assessment). Something more concentrated as to what exactly is expected of you....I've had very little training in triage. I learned by asking questions on the (triage form)." Interview revealed the nurse was trained to the ED by a preceptor when she was hired. Interview revealed there was no formal triage training program at the hospital, but rather it was included in "everyday orientation". Further interview revealed the nurse recalled Patient #5 had a lot of pain when she came into the ED on 03/21/2010. Interview revealed, "She looked uncomfortable, but everybody in triage looked uncomfortable." Further interview revealed there was no protocol for treating chronic pain in the triage area. Interview revealed the patient had to wait until she could go to a treatment room to be evaluated by a physician before she received treatment. Interview revealed, "We had no beds in the back (treatment area) to take her to....I saw her as I went back and forth to give registration charts. She looked pitiful. I felt worse for her than anyone in the waiting room....I called the charge nurse and she told me there was nowhere to put her." Interview confirmed the nurse reassessed the patient at 1755 (1 hour and 26 minutes after the first triage assessment) because the patient's daughter kept telling her the patient was in pain. Further Interview revealed the nurse didn't remember Patient #7, but she did remember that 03/21/2010 had been a busy day in the ED and most patients had to wait for long periods of time in the waiting room after they were triaged. Interview revealed the nurse went off duty at about 1900 (3 hours and 11 minutes after Patient #7's triage assessment). Interview revealed, "I probably didn't reassess her. I don't reassess patients in the waiting room unless they start to complain of a change in their condition....I wish I could go to every patient in the waiting room and reassess them, but on days like that I can't do it."

Interview on 06/10/2010 at 1130 with the ED Nurse Manager revealed RN #1 should have reassessed Patient #5 within 1 hour of the time the patient was triaged on 03/21/2010 at 1629. Interview confirmed there was no available documentation the nurse reassessed Patient #5 within 1 hour of triage. Further interview revealed RN #1 should have reassessed Patient #7 within 1-2 hours of the time the patient was triaged on 03/21/2010 at 1549. Interview confirmed there was no available documentation the nurse reassessed Patient #7 within 1-2 hours of the time the patient was triaged. Interview confirmed RN #1 did not follow the hospital's triage policy.

2. Personnel file review on 06/10/2010 for RN #2 revealed the nurse began to work in the ED as a registered nurse on 05/19/2008. File review revealed no documentation of triage training or validation of competency in triage assessment.

Interview on 06/10/2010 at 1025 with RN #2 revealed the nurse independently staffed in all areas of the ED, including triage.

Interview on 06/10/2010 at 1600 with the Administrative Director of Clinical Effectiveness revealed RN #2 independently staffed in triage in the ED. Interview confirmed there was no available documentation that RN #2 had completed triage training and was competent in triage assessment.


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