HospitalInspections.org

Based on findings from medical record (MR) review, document review, and interview, the facility did not ensure that all patients received care according to its policies and procedures (P&P) and current standards of practice. Specifically, 2 of 6 ED MRs (Patients #2, #3) lacked documentation of timely triage and 6 of 6 ED MRs (Patients #2, #3, #4, #5, #6 and #7) lacked documentation of reassessment or monitoring while in the waiting room.

Findings include:

-- Per review of Patient #2's MR, he presented to the ED on 10/16/16 at 1:28 pm with a chief complaint of cough. Nursing triaged the patient at 2:52 pm, 1 hour and 24 minutes after presentation.

-- Per review of Patient #3's MR, she presented to the ED on 10/16/16 at 1:37 pm with a chief complaint of vaginal bleeding and spotting and was 5-6 weeks pregnant. Nursing triaged the patient at 3:02 pm, 1 hour and 25 minutes after presentation.

-- Review of the facility's P&P titled "Triage Patient Flow," last revised 4/2014, it indicated patients in the waiting room are monitored by the triage nurse and vital signs and reassessments will be performed at least hourly, or more frequently at the discretion of the triage nurse.

-- Per review of Patient #2's MR, he presented to the ED on 10/16/16 with a chief complaint of cough. Nursing triaged the patient at 2:52 pm with an acuity of level =3 (Emergency Severity Index (ESI) of 1-5, 1-resuscitation, 2-emergent, 3-urgent, 4-semi-urgent and 5-non-urgent). The next documentation by nursing was at 6:01 pm (3 hours later) indicating Patient #2 had left without being seen (LWBS).

-- Per review of Patient #3's MR, she presented to the ED on 10/16/16 with a chief complaint of vaginal bleeding and spotting and was 5-6 weeks pregnant. Nursing triaged the patient at 3:02 pm with an acuity level =4. The next documentation by nursing was at 6:57 pm (4 hours later) indicating Patient #3 had LWBS.

-- Per review of Patient #4's MR, he presented to the ED on 9/16/16 with a chief complaint of a fever and cough for 2 days. Nursing triaged the patient at 11:09 pm with an acuity level =4. The next documentation by nursing was at 2:45 am (3 1/2 hours later) indicating Patient #4 had LWBS.

-- The same lack of reassessment documentation was noted for Patients #5, #6 and #7.

-- During interview of Staff A (ED Director) on 10/19/16 at 12:00 pm, he/she acknowledged the above findings.

Based on findings from document review and interview, in 5 of 6 personnel files, the facility did not ensure Emergency Department (ED) staff had required training in accordance with New York State New York Codes, Rules and Regulations, Title 10 (405.19)

Findings include:

-- Staff C's (ED Medical Director) personnel file (employed since 7/2003) lacked training certificates for advanced cardiac life support (ACLS) and pediatric advance life support (PALS).

-- Staff D's (ED physician) personnel file (employed since 9/2014) lacked training certificates for ACLS and PALS.

-- Staff E's (registered nurse (RN) - float to ED) personnel file (employed since 6/2006) lacked training certificates for ACLS and PALS.

-- Staff F's (RN - ED) personnel file (employed since 8/2015) lacked training certificates for ACLS and PALS.

-- Staff G's (respiratory therapist) personnel file (employed since 5/2011) lacked a training certificate for ACLS. Also the respiratory therapy job description dated 4/2016, indicated that respiratory therapy staff provide care to pediatric patients. However, the job description did not require PALS certification.

-- During interview with Staff B (Director of Quality/Case Management) on 10/19/16 at 5:00 pm, he/she acknowledged the above findings.