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Based on medical record review, review of policy and staff interview it was determined the hospital failed to ensure Emergency Department (ED) nursing personnel met the needs of one (1) of three (3) patients reviewed (patient #1) who presented to the emergency department for evaluation of mental status and medical clearance. Nursing staff failed to assess, monitor and carry out orders for this patient. This failure creates the potential for an adverse impact and outcome to all patients who require evaluation of mental status and medical clearance.

Findings include:

1. Review of the ED record for patient #1 revealed he arrived at the ED, accompanied by police, at 1245 on 6/30/14. The triage nurse noted in part: "missing for 2 days...found by police...states he has been in the woods for a couple days...police officer said he was having thoughts of suicide but the patient denies this..."

Further review of the record revealed no further nursing documentation of assessment or monitoring of the patient, following the completion of the triage assessment at 1253. The record reflects eleven (11) stat (immediately, without delay) orders for labwork, including toxicology, were written at 1339. These labs were never completed. At 1506 the Primary RN documented; "1503. Pt ran out the ambulance doors. Security called."

Interview was conducted with the ED Nurse Manager on 1310 on 8/11/14. This record was reviewed and discussed. She stated the expectation is that ED patients are assessed within thirty (30) minutes of arrival and orders should be initiated within that timeframe also. She agreed the record for patient #1 lacked any nursing assessment or monitoring following triage and the stat orders for laboratory testing were not completed. She confirmed ED nursing staff are responsible for obtaining laboratory specimens, as ordered, in the ED. She also stated that hourly rounding and documentation is required by ED nursing staff, at a minimum.

The Assessment/Reassessment Policy, effective 10/2013, was provided for review. The policy states in part: ED, A registered nurse will assess each patient. The assessment is recorded...Reassessments are recorded. Area: Emergency Room, Initial Time: Upon receipt of Report, Completion time: 30 minutes."