HospitalInspections.org

Based on staff interview and review of medical records and policies, it was determined the CAH failed to ensure emergency care was provided sufficient to meet the needs of 9 of 19 patients (#4, #5, #7, #11, #12, #13, #14, #17, and #19) who presented to the ER seeking care and whose records were reviewed. This resulted in the inability of the CAH to triage patients and to ensure they were monitored while waiting for examination by a practitioner. Findings include:

1. Policies directing ER staff included:

a. The policy "URGENCY CLASSIFICATIONS," dated 8/04/10, listed 3 classifications of patients. These included "Emergent," which required immediate evaluation by a physician, "Urgent," which required treatment within 30 minutes, and "Delayed," for which treatment could be delayed 2 hours or longer. The policy did not state which staff could make these determinations or how patients with lower classifications would be monitored until they were treated. In addition, the policy did not include a procedure to explain how these determinations would be made or documented.

b. The policy "STAFFING: EMERGENCY ROOM NURSING AND PHYSICIANS," revised January 2010, stated the ER would be staffed 24 hours a day with "...a licensed nurse (RN or LPN) or Certified Paramedic qualified to assist the physician or PA in the care and treatment of patients presenting for medical attention." The policy also stated an RN would be available to the ER at all times "...to supervise nursing activities in the Emergency Room, and provide direct patient care when indicated." This policy did not define the RN's role in triaging and monitoring patients who were waiting to be examined by a practitioner.

c. The policy "MEDICAL SCREENING EXAMINATION and EMERGENCY ROOM RECORD," revised October 2011, stated the "Triage nurse evaluates presenting symptoms" when a patient presented to the ER. The policy did not define the qualifications of the triage nurse nor did it define the triage process.

The DON was interviewed on 2/16/12 beginning at 3:10 PM. He confirmed the CAH policies did not address triage of patients or how patients would be monitored while they were waiting to be examined by a physician or a PA.

The ER Director, a physician, was interviewed on 2/17/12 beginning at 1:45 PM. He referred to policies which defined "medical screening examinations" but he was not able to define a triage process for patients presenting to the ER.

The CAH had not developed a procedure to triage and monitor patients in the ER who had to wait to be examined by a practitioner.

2. Triage assessments had not been conducted for patients. Examples include:

a. Patient #5's medical record documented a 30 year old female who presented to the ER on 1/29/12 at 8:09 PM. She complained of headache, facial numbness, and visual disturbances. An assessment of Patient #5 was documented by the LPN at 8:31 PM. Vital signs were documented at 8:34 PM, including a blood pressure and pulse of 151/71 and 91, respectively. A neurological check, including checking for one sided weakness and facial droop, was not documented. Patient #5 left the hospital against medical advice at 10:11 PM, 2 hours and 2 minutes later. She had not been evaluated by a practitioner. There was no documentation that Patient #5 had been assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation that Patient #5's condition had been monitored by an RN while she waited to be seen by a practitioner.

The LPN who treated Patient #5 was interviewed on 2/17/12 beginning at 9:45 AM. He stated Patient #5 was not seen or assessed by an RN or a member of the medical staff. He confirmed he was not aware of a specific process to triage patients or to monitor them while they waited to be examined by a practitioner.

b. Patient #14's medical record documented a 9 month old male who was brought to the ER on 2/13/12 at 7:14 AM with fever and a cough. At 7:20 AM, the medical record documented his temperature was 100.5, pulse was 153, and respirations were 20. No other vital signs were documented. The medical record documented he was assessed by a paramedic at 7:20 AM. The medical record documented he was examined by a physician at 8:50 AM. No documentation was present that Patient #14 received a triage assessment. An urgency classification was not documented. No documentation was present that Patient #14 was seen by an RN or that he was monitored between 7:20 AM and 8:50 PM, one and a half hours.

The record was reviewed with the DQM beginning at 2:30 PM on 2/16/12. She confirmed triage and monitoring of Patient #14 by an RN, between the time he arrived and the time he was seen by a physician, was not documented. She also confirmed a policy specific to triage and monitor patients, while waiting to be examined, had not been developed.



30044

c. Patient #4 was a 76 year old female who presented to the ER on 2/09/12 at 9:47 PM. She complained of an erratic heart rate, near fainting episode, and shortness of breath. An assessment was documented by the LPN beginning at 9:57 PM, including a blood pressure of 154/89 and pulse of 69. Patient #4's ER physician was documented as "in to see pt" at 10:55 PM, 1 hour and 8 minutes later. There was no documentation that Patient #4 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN's and physician's assessments.

The DQM was interviewed on 2/16/12 at 2:27 PM. She reviewed Patient #4's medical record and stated she agreed with the timeframe outlined above. She stated there was no triage assessment, urgency classification, or monitoring by an RN documented for Patient #4.

d. Patient #7 was a 66 year old male who presented to the ER on 1/26/12 at 6:31 PM. He complained of sweating, headache, ringing in the ears, and having to drag his left leg for about 3 hours. An assessment was documented by the LPN beginning at 6:55 PM, including a blood pressure of 211/107 and pulse of 83. A neurological check, including checking for one-sided weakness and assessing gait, was not documented. Patient #7's ER physician was documented as "in to see pt" at 7:08 PM, 37 minutes later. There was no documentation that Patient #7 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented.

The DQM was interviewed on 2/16/12 at 2:25 PM. She reviewed Patient #7's medical record and stated she agreed with the timeframe outlined above. She stated there was no neurological check, triage assessment, or urgency classification documented for Patient #7.

e. Patient #11 was a 35 year old female who presented to the ER on 1/29/12 at 8:32 PM. She complained of severe pain following a seizure. An assessment was documented by the LPN beginning at 9:10 PM, including a blood pressure of 126/82, pulse of 71, and pain score of 7 out of 10. Patient #11's ER PA was documented as "in to see pt" at 10:46 PM, 2 hours and 14 minutes later. There was no documentation that Patient #11 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN and PA assessments.

The DQM was interviewed on 2/16/12 at 2:55 PM. She reviewed Patient #11's medical record and stated she agreed with the timeframe outlined above. She stated there was no triage assessment, urgency classification, or monitoring by an RN documented for Patient #11.

f. Patient #12 was an 84 year old male who presented to the ER on 2/06/12 at 1:51 PM. He complained of left arm numbness and cramping with swelling. An assessment was documented by the LPN beginning at 3:20 PM, including a blood pressure of 175/98 and pulse of 94. A neurological check was not documented. Patient #12's ER physician was documented as "in to see pt" at 4:15 PM, 2 hours and 24 minutes later. There was no documentation that Patient #12 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN and physician assessments.

The DQM was interviewed on 2/16/12 at 2:55 PM. She reviewed Patient #12's medical record and stated she agreed with the timeframe outlined above. She stated there was no neurological check, triage assessment, urgency classification, or monitoring by an RN documented for Patient #12.

g. Patient #13 was a 64 year old female who presented to the ER on 1/26/12 at 5:26 PM. She complained of slurred speech, diarrhea, frequent falls, and a headache lasting 4 hours. An assessment was documented by the LPN beginning at 5:32 PM, including a blood pressure of 120/78 and pulse of 124. Patient #13's ER physician was documented as "in to see pt" at 6:54 PM, 1 hour and 28 minutes later. There was no documentation that Patient #13 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN and physician assessments.

The DQM was interviewed on 2/16/12 at 2:55 PM. She reviewed Patient #13's medical record and stated she agreed with the timeframe outlined above. She stated there was no triage assessment, urgency classification, or monitoring by an RN documented for Patient #13.

h. Patient #17 was a 1 year old male who presented to the ER on 2/07/12 at 7:01 AM. His parents stated Patient #17 had an unbroken fever after taking acetaminophen. An assessment was documented by the paramedic beginning at 7:03 AM, including a rectal temperature of 102.8. An LPN assumed care of Patient #17 at 7:04 AM. Patient #17's ER physician was documented as "arrives to see pt. exam completed" at 8:28 AM, 1 hour and 27 minutes later. There was no documentation that Patient #17 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN and physician assessments.

The DQM was interviewed on 2/17/12 at 11:25 AM. She reviewed Patient #17's medical record and stated she agreed with the timeframe outlined above. She stated there was no triage assessment, urgency classification, or monitoring by an RN documented for Patient #17.

i. Patient #19 was a 1 year old female who presented to the ER on 1/25/12 at 3:42 PM. Her parents stated Patient #19 had fallen with resulting bruising to her face. An assessment was documented by the LPN beginning at 3:55 PM, including behavioral indications of pain. A neurological check was not documented. Patient #19's ER physician was documented as "in to see pt" at 4:50 PM, 1 hour and 8 minutes later. There was no documentation that Patient #18 was assessed by an RN or that a triage assessment was conducted. An urgency classification was not documented. There was no documentation of monitoring by an RN between the LPN and physician assessments.

The DQM was interviewed on 2/17/12 at 11:27 AM. She reviewed Patient #19's medical record and stated she agreed with the timeframe outlined above. She stated there was no neurological check, triage assessment, urgency classification, or monitoring by an RN documented for Patient #19.

The cumulative effect of these negative systemic practices seriously impeded the ability of the CAH to provide emergency services of adequate quality.