HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure nursing staff documented reassessment of patients for change in status prior to discharge from the Emergency Department (ED) for 1 of 3 (Patient #3) sampled patients reviewed.

The findings included:

1. Review of the facility's "TRIAGE NURSE, GUIDELINES FOR DUTIES" policy (2/26/2020) revealed, "...The nurse will evaluate based on ESI [Emergency Severity Index] levels...Patients will also be reassessed if any change in condition occurs..."

2. Medical record review revealed Patient #3 arrived to the ED on 12/2/2025 at 4:08 PM with chief complaint of "multiple complaints". Patient requested pain medication for fractured spine, which was diagnosed on 12/1/2025 while in the ED.

Review of ED Physician #1's history of present illness (HPI) revealed Patient #3 had history of lung cancer and presented to the ED with back pain and feeling short of breath. Patient woke up from a nap and noticed his oxygen levels were in the 60's and 70's until he got to the ED. Patient was seen in the ED on 12/1/2025 with compression fracture and stated pain had not improved.

Review of Patient #3's vital signs on 12/2/2025 from 5:03 PM until 9:14 PM revealed oxygen saturation levels ranged from 92 % to 98% (normal oxygen level is 92% and greater) on room air. Oxygen saturation level at 9:34 PM was documented as 81%. Oxygen saturation level at 9:49 PM was documented as 84%.

Patient #3 was discharged to home from the ED on 12/2/2025 at 10:03 PM.

There was no documentation nursing staff reassessed Patient #3's decreased oxygen saturation levels prior to discharge.

3. In an interview on 12/9/2025 at 10:50 AM, the ED manager stated if the last two oxygen saturation levles were correct, he would expect to see them rechecked, and a physician notified if they were accurate. The ED manager stated the Patient would not have been discharged. The ED manager stated, "The standard is no discharge if the sats (oxygen saturation) are below 90%"

In an interview on 12/9/2025 at 11:30 AM, the Chief Nursing Officer (CNO) stated she would expect to see the nurse keep rechecking the oxygen saturation levels until the levels came up, and to let the physician know.

In an interview on 12/10/2025 at 8:15 AM, ED Nurse #1 revealed she reviewed Patient #3's chart and stated that the 81% and 84% oxygen levels were documentation errors. The Nurse stated she would never have discharged anyone with oxygen levels in the 80's. ED Nurse #1 stated she would have kept rechecking and she would have let the physician know. ED Nurse #1 stated the computer system didn't flag you with outside ranges. ED Nurse #1 stated Patient #3 was in no distress and had no indicators the Patient was not stable for discharge. The oxygen saturation levels were a documentation error.