HospitalInspections.org

Based on policy and procedure review, medical record review, and personnel interview, the facility failed to ensure consistent written policies and procedures governing medical care related to triage classification for 1 of 1 (Emergency Department [ED]) area toured.

Findings:
1. Policy No.: 078.145 titled, "Triage in the Emergency Department" was reviewed on 7/11/12 at approximately 1:00 PM and indicated on pg. 2, under Procedure section, point 5., "During the triage process, all patients are classified with the current Emergency Severity Index using 5 levels: resuscitation (level 1), emergent (level 2), urgent (level 3), non-urgent (level 4), or referred (level 5).

2. Policy No.: 078.137 titled, "Standards of Practice or Care (ED)" was reviewed on 7/11/12 at approximately 1:00 PM and indicated on pg. 2, under Important Aspects of Patient Care section, bulleted points, "The patient is evaluated according to Triage Categories: Class I - Emergent...Third degree burns (over large area); Class II - Urgent...Burns; and Class III - Non Urgent...Minor burns."

3. Review of closed patient medical records on 7/11/12 at approximately 1:00 PM indicated:
A. Patient N1 presented to the ED on 6/1/12 at 23:01 PM for chief complaint of "fell into fire and has burns to both hands." Documentation in the medical record included:
a. per ED Triage, ED Assessment, ED Physician Record & Orders, and History & Physical dated 6/1/12, at 23:03 PM, an acuity level of urgent was assigned to the patient and at 23:10 PM, examined by physician. Right hand has partial thickness burns from mid way of the middle finger to the base on posterior side, base of 4th & 5th fingers, also on posterior side. Left hand: 2nd degree burn of left palm with partial thickness burns to the anterior tips of the 3rd, 4th, & 5th fingers, anterior and posterior burn to ulnar side of hand.

B. Patient N2 presented to the ED on 6/1/12 at 17:00 PM for chief complaint of "sunburn pain." Documentation in the medical record included:
a. per ED Triage and Assessment dated 6/1/12, at 17:00 PM, an acuity level of non-urgent was assigned to the patient and at 17:25 PM, examined by physician. Small blisters noted across shoulders.

C. Patient N3 presented to the ED on 6/12/12 at 14:44 PM for chief complaint of "2nd degree burn to left hand." Documentation in the medical record included:
a. per ED Triage and Assessment dated 6/12/12, at 14:44 PM, an acuity level of urgent was assigned to the patient and at 14:58 PM, examined by physician.

D. Patient N4 presented to the ED on 6/19/12 at 08:47 AM for chief complaint of "burn to lateral left foot, burned by iron at work." Documentation in the medical record included:
a. per ED Triage and Assessment dated 6/19/12, at 08:47 AM, an acuity level of non-urgent was assigned to the patient and at 08:58 AM, examined by physician. Has second and third degree burn to lateral aspect left foot...Burn is approximately 5-7 cm in diameter, with charred center. Also has 2 cm diameter burn to plantar aspect left foot, appears to be third degree.

E. Patient N5 presented to the ED on 6/21/12 at 15:16 PM for chief complaint of "burn to medial aspect of left calf times one week ago. Patient states that it is more swollen today." Documentation in the medical record included:
a. per ED Triage and Assessment dated 6/21/12, at 15:16 PM, an acuity level of non-urgent was assigned to the patient and at 15:25 PM, examined by physician. Surrounding tissue erythematous and edematous, four small opened areas with yellowed scabs present, no drainage noted.

4. Personnel P4 was interviewed on 7/11/12 at approximately 12:38 PM and 12:45 PM and confirmed, the facility triage policy titled, "Triage in the Emergency Department", Policy No.: 078.145, lists 5 levels of assessing a patient following the ESI classification system. However, a 3 level (emergent, urgent, and non-urgent) triage classification system is being used and documented in electronic patient medical records. This policy is not compatible with our triage process.

5. The policies titled, "Triage in the Emergency Department", Policy No.: 078.145 and "Standards of Practice or Care (ED)", Policy No.: 078.137 are not consistent in describing the triage classification system used in the ED. Number 078.145 stated a 5 level ESI classification system (Levels 1-5) was being used and number 078.137 stated a 3 level classification system (urgent, emergent, and non-urgent) was being used. The system being used in the electronic medical record is the 3 level classification system. Also, in policy 078.137, types of burns are not clearly identified in the different classifications. These classifications are: Class I - Emergent...Third degree burns (over large area); Class II - Urgent...Burns; and Class III - Non Urgent...Minor burns. It is not clearly defined as to what a large area is in Class I, what type of burn in Class II, and what a minor burn is in Class III. This makes it difficult to assign a classification of urgent, emergent, and non-urgent in the patient's medical record and it cannot be determined whether or not patients N1-N5 have been placed in the correct triage classification.

Based on policy and procedure review, document review, and personnel interview, the facility failed to ensure a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel related to hand washing monitoring/compliance for 1 of 1 (Emergency Department [ED]) area toured.

Findings:
1. Policy No.: 171.05 titled, "Infection Control Plan", was reviewed on 7/11/12 at approximately 1:00 PM and indicated on pg.:
A. 1, under Policy section, "The ICC (Infection Control Committee) shall institute, at any time, control measures to protect patients, employees, visitors and other persons."
B. 2, under Infection Control Plan section, point 2., "The plan encompasses all departments and patient services located within the hospital."

2. Review of the Infection Control Annual Plan/Report 2012 on 7/11/12 at approximately 1:00 PM, indicated on pg. 3, under section II. Surveillance for 2012, point f., "The Infection Control Committee oversees the performance of all surveillance based on analysis of collected data. The ICC determines the surveillance activities to be completed on an annual basis. The following surveillance was established for 2012...Hand Washing Compliance Surveillance."

3. Review of 2012 [Facility] Hand Hygiene Compliance on 7/11/12 at approximately 1:00 PM, indicated a lack of data collected from the ED related to monitoring of hand washing for 2012.

4. Personnel P4 was interviewed on 7/11/12 at approximately 12:38 PM and 12:45 PM and confirmed, hand washing compliance is supposed to be monitored quarterly by ED staff utilizing a hand washing surveillance tool. These completed tools are then sent to the Infection Control Nurse and then reviewed by the Infection Control Committee at their meetings. This process has not been completed for 2012 for the ED.