HospitalInspections.org

This condition was cited based on review of emergency department logs, medical records, ER (Emergency Room) schedules for staff, including the physician covering the ER on 8/26/14, staff Time Reports for 8/26/14, facility policies and interviews with facility staff, it was determined the Governing Body failed to ensure:

1. Emergency Department (ED) staff followed the policy for the completion of a triage assessment within 15 minutes of admission to the ED.

2. Facility staff followed the policy for patient registration after the Registered Nurse has completed the triage assessment.

3. Emergency Department (ED) policies were updated to reflect current acuity levels for triage utilized in the ED.

4. All ED staff were knowledgeable of the current acuity levels used in the ED triage process.

5. Nursing staff followed facility policy for Emergency Department (ED) Standards of Practice for nursing interventions related to reassessment of patient vital signs.


Findings include:


Refer to findings cited at A395 and A1104.

Based on review of medical records, Emergency Room (ER) Log, facility policy and interviews with facility staff, it was determined the nursing staff failed to follow the facility policy for Emergency Department (ED) Standards of Practice for nursing interventions related to reassessment of patient vital signs for 11 of 17 patients who were evaluated and treated in the ED. This deficient practice affected Patient Identifiers (PI) # 1, 2, 5, 7, 10, 12, 13, 20, 21, 22 and 24 and had the potential to affect all patients who present to the facility for emergency care services.

Findings include:

Review of the facility's Emergency Department Policy:

Subject: Emergency Department Standards of Practice or Care
Date Issued: 10/2000

Statement of Purpose:
To establish standards of practice or care for patients presenting to the Emergency Department for treatment...

... Standard III:
Nursing interventions identified in multidisciplinary patient treatment by skillful and competent providers of care, who utilize current standards of practice.


Standard III:

... Fundamental Emergency Department nursing interventions include, but are not limited to the following:

Vital signs every 30 minutes on Class I patients, unless ordered more frequently, Vital signs every 2 hours on Class II patients, unless ordered more frequently, Vital signs on admission and PRN (as needed) on Category III patients, unless ordered more frequently, Vital signs will be repeated if not within normal limits, as follows:
Adult ranges:
Temp (temperature): 96 - 101 degrees F (Fahrenheit)
B/P (blood pressure): 100/60 - 140/90 mm/Hg (millimeters/Mercury)
Pulse: 60 - 100 bpm (beats per minute)
RR (respiratory rate): 12 - 24/ min (minute)

Vital signs will be repeated after administration of medications with potential side effects...


1. Review of PI # 1's medical record revealed the patient presented to the ED on 9/1/13 with complaints of swollen lip. Review of the medical record revealed the triage assessment was completed at 5:56 AM and discharged from the ED at 7:38 AM (1 hour and 26 minutes in the ED). Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


2. Review of PI # 2's medical record revealed the patient presented to the ED on 9/1/13 for psychiatric evaluation. Review of the medical record revealed the triage assessment was completed at 3:32 PM and admitted to the hospital from the ED at 6:40 PM (3 hour and 8 minutes in the ED).Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


3. Review of PI # 5's medical record revealed the patient presented to the ED on 12/25/13 with complaint of pelvic pain with a history of UTI (urinary tract infection). Review of the medical record revealed the triage assessment was completed at 6:28 PM and admitted to the hospital from the ED at 10:15 PM (3 hour and 47 minutes in the ED). Review of the ER Triage Form revealed the nurse documented the patient acuity was 5 on a 1 to 5 scale. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


4. Review of PI # 7's (small child) medical record revealed the patient presented to the ED on 1/1/14 with complaints of ear ache. Review of the medical record revealed the triage assessment was completed at 6:30 PM and the patient acuity was 4 on a 1 to 5 scale. Review of the ER Nursing Record revealed the RN administered Motrin at 6:55 PM for the patient's elevated temperature of 101.7 degrees. There was no documentation the nurse reassessed the patient's temperature after having administered Motrin or at any time prior to the patient's elopement with the mother at 8:40 PM (2 hours and 10 minutes in the ED).


5. Review of PI # 10's medical record revealed the patient presented to the ED on 1/1/14 with complaint of dizziness and lightheadedness. Review of the medical record revealed the triage assessment was completed at 4:00 PM and transferred to another hospital at 7:40 PM (3 hour and 40 minutes in the ED). Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


6. Review of PI # 12's (8 month old child) medical record revealed the patient presented to the ED on 1/1/14 with complaint of swallowed something, per mother's report. Review of the medical record revealed the only vital signs assessed for PI # 12 was the patient's temperature. There was no documentation the nurse assessed the patient's respiratory rate, nor was there documentation the nurse reassessed the patient's vital signs during the time the patient was in the ED from 7:10 PM until the patient was transferred to another hospital at 8:15 PM (1 hour and 10 minutes in the ED). There was no documentation of the patient's acuity level on the ER Triage Form.


7. Review of PI # 13's medical record revealed the patient was transported on 8/26/14 by ambulance with complaint of passing out and right side numbness and was placed in the treatment room in the ED at 6:30 PM and discharge from the ED at 11:54 PM (5 hours and 24 minutes in the ED). Review of the medical record revealed the nurse performed the triage assessment at 6:30 PM and assessed the patient's vitals signs. The nurse documented the patient acuity was 4 on 1 to 5 scale. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


8. Review of PI # 20's medical record revealed the patient presented to the ED on 8/26/14 at 7:53 PM with complaints of possible overdose. Review of the ER Triage Form revealed the nurse documented the triage assessment at 7:55 PM (3 minutes after the patient had been registered) and discharged from the ED at 11:00 PM (3 hours and 55 minutes in the ED). There was no documentation of the patient's acuity level on the ER Triage Form. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


9. Review of PI # 21's medical record revealed the patient presented to the ED on 1/1/14 with complaint of syncopal episode. Review of the ER Triage Form revealed the nurse documented the triage assessment at 3:40 PM and admitted to the facility from the ED at 8:05 PM (4 hours and 25 minutes in the ED). Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale. Review of the ER Triage/Physician Order Form revealed an order at 4:10 PM for the nurse to obtain Orthostatic blood pressure and pulse (Orthostatic vital signs are a series of vital signs of a patient taken while the patient is supine, then repeated sitting up, then again while standing). Review of the medical record revealed the only documented vital signs were at 5:28 PM, 5:30 PM, 5:31 PM, 7:36 PM and 7:45 PM. There was no documentation in the medical record if any of the documented vital signs were standing, siting or lying down, nor was there documented vital signs on the triage or nursing assessment.


10. Review of PI # 22's medical record revealed the patient presented to the ED on 1/1/14 with complaint of shortness of breath. Review of the medical record revealed the triage assessment was completed at 9:20 PM and discharged from the ED at 12:05 AM (2 hour and 45 minutes in the ED). There was no documentation of the patient's acuity level on the ER Triage Form. There was no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.


11. Review of PI # 24's medical record revealed the patient presented to the ED on 9/1/14 with complaint of a fall. Review of the ER Triage Form revealed the nurse documented the patient acuity was 3 on a 1 to 5 scale. Further review of the ER Triage Form revealed the nurse documented at 8:05 AM, the patient's blood pressure was 213/93. There was no documentation the nurse reassessed the patient's blood pressure due to the abnormal blood pressure reading during the triage assessment, nor was there no documentation in the medical record the nurse reassessed the patient's vital signs after the triage assessment was completed.
There was no documentation in the medical record of PI # 24's disposition or time.

Review of the ER Log dated 9/1/14 revealed the patient was transferred to another hospital on 9/1/14 at 12:11 PM.


An interview was conducted on 9/2/14 at 10:50 AM with Employee Identifier (EI) # 3, Registered Nurse (RN) concerning when vital signs are assessed and reassessed. EI # 3 stated that he assesses the patient's vital signs during triage and then it's according to the acuity of the patient. Some vital signs are assessed every 5 minutes, 15 minutes or every hour.

An interview was conducted on 9/3/14 at 10:25 AM with EI # 4, RN concerning when vital signs are assessed and reassessed. EI # 4 stated the patient's vital signs are assessed during triage, then if the patient has to return to the lobby (ED rooms full) then when the nurse brings the patient back to the room, the patient's vital signs are rechecked or if the patient has hypertension, the nurse checks vital signs more often.

An interview was conducted on 9/4/14 at 11:30 AM with EI # 2, Licensed Practical Nurse (LPN), Quality Assurance/Risk Manager, who verified there was no documentation in the above medical records the nurse reassessed the patients' vital signs.

This condition level deficiency is being cited based on review of emergency department logs, medical records, ER (Emergency Room) schedules for staff, including the physician covering the ER on 8/26/14, staff Time Reports for 8/26/14, facility policies and interviews with facility staff, it was determined the facility failed to ensure:

1. Emergency Department (ED) staff followed the policy for the completion of a triage assessment within 15 minutes of admission to the ED.

2. Facility staff followed the policy for patient registration after the Registered Nurse has completed the triage assessment.

3. Emergency Department (ED) policies were updated to reflect current acuity levels for triage utilized in the ED.

4. All ED staff were knowledgeable of the current acuity levels used in the ED triage process.


Findings include:


Refer to A1104 for additional findings.

Based on review of emergency department logs, medical records, ER (Emergency Room) schedules for staff, including the physician covering the ER on 8/26/14, staff Time Reports for 8/26/14, facility policies and interviews with facility staff, it was determined the facility failed to ensure:

1. Emergency Department (ED) staff followed the policy for the completion of a triage assessment within 15 minutes of admission to the ED.

2. Facility staff followed the policy for patient registration after the Registered Nurse has completed the triage assessment.

3. Emergency Department (ED) policies were updated to reflect current acuity levels for triage utilized in the ED.

4. All ED staff were knowledgeable of the current acuity levels used in the ED triage process.

These deficient practices effected 18 of 25 records reviewed, including Patient Identifiers (PI) #s 1, 2, 5, 6, 7, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 24 and had the potential to negatively effect all patients that present to this hospital for ED services.


Findings include:

Review of the ER schedule for August 2014 revealed Employee Identifier (EI) # 14, ED Medical Director was the physician scheduled to cover the ED from 7 AM to 7 AM (24 hour shift).

Review of the ER Schedule dated 8/26/14 revealed the following staff were scheduled to work in the Emergency Department (ED):
AM shift (6 AM to 6 PM) - Two (2) Registered Nurses (RN) - Employee Identifiers (EI) #s 3 and 4 and One (1) Emergency Room Technician (ERT) - EI # 7
PM shift (6 PM to 6 AM) - Two (2) RNs - EI #s 5 and 6 and One (1) ERT - EI # 8

Registration Clerks (RC) were scheduled for the following times:
One (1) RC (EI # 9) from 6 AM to 4 PM, One (1) RC (EI # 10) from 10 AM to 8 PM, One (1) RC (EI # 12) from 11 AM to 7 PM and One (1) RC (EI # 11) from 8 PM to 6 AM.


Review of the staff Time Reports dated 8/26/14 revealed the following staff were clocked in to work at the following times:
(AM shift)
EI # 3, RN - 6:05 AM to 8:08 PM
EI # 4, RN - 5:55 AM to 6:20 PM
EI # 7, ERT - 6:02 AM to 3:29 PM

(PM shift)
EI # 5, RN - 5:28 PM to 7:06 AM
EI # 6, RN - 6:01 PM to 6:44 AM
EI # 8, ERT - 5:50 PM to 6:02 AM

Review of the ER Log dated 8/26/14 revealed the last patient seen in the ED during the AM shift presented at 3:00 PM and was discharged at 4:10 PM.

Further review of the ER Log dated 8/26/14 revealed the following:

1. Review of the ER Log dated 8/26/14 revealed Patient Identifier (PI) # 15 presented to the ED at 5:39 PM with complaints of Blisters on the legs, itchy and burning. There was no documentation of a Triage assessment. Review of PI # 15's medical record revealed at 7:30 PM the nurse documented the patient left without being seen (LWBS), which was 1 hour and 21 minutes after the patient presented to the ED.

2. Review of the ER Log dated 8/26/14 revealed PI # 16 presented to the ED at 6:13 PM with complaints of Finger laceration. There was no documentation of a Triage assessment. Review of PI # 16's medical record revealed at 9:53 PM the nurse documented the patient LWBS, which was 3 hours and 40 minutes after the patient presented to the ED.


3. Review of the ER Log dated 8/26/14 revealed PI # 17 presented to the ED at 6:27 PM with complaints of Unusual behavior. There was no documentation of a Triage assessment. Review of PI # 17's medical record revealed at 7:24 PM the nurse documented the patient LWBS, which was 57 minutes after the patient presented to the ED.


4. Review of PI # 13's medical record revealed the patient was transported on 8/26/14 by ambulance with complaint of passing out and right side numbness and was placed in the treatment room in the ED. Review of the medical record revealed the nurse performed the triage assessment at 6:30 PM and the nurse documented the patient acuity was 4 on 1 to 5 scale.

5. Review of the ER Log dated 8/26/14 revealed PI # 18 presented to the ED at 6:38 PM with complaints of sore throat, cough and congestion. There was no documentation of a Triage assessment. Review of PI # 18's medical record revealed at 9:45 PM the nurse documented the patient LWBS, which was 3 hours and 7 minutes after the patient presented to the ED.


6. Review of PI # 20's medical record revealed the patient presented to the ED on 8/26/14 at 7:53 PM with complaints of possible overdose. Review of the ER Triage Form revealed the nurse documented the triage assessment at 7:55 PM (3 minutes after the patient had been registered). There was no documentation of the patient's acuity level on the ER Triage Form.

7. Review of the ER Log dated 8/26/14 revealed PI # 19 presented to the ED at 8:04 PM with complaints of bloody diarrhea, watery stool. There was no documentation of a Triage assessment. Review of PI # 19's medical record revealed at 8:42 PM the nurse documented the patient LWBS, which was 38 minutes after the patient presented to the ED.


8. Review of PI # 6's medical record revealed the patient presented to the ED on 12/25/13 at 11:34 PM with complaints of lower abdominal pain. There was no documentation of a Triage assessment. Review of PI # 6's medical record revealed at 12:55 AM, the nurse documented, "... Went out lobby to call patient back to be triaged. Was informed by... in Admissions that the patient had left the building... patient stated... was leaving...". This was 1 hour and 39 minutes after the patient presented to the ED.

9. Review of PI # 14's medical record revealed the patient presented to the ED on 8/5/14 at 3:22 PM with complaints of hurting in back, knees and ankles. There was no documentation of a Triage assessment. Review of PI # 14's medical record revealed the nurse documented at 4:25 PM, "To lobby to call pt (patient) to triage room. Pt not present...". This was 1 hour and 3 minutes after the patient presented to the ED. Further review of PI # 14's medical record revealed the nurse documented at 4:50 PM, "To lobby to call pt to triage room Pt not present. Pt discharge from system, Pt condition is unknown...". This was 1 hour and 28 minutes after the patient presented to the ED.

10. Review of PI # 1's medical record revealed the patient presented to the ED on 9/1/13 with complaints of swollen lip. Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale.

11. Review of PI # 2's medical record revealed the patient presented to the ED on 9/1/13 for psychiatric evaluation. Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale.

12. Review of PI # 5's medical record revealed the patient presented to the ED on 12/25/13 with complaint of pelvic pain with a history of UTI (urinary tract infection). Review of the ER Triage Form revealed the nurse documented the patient acuity was 5 on a 1 to 5 scale.

13. Review of PI # 7's medical record revealed the patient presented to the ED on 1/1/14 at 6:03 PM with complaints of ear ache. Review of the medical record revealed the ER Triage Form revealed the triage assessment was completed by the Registered Nurse at 6:30 PM , which was 27 minutes after the patient presented to the ED. Further review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale.

14. Review of PI # 10's medical record revealed the patient presented to the ED on 1/1/14 at 3:14 PM with complaints of dizziness and lightheadedness. Review of the medical record revealed the ER Triage Form revealed the triage assessment was completed by the Registered Nurse at 4:00 PM , which was 46 minutes after the patient presented to the ED. Further review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale.

15. Review of PI # 12's medical record revealed the patient presented to the ED on 1/1/14 with complaint of swallowed something, per mother's report. There was no documentation of the patient's acuity level on the ER Triage Form.

16. Review of PI # 21's medical record revealed the patient presented to the ED on 1/1/14 with complaint of syncopal episode. Review of the ER Triage Form revealed the nurse documented the patient acuity was 4 on a 1 to 5 scale.

17. Review of PI # 22's medical record revealed the patient presented to the ED on 1/1/14 with complaint of shortness of breath. There was no documentation of the patient's acuity level on the ER Triage Form.

18. Review of PI # 24's medical record revealed the patient presented to the ED on 9/1/14 with complaint of a fall. Review of the ER Triage Form revealed the nurse documented the patient acuity was 3 on a 1 to 5 scale.


Hospital Policy review:

Department: Emergency Department
Subject: Purpose and Objectives

Statement of Purpose:

One purpose of this Hospital is to provide quality care for all patients who arrive at the Emergency Department 24 hours a day regardless of age, race, religion or ability to pay, as defined by federal and state laws.

All patients will receive an evaluation by the Emergency Department physician...

... Objectives:

Emergency care shall be delivered in accordance with written policy and procedure and standard of care...

Provide initial triage and treatment of all patients...

Provide treatment to patients within a reasonable period of time, depending on the critical nature of the injury or illness...


Hospital Policy

Department: Emergency Department
Subject: Triage
Date Issued: 10/2000

... Procedure:

The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either: Emergency, Urgent or Non-Urgent categories...

Classification: Emergent - Immediate Care, Life Threatening Conditions: Airway and breathing difficulty or arrest
Cardiac arrest
Irregular pulse with symptoms
Acute chest pain with dyspnea
Status seizure
Unconscious, unresponsive, altered LOC (level of consciousness)
Drug overdose with symptoms
Shock
Uncontrolled bleeding or hemorrhage...


Classification: Urgent - Major Injury or Illness but Stable:
First or second degree burns
Severe pain
Chest pain, sharp non-cardiac...
Open wounds...

Classification: Non-Urgent - Minor Injury or Illness and Ambulatory:
Cough, nonproductive
Minor burns
Sprains and strains
Minor complaints of pain and pain for over 36 hours
Minor lacerations with bleeding controlled...

In the event the Registered Nurse is unable to do triage, a call can be placed to the Emergency Department Nurse Manager or Nursing Supervisor to assist with triage until the Registered Nurse is available.

Until the patient is triaged by the Registered Nurse and deemed to have a non-life threatening condition, the Registration Clerk is not to obtain or request any financial information or demographic information.


Hospital Policy

Subject: Emergency Department Standards of Practice or Care
Date Issued: 10/2000

Statement of Purpose:
To establish standards of practice or care for patients presenting to the Emergency Department for treatment.

Text: Standards of practice or care shall be observed.

Standard I:
The Registered Nurse performs a comprehensive nursing assessment and develops and implements patient treatment consistent with the objectives of multidisciplinary treatment. The patient and family members are included in patient care planning and planning for discharge.

Important Aspects of Patient Care:

... The patient assessment is completed within 15 minutes after admission to the treatment area and includes:
Chief complaint and present physical and emotional status; The presence of pain; Focused review of affected systems and medical history, including current medications and chief complaint...

The patient is evaluated according to Triage Categories:
Class I - Emergent:
Airway and breathing difficulties, Cardiac arrest, Chest pain/acute dyspnea/cyanosis, uncontrolled seizure status, Severe head injury/comatose/altered LOC (Level of Consciousness), Drug overdose...

Class II - Urgent:
Burns, Obvious fracture (not femur), Open wounds (not minor lacerations), back injuries without spinal cord damage, Persistent nausea, vomiting, diarrhea, severe pain... Lacerations, abdominal pain - less than 36 hour duration...

... Special Classifications for Class II:
Patients with the following conditions should be classified at least as Class II (Urgent) no matter how insignificant the complaint because they are a high-risk population:
Patients with artificial heart valves... with organs transplants, ... on renal dialysis... with cancer, ... are paraplegics or quadriplegics...

Class III - Non-Urgent
Chronic back pain without neuro deficit, moderate headache of non-acute onset, minor fractures or other injuries of minor nature, medication refills, upper respiratory complaint, except SOB (shortness of breath)... minor complaints of pain, non-specific, minor lacerations, with controlled bleeding...

Assessment and supportive data are thoroughly documented, properly stored and retrievable in the:
Emergency Department Nursing Notes, Triage Assessment, Laboratory results, Progress Notes, History and Physical, Nursing Flowsheets, Radiology Results

Assessments are consistent with the overall treatment plan coordinated by the multidisciplinary team... Assessment reflect changes in patient's condition and are appropriately charted and communicated... Patient's response to treatment and interventions is reflected in the patient progress notes/nursing notes...

Related Standards of Patient Care:
All patients receive initial triage assessment within five (5) minutes of arrival to the Emergency Department based on their chief complaint(s)...

... Standard VI:

Nursing practice is reviewed and evaluated is a systematic manner to validate compliance with standards...

Important Aspects of Performance Improvement Activity:

Ongoing Performance Improvement (PI) in nursing practice is comprehensive in scope and implementation. Performance improvement activities determine compliance to standards (structure, process and outcome). JCAHO's (Joint Commission on the Accreditation of Healthcare Organizations) Ten Step Process is used for monitoring and evaluation (M & E) activities.

Nursing practice standards related to important aspects of care associated with high-volume, high-risk conditions are monitored and evaluated. An annual calendar outlines indicators of monitoring and evaluation activities related to:
Structure Standards (policy)
Process Standards (protocols, procedures, guidelines, position descriptions)
Outcome Standards (patient discharge goals, morbidity, risk management, case management, patient satisfaction, volume indicators)...

Related Standards of Patient Care:
The patient will receive quality patient care verified through monitoring and evaluation of the important aspects of patient care...


An interview was conducted on 9/2/14 at 10:50 AM with EI # 3, Registered Nurse (RN) who worked on 8/26/14 during the day shift. The surveyor asked EI # 3 who makes the nurse assignments for the day. EI # 3 stated there are 6 rooms in the ED and the rooms are divided between the nurse. EI # 3 verified there was no set assignment of each room or patients. EI # 3 stated that the nurses take the patients as they come, alternating between the two nurses. The surveyor asked about the process for triaging a patient. EI # 3 stated that there was no way for the nurses to see the front lobby, registration staff call us back here (in the ED) and we go to the front. "If the patient is acute, we triage the patient, as soon as the patient is triaged, I bring them back, if we have room. It's according to acuity. Acuity is a 1 to 5 system with 1 being most severe and 5 least severe." The surveyor asked if he recalled anything going on out of the ordinary after 5 PM and the end of his shift that would cause a delay in patients being triaged. EI # 3 stated he did not recall anything.

An interview was conducted on 9/2/14 at 12:42 PM with EI # 13, Supervisor in Admissions. The surveyor asked what is the process for patients wanting to be seen in the ED. EI # 13 stated the patients come in and sign in the log in the lobby, I asked for the patient's name and date of birth. EI # 13 stated that she verifies the patient's insurance and address, places an armband on patient and asks them to sit in lobby. EI # 13 stated that she puts the chart together, takes it to the ED and places it in the rack on the nurses desk.

An interview was conducted on 9/3/14 at 9:50 AM with EI # 9, Registration Clerk that worked on 8/26/14 on the AM shift. The surveyor asked what is the process for patients wanting to be seen in the ED. EI # 9 stated that she asks for the patient's date of birth, verifies address, phone number, insurance and emergency contact information. EI # 9 stated that she asks the patient what symptoms they are experiencing, places an armband on the patient and asks them to wait in the lobby. EI # 9 stated she puts together a chart and takes it to the ED and places it in the rack on the nurses desk. EI # 9 stated that some patients get upset about the wait and that she tells them the ED takes the critical patients first according to severity. EI # 9 stated that if she has a patient come in that is having shortness of breath, chest pain or a large cut, she will call the nurse for immediate attention.

An interview was conducted on 9/3/14 at 10:00 AM with EI # 10, Registration Clerk, (worked on 8/26/14 from 10 AM to 8 PM), who verified the same process above for patients wanting to be seen in the ED who are not in a lot of stress. EI # 10 stated that if the patient is having a lot of stress, chest pain or shortness of breath, then she calls the nurse in the ED. The surveyor asked EI # 10, if she had any previous medical experience. EI # 10 replied that she worked as an aide in a previous job, but was not a Registered Nurse or Licensed Practical Nurse (LPN).

An interview was conducted on 9/3/14 at 10:25 AM with EI # 4, RN, worked on 8/26/14 on the AM shift. The surveyor asked who prepares the assignments for each day. EI # 4 stated there are usually 2 RNs from 6 AM to 6 PM and most days there is an ERT. The surveyor asked how does triage work? EI # 4 stated that Registration usually takes place first, unless the patient is experiencing Chest pain, Shortness of breath or signs of Stroke. If a patient is experiencing chest pain, shortness of breath or signs of stroke, Registration will call and inform the ED, otherwise, the Registration clerk puts everything in a folder and places the folder in the rack at the nurse's station. EI # 4 stated the RN will pick up the folder and go to triage area. The surveyor asked, who performs triage. EI # 4 stated there was not a specific nurse assigned to triage. EI # 4 stated the sometimes the patients are triaged back to the lobby, but most times are triaged to a room (exam area in ED). The surveyor asked if he recalled anything going on 8/26/14 that would have caused a delay in patients being triaged and treated in the ED? EI # 4 stated there were no codes or problems that he recalled that would delay Patient Identifier (PI) # 15, who presented at 5:39 PM, from being triaged and treated.

A telephone interview was conducted on 9/3/14 at 5:45 PM with EI # 6, RN who worked in the ED on 8/26/14, PM shift. EI # 6 verified they ED does not have a designated triage nurse. There are two RNs on each shift and they take turns doing the triage assessment. It the patient is truly emergent we will perform the triage assessment and nursing assessment at the same time. The surveyor asked what the was the purpose of performing a triage assessment. EI # 6 replied, to find out what the patient's acuity was and what is going on with them in order to take the more emergent cases first. EI # 6 was asked if she recalled anything specific going on in the ED on 8/26/14 that would delay patients being triaged. EI # 6 stated that she did not recall anything specific.

An interview was conducted on 9/3/14 at 6:15 PM with EI # 5, RN who worked in the ED on 8/26/14, PM shift. EI # 5 verified there is no designated triage nurse, there are two RNs on each shift and they take turns with performing the triage assessment. The surveyor asked EI # 5 about acuity. EI # 5 stated the ED does not do a lot of acuity, that it was mostly on the medical floor and how much medical care or medical attention the patient requires. The surveyor asked about the number system the ED uses. EI # 5 was able to describe the 1 to 5 system with "1" being more severe and "5' being less severe. EI # 5 stated, "We don't discuss acuity, we just do it." The surveyor asked EI # 5 if she recalled anything going on the night of 8/26/14 that would cause a delay in patients being triaged and treated. EI # 5 replied that she and EI # 6 had problems with Pixis training and were unable to get into the training on the computers to complete the training. The surveyor asked EI # 5 how much orientation to the ED she had received. EI # 5 stated there was no formal training in the ED, the education received was sporadic. EI # 5 stated she had been working in the ED intermittently in 2011, 2012 and 2013 and began working in the ED full time in April 2014.

An interview was conducted on 9/4/14 at 1:45 PM with EI # 2, Licensed Practical Nurse (LPN), Quality Assurance/Risk Manager. The surveyor asked what Quality Assurance items are looked at for the ED. EI # 2 stated that the hospital looks at transfers, patients leaving AMA (Against Medical Advice) including inpatient and ED patients and the top 3 reasons for patients to be seen in the ED.

An interview was conducted on 9/4/14 at 2:35 PM with EI # 1, Chief Nursing Officer about patient turn around times in the ED (how long it was taking for patients to be seen, treated and discharged, admitted or transferred). EI # 1 stated the facility had not been looking at turn around times and had just started looking at patients who have left without being seen.


Summary: The facility failed to follow the policy for the triage process within 15 minutes of patients' presentations to the ED. The facility failed to ensure the staff were knowledgeable of the Acuity levels utilized by the ED and all patients were triaged according to the 1 to 5 Acuity scale utilized in the ED medical records. The facility failed to update the ED policy related to the standards of practice utilized in the ED related to patient triage and acuity. The facility failed to identify, monitor and evaluate the time patients are waiting to be seen, assessed and treated in the ED and incorporate this information in the Performance Improvement plan to improve patient outcomes and the potential for patients to leave without being seen in this facility's ED.