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Based on record review and interview the facility failed to ensure the completion and documentation of assessments per facility policies in 1 of 10 (Patient # 1) Emergency Department medical records reviewed in a total universe of 10 Emergency Department (ED) medical records reviewed.

Findings include:

The facility policy titled "Emergency Departments at University Hospital and the American Center Standards of Emergency Nursing Practice" #3.0 last reviewed July, 2018 was reviewed on 1/28/2020. This document revealed "Emergency nursing care expands across the lifespan and involves caring for persons with actual and potential physical and/or psychosocial illnesses and injuries. Care delivery is patient and family centered, and the nurse integrates unique patient characteristics into the plan of care. Triage: The emergency nurse triages patients using the Estimated Severity Index (ESI) model, a validated tool, for safely prioritizing patients based on their acuity and resource needs. The emergency nurse interprets a patient's assessment data for prioritization based on the seriousness of his/her medical and/or psychological needs. A. The emergency nurse promotes access to care through appropriate screening of patients along with a medical screening examination by a physician, in accordance with the Emergency Medical Treatment Active Labor Act (EMTALA) and UW Health policies and guidelines. Assessment: A. The initial assessment is based on the patient's presentation and chief complaint. The nurse will obtain initial focused subjective and objective data through history taking, physical examination, review of records (if applicable), and communication with health care providers. The emergency nurse establishes priorities based on the patient's condition, immediate and anticipated needs or situation. Disposition: The emergency nurse will integrate patient information including assessment data, throughout the ED course in planning appropriate discharge plans, based on the patient's illness or injury, and needed support mechanisms. This will involve communication and collaboration with other health care providers to facilitate patient care."

Patient #1's medical record was reviewed on 1/28/2020. Patient #1 was taken to the Emergency Department on 12/8/2019 by her mother for suicidal ideations, attempted overdose of medication (mother caught her before actual ingestion) and self harming behaviors on 12/7/2019 of cutting and burns on arms (Patient #1 used a torch to burn self). Patient #1 was triaged per facility policy and was assessed by a Registered Nurse, seen by a physician and had a psychiatry consult. Documentation completed by RN, MD, and Psychiatrist documented that Patient #1 had cut and burned herself on 12/7/2019. There was no documented assessment of the wounds, need for treatment or treatment given. The "After Visit Summary" given to patient and her mother included "Instructions: Adhere to the safety plan contract and if any worsening of the symptoms or any concerns please return to the emergency department. And please keep the appointment on Tuesday with her therapist." There was no documented discharge instructions about how to care for the burns/cuts on both arms.

An interview was conducted on 1/28/2020 at 3:45 PM with Quality Accreditation Specialist A, Interim Director of Emergency Department B and RN Manager Emergency Department C. All staff accessed Patient #1's medical record and were asked if they could locate any skin assessment completed by a Registered Nurse or Physician and/or treatment given to the areas. RN Manager C stated "Yeah, everyone talked about that she had injured herself but there is not a nursing skin assessment or description of the areas in the chart." When asked the expectation of the assessment Quality Accreditation Specialist A stated "There should be a documented assessment of the areas."

Based on record review and interview the facility failed to ensure the appropriate assessments were completed and documented for patients (skin assessments and/or wounds) in 1 of 10 (Patient #1) Emergency Department (ED) medical records reviewed in a total universe of 10 Emergency Department medical records reviewed.

Findings include:

The facility policy titled "Emergency Departments at University Hospital and the American Center Standards of Emergency Nursing Practice" #3.0 last reviewed July, 2018 was reviewed on 1/28/2020. This document revealed "Emergency nursing care expands across the lifespan and involves caring for persons with actual and potential physical and/or psychosocial illnesses and injuries. Care delivery is patient and family centered, and the nurse integrates unique patient characteristics into the plan of care. Triage: The emergency nurse triages patients using the Estimated Severity Index (ESI) model, a validated tool, for safely prioritizing patients based on their acuity and resource needs. The emergency nurse interprets a patient's assessment data for prioritization based on the seriousness of his/her medical and/or psychological needs. A. The emergency nurse promotes access to care through appropriate screening of patients along with a medical screening examination by a physician, in accordance with the Emergency Medical Treatment Active Labor Act (EMTALA) and UW Health policies and guidelines. Assessment: A. The initial assessment is based on the patient's presentation and chief complaint. The nurse will obtain initial focused subjective and objective data through history taking, physical examination, review of records (if applicable), and communication with health care providers. The emergency nurse establishes priorities based on the patient's condition, immediate and anticipated needs or situation. B. Patient screening information will be assessed and documented with the initial assessment, as required. Planning: The emergency nurse formulates a plan of care intended at reaching desirable and measurable outcomes. This plan includes evidence-based strategies based on priorities in tandem with the interdisciplinary team and patient. A. The plan of care is based on patient, family and staff safety. Priorities will also focus on the patient's emotional and physical safety. B. The plan of care is documented in a patient's electronic medical record and communicated verbally with physicians, ED technicians, and other member of the healthcare team. Documentation will reflect the ongoing plan of care. Implementation: A. Interventions will be implemented and documented per UW Health policies and procedures. Evaluation: The emergency nurse evaluates and modifies the plan of care based upon patient's progress. Ongoing assessment date is integrated into the plan of care. Disposition: The emergency nurse will integrate patient information including assessment data, throughout the ED course in planning appropriate discharge plans, based on the patient's illness or injury, and needed support mechanisms. This will involve communication and collaboration with other health care providers to facilitate patient care."

Patient #1's medical record was reviewed on 1/28/2020. Patient #1 was taken to the Emergency Department on 12/8/2019 by her mother for suicidal ideations, attempted overdose of medication (mother caught her before actual ingestion) and self harming behaviors on 12/7/2019 of cutting and burns on arms (Patient #1 used a torch to burn self). Patient #1 was triaged per facility policy and was assessed by a Registered Nurse, seen by a physician and had a psychiatry consult. Documentation completed by RN, MD, and Psychiatrist documented that Patient #1 had cut and burned herself on 12/7/2019. There was no documented assessment of the wounds, need for treatment or treatment given. The "After Visit Summary" given to patient and her mother included "Instructions: Adhere to the safety plan contract and if any worsening of the symptoms or any concerns please return to the emergency department. And please keep the appointment on Tuesday with her therapist." There was no documented discharge instructions about how to care for the burns/cuts on both arms.

An interview was conducted on 1/28/2020 at 3:45 PM with Quality Accreditation Specialist A, Interim Director of Emergency Department B and RN Manager Emergency Department C. All staff accessed Patient #1's medical record and were asked if they could locate any skin assessment completed by a Registered Nurse or Physician and/or treatment given to the areas. RN Manager C stated "Yeah, everyone talked about that she had injured herself but there is not a nursing skin assessment or description of the areas in the chart." When asked the expectation of the assessment Quality Accreditation Specialist A stated "There should be a documented assessment of the areas."