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Based on the review of the facility's 'Emergency Room Register', medical records, policy and procedures and staff interviews it was determined that the facility failed to ensure that emergency services were rendered within standards of practice and facility policy and procedures when one patient (P#6) out of five sampled emergency department (ED) patients (P#6, P#7, P#8, P#9, and P#10) requested an examination and treatment of complaints of weakness, high blood sugar levels, and a yellow appearance. The facility failed to meet P#6's needs by not conducting a timely triage assessment by a nurse that resulted in the delay of initiation of stabilizing treatment and eventual transfer to a higher level of care. The facility failed to ensure that trained staff dedicated to triage were present and that an effective triage process was in place.

Cross refer to A-1112 as it relates to the facility's failure to ensure that there were adequate numbers of staff available to assess and render care for individuals requesting emergency services.

Based on a review of the facility's 'Emergency Room Register,' a review of medical records, a review of policy and procedures, observations, and interviews with staff, it was determined that the facility failed to ensure that there were adequate numbers of qualified nursing personnel to meet the needs of patients requesting emergency services when one (P#6) of five (P#6, P#7, P#8, P#9 and P#10) sampled emergency department patients requested an examination and treatment for complaints of weakness, high blood sugar levels, and a yellow appearance. The facility failed to ensure that there were qualified nursing personnel available to perform a triage assessment. This failure had the potential to affect all patients requesting emergency services.

Findings included:

A review of the facility's 'Emergency Room Register' for 11/27/22 revealed that Patient (P) #6 arrived at the facility at 10:23 a.m. complaining of weakness, elevated blood sugar, and yellow eyes. P#6 was triaged at 1:15 p.m. or 2 hours 52 minutes after arrival. An acuity level of II (urgent) was assigned to P#6.

A review of the 'Emergency Room Note' revealed that P#6 was seen at 2:00 p.m. by the physician or 3 hours 37 minutes after arrival. The review of systems (ROS) revealed reports of dizziness, weakness, and abdominal pain. The exam revealed that P#6's abdomen was questionably distended, tenderness to the right/lower abdomen, and questionable enlarged liver.

A review of physician orders revealed that laboratory, radiology, and intravenous (IV) fluids were ordered at 2:26 p.m. STAT (urgent) laboratory tests were drawn at 3:23 p.m., radiology tests were performed at 5:12 p.m., and IV fluids were initiated at 8:04 p.m.

A continued review of the medical record (MR) revealed the physician determined that P#6 had an emergency medical condition (EMC) requiring transfer to a higher level of care. P#6 was transported by emergency medical services (EMS) on 11/28/22 at 12:30 a.m.

A review of the MR failed to reveal a reassessment of P#6 after triage at 1:15 p.m.

A review of the facility's policy titled, 'Triage,' last reviewed 9/2022, revealed that the purpose was to provide a standardized system whereby patients presenting to the emergency department (ED) seeking medical care were seen in order of priority based upon acuity level. The policy revealed that all persons that presented to the ED received immediate appropriate medical screening without regard to the method of payment or insurance status per the Patient Anti-Dumping Statute. The facility defined 'triage' as the process by which a patient was assessed in a timely manner by the ED to determine the urgency of the problem and the appropriate health service/care resources needed to care for the identified problem.
Procedure:
1. Each patient would be triaged by a registered nurse (RN) at the time in a timely manner (as soon as possible) in the Registration area/ED office. (In the event the emergency room RN was unable to triage timely, the floor supervisor was notified)

2. Upon triage, each patient was assigned a triage category which determined the priority in which the patient was seen by the physician. Based on the triage level assigned, the more critically ill patients were seen first. Treatment was rendered upon orders by the physician.
Any patient that appeared in emergent need of care was immediately brought into the emergency treatment area for evaluation. A nurse may initiate any treatment protocols.

Triage Criteria:

An EMC was defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy
b. Serious impairment to bodily functions, or
c. Serious dysfunction of any bodily organ or part, or
d. Jeopardizing the health of an unborn child

Triage guidelines revealed that Level II (urgent) required prompt attention (less than one hour). Vital signs were done every two hours unless the condition warranted more frequent.

A review of the facility's policy titled, 'Assessment of the Emergency Department Patient,' last reviewed 9/22, revealed that all patients that presented to the ED were triaged and categorized as either emergent, urgent or non-urgent. All patients admitted to the ED had the following documented:

1. Level I- every 30 minutes or less
2. Level II- every two hours or less
3. Level III- on admission and discharge.
If a patient remained longer than four hours, every two hours.

On 12/6/22 at 1:30 p.m. in the conference room, DON GG explained that she had been in the DON role for a few months. DON GG confirmed that she had reviewed P#6's ED MR and found that there had been a wait for a triage assessment of about three hours. DON GG explained that P#6's chief complaint had been present for three weeks. DON GG said the ED had six rooms, four regular treatment rooms, and two trauma rooms. There was also a room dedicated to behavioral health and one dedicated to obstetrics. On 11/27/22, all rooms were filled except the obstetrics room. She stated that P#6 was placed in the obstetrics room after the patient's daughter complained about the wait. DON GG said that it had been determined that P#6 required transfer to another facility for a higher level of care. DON GG explained that the ED was usually staffed with two RNs and one provider.

An interview with RN HH took place on 12/6/22 at 3:00 p.m. in the conference room. RN HH recalled working on the day P#6 had come into the ED with her daughter. She recalled that she overheard P#6's daughter tell the ward clerk that she was 'going to call OSHA' (Occupational Safety and Health Administration; ensures safe working conditions by enforcing standards) because triage was supposed to be conducted within 30 minutes. She recalled that she had been one of two RNs working that day. RN HH explained that patients signed in at the registration desk, and there was sometimes a wait since the ED was staffed with two RNs and one physician. RN HH explained that the ward clerk kept a watch out for patients in the waiting room and called a nurse if needed. There was not a nurse assigned to conduct triage assessments.

An interview with RN II took place on 12/6/22 at 3:30 p.m. in the conference room. RN II recalled that P#6 was brought to ED by her daughter. RN II recalled that the patient's daughter complained about the wait, and P#6 was placed in the obstetric room. She recalled that P#6 was able to get on the bed, and she was moved to a more comfortable room when one was available. RN II explained that the ward clerk would let the nurses know what the chief complaint was when patients signed in, and if there was an emergency, patients could be moved around to accommodate critical patients. RN II confirmed that a triage assessment was not done until the patient was taken back to an ED room. She explained that the ward clerk monitored patients in the lobby.

During a tour of the facility's ED, accompanied by DON GG, on 12/7/22 beginning at 9:30 a.m., a ward clerk was observed sitting just inside the entrance. The ward clerk's desk was outside the waiting room entrance, and a window allowed the clerk to observe persons in the lobby. A triage desk was observed adjacent to the ward clerk's desk. DON GG stated that the triage desk could be used if needed and there was not a dedicated triage nurse scheduled. The ED consisted of four treatment rooms and two trauma rooms. There was also a room equipped for behavioral health and one for obstetrics. RN HH, RN II, and an ED supervisor were working during the tour. The ED supervisor explained that all the ED rooms were full except the dedicated obstetrics room. There was one provider on duty. DON GG explained that laboratory and radiology services were available 24 hours a day. There were usually two RNs scheduled per shift. DON GG explained that there was an ED supervisor who was an RN, and she had been out on leave unexpectedly for most of November.

A review of the ED staffing schedule revealed that there were three RNs scheduled on 11/27/22 at the time P#6 presented to the ED.

A review of the schedule for 11/6/22 through 12/3/22 revealed that the ED was staffed with two or more RNs on the day shift (7:00 a.m. to 7:00 p.m.) and two RNs on night shift (7:00 p.m. to 7:00 a.m.) with the following exceptions:

Date Shift Beginning Staff Scheduled

11/9/22 7:00 a.m. One RN and one RN on orientation
11/10/22 7:00 a.m. Two RNs decreased to one RN at 11:00 a.m. and one RN on orientation
11/18/22 7:00 a.m. One RN and one RN on orientation
11/20/22 7:00 a.m. Two RNs, decreased to one RN at 3:00 p.m. and one RN on orientation
11/21/22 7:00 p.m. One RN
11/22/22 7:00 p.m. One RN
11/23/22 7:00 a.m. One RN and one RN on orientation
11/28/22 7:00 a.m. One RN, increased to two at 11:00 a.m., one RN on orientation and one supervisor (RN)
11/28/22 7:00 p.m. One RN
11/29/22 7:00 a.m. One RN, decreasing to zero RNs at 11:00 a.m., one RN on orientation, and one supervisor (RN)
12/2/22 7:00 a.m. One RN on orientation and one supervisor (RN)
12/3/22 7:00 a.m. One RN on orientation and one supervisor (RN)


A review of the 'Emergency Room Register' for 11/27/22 revealed that at the time P#6 arrived, there were six patients signed in on the register.

Two of the six registered patients were discharged at 11:30 a.m. and 11:40 a.m. respectively.