HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patient vital signs were taken when assessed in the Triage area of the Emergency Department (ED) for nine of 10 medical records reviewed (MR1. MR2, MR3, MR4, MR5, MR6, MR7, MR8 and MR9).

Findings include:

Review on May 16, 2019, of the facility's "Acute Stroke Practice Guidelines for the Emergency Department" policy, no review date, revealed "Purpose Lehigh Valley Hospital - Pocono (LVH-P) has adopted these practice guidelines in order to provide an evidence-based approach to treating patients who present with signs and symptoms consistent with acute stroke. Although these guidelines assist in guiding care, responsibility to determine appropriate care for each individual remains with the provider themselves. ... Guidelines 1. Patient's chief complaint will be documented. Stroke symptoms include: sudden onset of numbness or weakness of the face, arm or leg, especially on one side of the body; confusion, trouble speaking or understanding speech; trouble seeing in one to both eyes; trouble walking, dizziness, or loss of balance or coordination; severe headache with no known cause or "worst headache of my life". ... 3. For patients with the last known well/last normal 24 hours or less, a stroke alert will be called ..."

Review on May 16, 2019, of the facility's "Standard of Care: Emergency Department" policy, no review date, revealed "... Guidelines 1. Triage & Assessment a. All patients presenting to the Emergency Department shall receive a screening exam to determine if they have an emergency medical condition. ...b. The ESI - Emergency Severity Index tool will be used to triage all patients in the emergency department. ...iv. Level - 3 (Non-urgent) the patient presents with a condition that could progress to a serious problem requiring emergency interventions. The vital signs of a level three patient may or may not be outside normal limits (danger zone) and presenting condition is anticipated to require the utilization to two or more resources. v. Level 4 - (Non-urgent) the patient presents and has a low potential for deterioration or complication. One resource is expected to treat this patient. ... 18. Please note a complete set of vital signs are obtained on all patients on arrival and within one hour of discharge. ..."

Review of MR1 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of left side numbness for three days and was triaged with an ESI level 3. There was no documentation ED staff took MR1's vital signs as per facility policy.

Review of MR2 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of dizziness and was triaged with an ESI level 3. There was no documentation ED staff took MR2's vital signs as per facility policy.

Review of MR3 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of dizziness and was triaged with an ESI level 3. There was no documentation ED staff took MR3's vital signs as per facility policy.

Review of MR4 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of left upper abdomen pain and right arm swelling and was triaged with an ESI level 3. There was no documentation ED staff took MR4's vital signs as per facility policy.

Review of MR5 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of right-side flank pain and was triaged with an ESI level 3. There was no documentation ED staff took MR5's vital signs as per facility policy.

Review of MR6 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of cough and short of breath and was triaged with an ESI level 3. There was no documentation ED staff took MR6's vital signs as per facility policy.

Review of MR7 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of a laceration to the head and was triaged with an ESI level 4. There was no documentation ED staff took MR7's vital signs as per facility policy.

Review of MR8 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of a sore throat and congestion and was triaged with an ESI level 4. There was no documentation ED staff took MR8's vital signs as per facility policy.

Review of MR9 revealed this patient presented to the ED as a walk in on April 29, 2019, with a chief complaint of lower back pain and was triaged with an ESI level 4. There was no documentation ED staff took MR9's vital signs as per facility policy.

Interview with EMP1, EMP2, EMP3 and EMP4 on May 16, 2019, at approximately 11:00 AM confirmed ED staff did not document vital signs on patients assessed in the Triage area of the ED for MR1. MR2, MR3, MR4, MR5, MR6, MR7, MR8 and MR9. EMP3 revealed it is expected that patient vital signs be taken and documented when a patient is triaged in the ED.