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Based on record review and interview. The facility failed to ensure patient rights were protected by not completing the investigation into the grievances filed by Patient #3.

The facility failed to honor patient rights to an assessment and treatment in a timely/safe manner by having a patient presented with chest pain and shortness of breath wait over 2 hours to be triaged (Patient # 3).

The findings include:

Based on interviews and record review the facility failed to ensure Patient #3's formal grievances was fully addressed and all concerns were investigated by each department involved with the grievance.

Refer to A- 0119 for additional information.

Based on interview and record review the facility failed to ensure 6 (Patients #1, #2, #3, #4, #5, and #6) of 8 emergency patients were assessed upon admission to the facility and all patient care needs were addressed timely.

Refer to A-0395 for additional information.

Based on interviews and record review the facility failed to ensure Patient #3's formal grievances were fully addressed and all concerns were investigated by each department involved with the grievance.

The findings include.

Review of Patient #3's Emergency Room (ER) medical records revealed Patient #3 arrived at the ER front desk on 9/01/10 at 21:52 (9:52 p.m.) with the chief complaint of heart pain, trouble breathing, and a rapid heart rate. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s), height and weight is written on the form in the lower right corner. The next timed entry is at 23:43 (11:43 p.m.), a 2 hour and 33 minute delay from when the patient checked in until they were triaged, a full assessment done by a nurse in ER department. The Triage form v/s matches the v/s written on the ER sign-in form. The form stated the patient is complaining of heart pain, trouble breathing and a rapid heart rate. The priority/severity is coded as a 4. A level 4 via the policy and procedure is coded as less-urgent with examples listed but not limited to simple laceration, fracture, sore throat, UTI, gyn (gynecology) complaints, orthopedic injuries. The policy and procedure indicates a patient with chest pain should be coded as a priority/severity of 2 which would indicate emergent/potentially unstable needing treatment right away. The next time entry is at 23:45 (11:45 p.m.) when the patient left the ER after being informed by the triage nurse there would be approximately 2 to 3 hour wait before seeing a physician. There was no documentation Patient #3's chest pain was assessed upon arrival to the ER and the severity was not coded prior to the Triage assessment.
12/13/10 at 6:30 p.m. with the Director of Emergency Services (DES), her assistant, Risk Manager (RM) and Guest Service Coordinator (GSC) after a full review of the medical record confirmed all the times listed above as correct. The GSC stated she had received an e-mail on 9/15/10 stating on 9/14/10 the facility had received an e-mail from Patient #3 complaining they had given the front desk their information and was not seen for 2 hours and therefore left without being seen. The second part of the complaint was they were charged for the ER visit.
The GSC stated she had a phone conversation with Patient #3 and they did confirm to her they had waited in the ER for over 2 hours but the primary concern was that they not be charged for the ER visit. They stated the triage nurse told them they would have a 2 to 3 hour wait to see the physician. She told Patient #3 they would not be charged for the ER visit and she thought the patient was satisfied. She then stated she told the DES about Patient #3's complaint of a long wait in the ER department.

The DES stated she was informed of Patient #3's complaint of waiting over 2 hours in the ER but she had not done an investigation because the patient seemed like she was more concerned with the ER charges.

The GSC then stated she received an interdepartmental e-mail indicating Patient #3 had mailed a 2 page letter dated 10/25/10 providing further details about their ER visit on 9/1/10 complaining they had a long wait and the staff was rude. Page 2 of the letter in the 3rd paragraph, Patient #3 reported they had a anxiety attack or asthma attack and the woman at the counter told them to sit down and wait their turn. When finally seen in Triage, the nurse told them they would have to wait a couple more hours before they would be able to see a physician. GSC stated she had responded to Patient #3's concern with a letter and told DES again about Patient #3's concern with their ER visit.

Further interview with the DES showed an interoffice e-mail dated 12/04/10 titled Managing Patient Experience and Expectations. In this e-mail she explained the facility is working on an overall plan on increasing patient satisfaction. She confirmed she was told about the 10/25/10 letter from Patient #3 but she had not done an investigation into Patients #3's concerns related to the staff being rude and telling Patient #3 they would have to wait a couple of hours to see a physician after having already waited over 2 hours to be triaged.

Based on record review and interview the facility failed to ensure the nursing services in the emergency department were adequate to assess patients upon arrival and failed to delivered care in a timely manner.


The findings include.


Based on interview and record review the facility failed to ensure 6 (Patients #1, #2, #3, #4, #5, and #6) of 8 emergency patients were assessed upon arrival and failed to have all patient care needs addressed timely, including a patient presenting with chest pain and shortness of breath who waited more than 2 hours for triage (Patient #3).

Refer to A 0395

Based on interview and record review the facility failed to ensure 6 (Patients #1, #2, #3, #4, #5, and #6) of 8 emergency patients were assessed upon admission to the facility and all patient care needs were addressed timely.


The findings include.


1. Review of Patient's #1 Emergency Room (ER) medical records revealed the patient had checked in at the ER front desk on 9/01/10 at 2145 (9:45 p.m.) with the chief complaint of right knee swollen, unable to walk, and in a lot of pain. An ER room sign-in form was completed by the patient at that time with their name, address and the reason for the visit. A set of vital signs (v/s), height, and weight is written on the lower section of the form. The next time entry is at 22:56 (10:56 p.m.), a 71 minute delay from when the patient checked at the front desk until they were triaged, a full assessment done by a nurse in ER department. The Triage form v/s matches the v/s written on the ER sign-in form. The form stated the patient's right knee is swollen and the patient is in a lot of pain. The pain is rated as 10 out of 10 at this time and the priority/severity is coed as a 5. A level 5 severity via the hospital policy and procedure is coded as non-urgent with examples listed but not limited to; medication refill, rash, common cold, impetigo, abrasion, sunburn, conjunctivitis and insomnia.

A physician assessment sheet was generated on 9/01/10 and timed 23:23 (11:23 p.m.), 1 hr and 38 minutes from when the patient first presented at the front desk. The v/s on the physician assessment sheet matches exactly the v/s taken by the triage nurse at 22:56 (10:56 p.m.). The pain scale is marked as moderate but none of the pain scale numbers where circled.

The progress notes state a nurse talked with Patient #1 at 23:10 (11:10 p.m.) about their plan of care. At 23:45 (11:45 p.m.) the notes state the physician visited the patient and they set up the patient for an I&D (incision and drainage) for the swollen knee. At 01:35 (1:35 a.m.) the progress note stated 44 cc of fluid was removed during the procedure and a specimen was sent to the lab. The patient was then discharge at 02:14 (2:14 a.m.) from the ER department.

The ER progress notes on 9/02/10 at 00:30 (12:30 a.m.) states Patient #1 s pain was assessed as a 10 out of 10, 2 hours and 45 minutes after the patient presented them self at the front desk and 90 minutes after the triage assessment was done indicating a pain scale of 10 out of 10. The progress notes also state Marcaine, a pain medication, was administered at 01:15 (1:15 a.m.) 3 hours and 30 minutes after Patient #1 presented them self at the front desk and 2 hours and 14 minutes after the triage assessment was completed indicating Patient #1 was assessed as 10 out of 10 for pain.

12/13/10 at 5:00 p.m. interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM), after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER front desk either by a nurse or a tech to see if they should go straight back to the ER rooms or they can wait in the lobby. She stated she was unable to tell if the patient was assessed upon presentation to the ER because the v/s are the same as the one in Triage and the same as the physician wrote on their assessment form. She also stated if the v/s were taken at the time of admission the Triage nurse should have taken them again when the patient was assessed in Triage. She was unable to show a justification of Patient #1 waiting 1 hour and 30 minutes from the Triage assessment with a pain scale of 10 out of 10 until they received pain medication 2 hours and 14 minutes later.

The Triage form assessed Patient #1 pain a 8 out of 10 during triage at 12:37 a.m. The next electronic entry related to pain is at 4:10 a.m. when the patient received Fentanyl 50 mcg IV push for pain a 3 hours and 30 minutes from when the patient was coded as a 8 out of 10 for pain in Triage. The severity code was left blank.


2. Review of Patient's #2 Emergency Room (ER) medical record revealed they had checked in at the ER front desk on 9/01/10 at 21:47 (9:47 p.m.) with the chief complaint of being 10 weeks pregnant, bleeding, and abdominal pain. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s) is written on the form in the lower right corner. The next time entry is at 23:09 (11:09 p.m.), a 1 hour and 23 minute delay from when the patient checked in at the front desk until they were Triaged, a full assessment done by a nurse in ER department. The Triage form v/s and the v/s written on the ER sign-in form were an exact match. The Triage form stated the patient is 10 weeks pregnant, spotting and having abdominal pain. The pain is rated as 3 out of 10 at this time and the priority/severity is coded as a 3. A level 3 via the policy and procedure is coded as urgent with examples listed as abdominal pain, lower leg pain and vaginal bleeding to list a few.

A physician assessment sheet was generated on 9/02/10 and timed 12:05 a.m. which is a 2 hours and 10 minutes from when the patient first presented at the front desk. The v/s on the physician assessment sheet matches exactly the v/s taken by the triage nurse at 23:09 (11:09 p.m.) and the ER admission form.

On 12/13/10 at 5:20 p.m. an interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM) after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER from desk either by a nurse or a tech to see if they should go straight back to the ER rooms or if they can wait in the lobby. She stated she was unable to tell if the patient was assessed upon presentation to the ER because the v/s are the same as the ones in Triage and the same as what the physician wrote on their assessment form. She also stated if the v/s were taken at presentation to the ER the Triage nurse should have taken the v/s again when the patient was assessed in Triaged. She was unable to show a justification or documentation Patient #2 was assessed upon presenting themselves with vaginal bleeding and abdominal pain until they were assessed in Triage. She was also unable to explain why all three v/s matched over a 2 hour and 15 minute time frame.

3. Review of Patient's #3 Emergency Room (ER) medical records revealed Patient #3 arrived at the ER front desk on 9/01/10 at 21:52 (9:52 p.m.) with the chief complaint of heart pain, trouble breathing, and a rapid heart rate. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s), height, and weight is written on the form in the lower right corner. The next timed entry is at 23:43 (11:43 p.m.), a 2 hour and 33 minute delay from when the patient checked in until they were triaged, a full assessment was done by a nurse in ER department. The Triage form v/s matches the v/s written on the ER sign-in form. The form stated the patient is complaining of heart pain, trouble breathing, and a rapid heart rate. The priority/severity is coded as a 4. A level 4 via the policy and procedure is coded as less-urgent with examples listed but not limited to simple laceration, fracture, sore throat, UTI, gyn (gynecology) complaints, orthopedic injuries. The policy and procedure indicates a patient with chest pain should be coded as a priority/severity of 2 which would indicate emergent/potentially unstable needing treatment right away. The next time entry is at 23:45 (11:45 p.m.) when the patient left the ER after being informed by the triage nurse there would be approximately 2 to 3 hour wait before seeing a physician. There was no documentation Patient #3's chest pain was assessed upon arrival to the ER and the severity was not coded prior to the Triage assessment.

12/13/10 at 5:45 p.m. interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM) after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER front desk either by a nurse or a tech to see if they should go straight back to the ER rooms of they can wait in the lobby. She stated she was unable to tell if Patient #3 was assessed upon presentation to the ER because the v/s are the same as the v/s on the Triage assessment form. She also stated if the v/s were taken at the time of presentation to the ER the Triage nurse is still required to take the v/s again when the patient was assessed in Triage. She was unable to show a justification or documentation why Patient #3 was not assessed upon presenting themselves with chest pain until 2 hours and 43 minutes later in Triage. She also stated that all patients presenting themselves with chest pain should be evaluated/assessed right-a-way to ensure prompt and accurate treatment is done.

4. Review of Patient #4's Emergency Room (ER) medical records revealed Patient #4 arrived at the ER front desk on 9/01/10 at 22:06 (10:06 p.m.) with the chief complaint of stomach pain since 7:00 p.m. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s), height and weight is written on the form in the lower left corner. The next timed entry is at 23:58 (11:58 p.m.), a 1 hour and 52 minute delay from when the patient checked in until they were triaged, a full assessment done by a nurse in ER department. The Triage form v/s matches the v/s written on the ER sign-in form. The Triage form stated the patient is having bad stomach pains. The pain was marked as a 7 out of 10 and the priority/severity is coded as a 3. A level 3 via the policy and procedure is coded as urgent with examples listed as abdominal pain, lower leg pain and vaginal bleeding to list a few.

12/13/10 at 6:05 p.m. interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM) after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER front desk either by a nurse or a tech to see if they should go straight back to the ER rooms of they can wait in the lobby. She stated she was unable to tell if Patient #4 was assessed upon presentation to the ER because the v/s are the same as the v/s on the Triage assessment form. She also stated if the v/s were taken at the time of presentation to the ER the Triage nurse is still required to take the v/s again when the patient was assessed in Triage. She was unable to show a justification or documentation why Patient #4 was not assessed upon presenting themselves with abdominal pain until 1 hour and 52 minutes later in Triage.

5. Review of Patient's #5 Emergency Room (ER) medical record revealed they had checked in at the ER front desk on 9/01/10 at 22:09 (10:09 p.m.) with the chief complaint of being discharge from the hospital at 8:00 p.m. tonight. When they returned home they checked their blood sugar and it was 392. As part of the discharge plan was that if they had a high blood sugar they needed to come back to the hospital. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s) is written on the form in the lower right corner. The next time entry is at 00:30 (12:30 a.m.), a 2 hour and 27 minute delay from when the patient checked in at the front desk until they were triaged, a full assessment done by a nurse in ER department. The Triage form v/s and the v/s written on the ER sign-in form were an exact match. The Triage form also did not contain a check of the blood sugar since the 392 blood sugar value was done when Patient #1 was at their home. The computer entry noted on 9/02/10 at 12:34 a.m. a blood sugar of 429. Review of the progress notes it dose not reveal the 429 blood sugar was called to the ER department. The next electron note is timed at 2:00 a.m. where Patient #1 received 10 units of Regular insulin to lower the high blood sugar. This is a 4 hour delay from entry to the ER depart and admission and a 1 hour and 26 minutes since the lab result of 429. The next blood sugar result which was done at 2:44 a.m. via an accu-check machine was 385, which read as high in the electronic records. The next couple of bloods an hour apart were 328, 312, 254, 222, 175, and 100 at discharge.

On 12/13/10 at 6:20 p.m. an interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM) after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER from desk either by a nurse or a tech to see if they should go straight back to the ER rooms or if they can wait in the lobby. She stated she was unable to tell if the patient was assessed upon presentation to the ER because the v/s are the same as the ones in Triage and the same as what the physician wrote on their assessment form. She also stated if the v/s were taken at presentation to the ER the Triage nurse should have taken the v/s again when the patient was assessed in Triaged. She was unable to show a justification or documentation Patient #2 was assessed upon presenting themselves with a blood sugar of 392 until they were assessed in Triage with a blood sugar via lab of 429. She was also unable to explain why all three v/s matched over a 2 hour and 45 minute time frame. She also could not explain why a patient who was assessed with a 8 out of 10 for pain was not given a pain medication until 4:10 a.m. 3 hours and 30 minutes later with the next pain evaluation at 9:11 a.m. of a 6 out of 10, 5 hours and 1 minutes after the pain medication was given.

6. Review of Patient #6's Emergency Room (ER) medical record revealed they had checked in at the ER front desk on 9/01/10 at 23:44 (11:44 p.m.) with the chief complaint of right sided pain. An ER room sign-in form was completed by the patient with their name, address and the reason for the visit. A set of vital signs (v/s) is written on the form in the lower right corner. The next time entry is at 01:05 (1:05 a.m.), a 1 hour and 21 minute delay from when the patient checked in at the front desk until they were triaged, a full assessment done by a nurse in ER department. The Triage form v/s and the v/s written on the ER sign-in form were an exact match. The Triage form stated the patient is complaining of pain on the right side and back. The pain is rated as 8 out of 10 at this time and the priority/severity is coded as a 3. A level 3 via the policy and procedure is coded as urgent with examples listed as abdominal pain, lower leg pain and vaginal bleeding to list a few. Via the medical record Patient #6 received Toradol 30 mg at 2:54 a.m., 1 hour and 48 minutes after being triage with a pain scale of 8 out of 10.

A physician assessment sheet was generated on 9/02/10 and timed 2:06 a.m. which is a 2 hours and 21 minutes from when the patient first presented at the front desk. The v/s on the physician assessment sheet matches exactly the v/s taken by the triage nurse at 01:05 (1:05 a.m.) and the ER admission form.

On 12/13/10 at 6:35 p.m. an interview with the Director of Emergency Services (DES), her assistant and the Risk Manager (RM) after a full review of the medical record confirmed all the times listed above as correct. The DES stated all patients are assessed when they first present themselves at the ER from desk either by a nurse or a tech to see if they should go straight back to the ER rooms or if they can wait in the lobby. She stated she was unable to tell if the patient was assessed upon presentation to the ER because the v/s are the same as the ones in Triage and the same as what the physician wrote on their assessment form. She also stated if the v/s were taken at presentation to the ER the Triage nurse should have taken the v/s again when the patient was assessed in Triaged. She was unable to show a justification or documentation Patient #6 was assessed upon presenting themselves with right side and back pain until they were assessed in Triage. She was also unable to explain why all three v/s matched over a 2 hour and 21 minute time frame.