HospitalInspections.org

Based on a review of the patient's medical record (MR1), facility documents, and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Emergency Department policies to ensure that Triage and reassessment procedures were implemented in one of one medical record (MR1).

Findings Include:

A review of PROCESS: DEPARTMENT OF EMERGENCY SERVICES, TRIAGE PROCESS, and PURPOSE: policy and procedure revealed, "... To provide guidelines for a quick, initial assessment of every patient who presents to the Emergency Department and to assure early identification of those with emergency problems. It also identifies those who are eligible for Fast Track and allows the RN to begin advanced Triage protocols. PROCESS: 1. all patients who come to the Emergency Department for care are triaged, either at bedside or in he [sic] triage area. At times, ambulance patients will be directed to Triage based on Medical Command report. 2. Triage responsibilities are: a) completing the reason for visit and assigning a triage acuity level. B) obtaining vital signs, accurate patient weight (all children must be weighed). C) obtain tetanus history if applicable. D) last normal menstrual period on all age appropriate females. E) obtain and document medications and allergies e) [sic] initiate the advanced triage protocols as appropriate. 3. The Triage nurse is responsible for monitoring patient condition and updating them on delays while in the Waiting room, working with the Triage tech and pt. advocate to keep patients and families informed regarding delays. ... ."

A review of Documentation of Vital Signs/Patient Assessment Protocol ED policy and procedure revealed, "... 4. Triage acuity 1 patients should have VS monitored and documented at least every 30 minutes, more frequently based on their condition or physician request. Patient assessment for these patients is ongoing to determine changes in condition and must be documented in the note at least every hour or more often if warranted. ... 6. All other patients should have VS monitored every 2 hours and documented as well as a brief pt assessment. ... Patient assessments done in the Emergency Department are centered on the Chief Complaint. It is expected that the reassessments include an updated evaluation of these systems and complaints as well as any additional areas of concern. Repeat assessments should include a statement about the patient's general appearance and comfort level. ... Vital signs refer to blood pressure and pulse. Patients that require cardiac monitoring must have a rhythm strip on admission to the ED and every 4 hours after if admitted to a monitored area. ... ."

1) Review of MR1 ER Facesheet dated May 6, 2015, revealed, "... Time of Arrival: 1723 ... Room: 29 ... Time in Room: 2118 ... Chief Complaint: Chest Pain ... Triage Priority: [blank] ... Time: 1725 ... Temp 36.7 ... Pulse 131 ... RR 18 ... BP 118/65 ... O2Sat 95% ... ... ."

MR1 "DEM Vital Signs/EKG Strips dated May 6, 2015, revealed that the patient was in bed "ER 29" with a set of vital signs documented at 10:45 PM. The initial set of vital signs were documented at 5:25 PM in triage. There were no vital signs, cardiac monitor assessments or reassessment of patient condition documented from 5:25 PM until 10:45 PM.

2) A telephone interview was conducted with EMP6 on June 1, 2015, at 9:00 AM. EMP6 confirmed the above and revealed, "There was no Triage score assigned to the patient."

3) A review of electronic mail documentation from EMP6 dated June 1, 2015, at 3:42 PM revealed that there was no reassessment until the patient was taken into a cubicle.