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Based on policy and procedure review, medical record review, and interview, the hospital does not ensure that nursing personnel meet the written emergency procedures and needs for emergency patients, as evidenced that nursing staff did not implement the facility's seizure protocol for Patient #1 or document patient assessments per policy when Patient #1 received care in the emergency department (ED); specifically:
1) Seizure precautions were not initiated for Patient #1, neither initially nor after he had a seizure in the ED.
2) Nursing staff did not document description of Patient #1's multiple episodes of seizure activity while he was a patient in the ED.
3) Nursing staff did not reassess Patient #1 in the ED per the facility's triage protocol.

Findings include:

Finding #1:
Review of facility policy #TX.NEURO.3 "Care of the Patient with Seizures - Adult/Pediatric" (revised 9/2014) revealed the protocol shall be initiated for any patient with seizures, a history of seizures, or potential for seizures. The protocol includes nursing activities such as: Pad the side rails and head of the bed. If seizure activity is observed, note type of seizure, parts of body affected, loss of consciousness, lip smacking, mastication, grimacing, rolling of the eyes, incontinence or diaphoresis, or apnea. Document assessments and interventions in the patient's record.

Medical record review for Patient #1 revealed that at 10:44 AM on 12/26/14, Patient #1 presented to the emergency department with chest pain and dizziness. Patient #1's medical history included seizure disorder. Patient #1 had two episodes of seizure activity in the ED. There was no evidence in the record that seizure precautions were initiated for Patient #1 while he was a patient in the ED.

Finding #2:
Medical record review for Patient #1 revealed that physicians documented that Patient #1 had two episodes of seizure activity while in the ED. However, nursing staff did not document the first seizure activity that occurred on 12/26/14 at approximately 10:00 PM. Nursing staff noted that seizure activity occurred on 12/27/14 at 12:30 AM, but did not document description and assessment of the seizure activity.

Finding #3:
Review of facility policy #ED.1123 "Patient ESI/Triage Process" (reviewed 4/2014) revealed that if a patient is not evaluated by a provider within the target time for that triage category, an emergency department registered nurse needs to do a reassessment and document it in the record. A change in the triage category may be necessary based on that assessment. The goal for a patient at ESI Level 3 is to evaluate the patient within one hour of arrival.

Medical record review for Patient #1 revealed that upon arrival to the ED on 12/26/15, he was triaged at 11:05 AM at the ESI (emergency severity index) level of 3. However, there is no evidence of RN reassessment of Patient #1 until after his first seizure, when RN documentation begins at 10:41 PM, but does not mention that the patient just had seizure activity.

All three of the above findings were confirmed by ED Director of Nursing Staff #4 on 4/30/15 at 9:30 AM.