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Based on record review and interview, the Hospital failed to ensure that: 1) five of twenty sampled patients (Patient #1, Patient #2, Patient #5, Patient #6 and Patient #10) were accurately triaged and 2) four of twenty sampled patients ( Patient #2, Patient #5, Patient #7 and Patient #19) nursing assessments were accurate and/or completed.

Findings included:

1) The Hospital's Policy/Procedure titled Triage, revised 7/11/12, indicated that the Emergency Department (ED) used the Emergency Severity Index (ESI, a 5 level tool used in triage to rate patient acuity. Levels range from LI - emergent to L5 -least resource intensive) to identify the patient's level of acuity.

PATIENT #1:

Review of video surveillance, dated 5/19/12 at 3:33 P.M, indicated that Patient #1 entered the ED Waiting Area from the Main Entrance and approached the Triage Area.

During the onsite visit for DPH Reference #12-0625 conducted on 6/28/12 and 7/2/12 , the Surveyor interviewed the triage nurse on duty 5/19/12 (Triage Nurse #1) on 6/28/12 at 1:50 P.M. Triage Nurse #1 said that when Patient #1 approached the Triage Area, he was in the process of triaging another patient. Triage Nurse #1 said Patient #1 was calm and told him that he/she was there for a mental health evaluation. Triage Nurse #1 said that he did not ask Patient #1 if he/she had any thoughts of hurting him/herself in any way in the last 2 weeks. Triage Nurse #1 said that he told Patient #1 that he would be finished triaging momentarily, and asked Patient #1 to take a seat in front of the Triage Area. Triage Nurse #1 said Patient #1 requested to go to the restroom and he directed Patient #1 to the Waiting Room Restroom.

Triage Nurse #1 said that when he finished triaging the patient, Patient #1 had not returned from the Waiting Room Restroom. Triage Nurse #1 said that he went back into the Treatment Area to let the staff know they may need a mental health bed and he heard an alarm sound.

The ED Physician Record, dated 5/19/12, indicated that when Patient #1 was found, he/she was unconscious and limp and initially was not breathing. The ED Physician Record indicated that after Patient #1 was placed on a stretcher/he she began to gasp with stridorous breathing (high-pitched sound made due to compromised airway).

The Triage Assessment, dated 5/19/12 at 3:45 P.M., indicated that Patient #1 presented to the Emergency Department (ED) as a walk-in and was found in the Waiting Room Restroom hanging on the back of the restroom door by his/her belt.

The Triage Assessment, dated 5/19/12, indicated that Patient #1 was assigned an ESI Level
2. The Triage Assessment indicated that Patient #1's blood pressure was unobtainable or not recorded and his/her pulse rate was elevated.

The ESI Version 4 Manual, Chapter 3 (ESI Level 2), Page 22, indicated that if a trauma patient presented with unstable vital signs and required immediate attention, then the patient should be triaged as an ESI level 1 and not an ESI Level 2.

The Triage and Ongoing Assessment, dated 5/19/12, indicated that Patient #1 was transported back into to ED Treatment Room and was intubated (tube passed through the mouth, down the throat and to the trachea to provide a patent airway).

The Radiology Report, dated 5/19/12, indicated that that Patient #1 suffered from a ligamentous injury of the cervical spine.

The Ongoing Assessment, dated 5/19/12, indicated that Patient #1 was transferred to the Intensive Care Unit.

PATIENT #2:

The Triage Assessment, dated 5/26/12 at 5:34 P.M., indicated that Patient #2 presented to the ED at 5:34 P.M. accompanied by staff from his/her residence for a psychiatric evaluation for suicidal ideation with a plan to jump out of a car window. The Triage Assessment indicated that Patient #10 was triaged immediately as a Emergency Severity Index (ESI) Level 2 (urgent, high-risk situation).

The ED Nursing Director who said that the Triage Nurse brought Patient #2 directly back to the ED Treatment Area in Hall Bed C (located directly in front of the Security Station) and wrote Patient #2's name on the white board, but the Triage Nurse did not put the suicidal ideation identifier next to Patient #2's name. The ED Nursing Director said the Triage Nurse did not the Security Officer that Patient #2 reported suicidal ideation with a plan and did not inform the Resource or Primary Nurse of Patient #2's presence in the ED or the reason why .

The Ongoing Assessment, dated 5/26/12 at 7:45 P.M., indicated that Patient #2 "was not located in Hall Bed C, ? eloped".
The second Triage Assessment, dated 5/26/12 at 7:56 P.M., indicated that Patient #2 was returned to the ED by ambulance after he/she left the ED and darted in front of a car that resulted in an injury to the left elbow.
The Triage Assessment indicated that Patient #2 was not assigned an ESI Level.

The Ongoing Assessment, dated 5/26/12, indicated that Patient #2 was placed in a safe room (room designated for behavioral/suicidal patietns that is stripped of equipment that the patient may use to injure him/herself), started on 1:1 observation then admitted to the inpatient Psychiatric Unit.

PATIENT #5:

The Triage Assessment, dated 6/28/12 at 11:20 A.M., indicated that Patient #5 was brought to the ED via ambulance for a blood sugar of 37 (normal range is 70-99). The Triage Assessment indicated that Patient #5 was administered Dextrose to treat his/her low blood sugar while enroute to the ED. The Triage Assessment indicated that Patient #1 was pale and confused and his/her blood pressure was 190/90 then 224/86. The Triage Assessment indicated that Patient #5 was assigned an ESI Level 3.

The The ESI Version 4 Manual, Chapter 3 (ESI Level 2), Page 19, indicated that patients with very low blood glucose reading place them in the high-risk category as an ESI Level 2.

The Ongoing Assessment, dated 6/28/12, indicated that Patient #5 was brought directly into a treatment room.

The ED Physician Record, dated 6/28/12 at 12:15 P.M., indicated that Patient #5 refused treatment.

The Ongoing Assessment, dated 6/28/12, indicated that at 12:40 P.M. Patietn #5's blood sugar was 139 and at 12:50 P.M., he/she signed out against medical advice.

PATIENT #6:

The Triage Assessment, dated 6/28/12, indicated that Patient #6 was brought to the ED by family with a chief complaint of having trouble breathing, felt like a rock was sitting on his/her chest and diaphoresis (sweating). The Triage Assessment indicated that Patient #7 rated his/her chest pain as 7/10 (on a scale of 0 to 10 with 10 represents the worst possible pain).

The Ongoing Assessment indicated that Patient #6 was brought directly to a treatment room and evaluated by an ED Physician.

The ED Physician Record, dated 6/28/12, indicated that patient #6 was examined, diagnostic testing was performed and Patient #6 was diagnosed with an aortic dissection (when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart).

The Triage Assessment, dated 6/28/12, indicated that Patient #6 was assigned an ESI level 3.

The The ESI Version 4 Manual, Chapter 3 (ESI Level 2), Page 19, indicated that patients with chest pain who are hemodynamically unstable and require immediate interventions should be triaged an an ESI Level 1.

The ED Physician record, dated 6/28/12, indicated that Patient #6 was transferred to a tertiary care hospital.

PATIENT #10:

The Triage Assessment, dated 6/1/12, indicated that Patient #10 was transported to the ED from home via ambulance after experiencing grand mal seizure (also known as a tonic-clonic seizure - features a loss of consciousness and violent muscle contractions). The Triage Assessment indicated that Patient #10 had a history of seizure activity and had been recently hospitalized for seizures.
The ESI Version 4 Manual, Chapter 3 (ESI Level 2), Page 20, indicated that all patients with a reported seizure meet ESI level 2 criteria.
The Triage Assessment, dated 6/1/12, indicated that Patient #10 was assigned an ESI Level 3.
The Ongoing Assessment, dated 61/12, indicated that Patient #10 was brought directly to a treatment room and evaluated by the ED Physician.
The ED Physician Record, dated 6/1/12, indicated that diagnostic testing was peerformed, Patient #10 was stabilized and was transferred to an tertiary care hospital for further treatment.

2) The Policy/Procedure titled Triage indicated that nursing documentation standards for triage included documentation of : allergies, medications (should be listed on the medication reconciliation form), pain and alleged/suspected abuse/domestic violence.
PATIENT #2:
The Triage Assessment, dated 5/26/12 at 5:34 P.M., indicated that Patient #2 presented to the ED accompanied by staff from his/her residence, for suicidal ideation with a plan to jump out of a car window.
The Triage Assessment did not include Patient #2's allergy history and he/she was not assessed for pain.
The Secondary Assessment, dated 5/26/12, time not legible, indicated that although Patient #2 felt down, depressed and/or hopeless and had thoughts of killing him/herself over the past two weeks, Patient #2 was assessed as not to be a danger to self or others.
The Ongoing Assessment, dated 5/26/12 at 7:45 P.M., indicated that Patient #2 "was not located in Hall Bed C, ? eloped".
The second Triage Assessment, dated 5/26/12 at 7:56 P.M., indicated that Patient #2 was returned to the ED by ambulance after he/she left the ED and darted in front of a car that resulted in an injury to the left elbow.
PATIENT #5:
The Triage Assessment, dated 7/11/12, indicated that Patient #5 was brought to the ED under a Section 12 (involuntary hospitalization) because he/she was hallucinating and did not feel safe at home.
Review of the Triage Assessment indicated that Patient #5 was not assessed for pain.
The Secondary Assessment, dated 6/28/12 and not timed., indicated that Patient #5's cardiac and neurological assessments were not completed.
The Ongoing Assessment, dated 6/28/12, indicated that the disposition section was not completed.
PATIENT #7:
The Triage Assessment, dated 6/29/12, indicated that Patient #7 was not screened for alleged/suspected physical abuse/domestic violence.
PATIENT #19:
The Triage Assessment, dated 7/5/12, indicated that the mode of arrival, medication history, allergies, pain assessment and abuse screen were not completed.

Based on record review and interviews, the Hospital failed to ensure that triage Assessments, Secondary Assessments, Ongoing Assessments and ED Physician Records were dated, timed and/or signed for 9 of 20 sampled patients (patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #15 and patient #17).

Findings include:

PATIENT #2:
The Triage Assessment, dated 5/26/12, indicated that Patient #2 returned to the ED at 7:56 P.M. and was triaged. The Triage Assessment was not timed or signed.

PATIENT #3:
The Triage Assessment, dated 7/1/12, was not timed.

The Ongoing Assessment, dated 7/1/12, indicated that Patient #3 left without being seen by the ED Physician. The entry was not timed.

The ED Physician Record indicated that Patient #3 left without being seen. The ED Physician Record was not dated, timed, or signed.

PATIENT #4:
The Triage and Secondary Assessments, dated 7/1/12, was not timed.

The Ongoing Assessment, dated 7/1/12, indicated that Patient #4 was brought into a treatment room and security was called. The entry was not timed.

PATIENT #5:
The Triage Assessment, dated 7/11/12, was not timed.

The Ongoing Assessment, dated 6/28/12, indicated that progress notes were entered at 12:40 P.M. and 12:50 P.M. and were not signed.

PATIENT #6:
The Triage Assessment, dated 6/28/12, was not timed or signed.

The Secondary Assessment, dated 6/28/12, was not timed.

PATIENT #7:
The Ongoing Assessment, dated 6/29/12, indicated that progress notes were entered at 4:30 P.M., 3:40 P.M., 3:45 P.M. and 4:18 P.M. and were not signed.

PATIENT #9:
The Triage and Secondary Assessments, dated 5/4/12, were not timed.

PATIENT #15:
The Triage and Secondary Assessments, dated 2/4/12, were not timed.

PATIENT #17:
The Triage Assessment, dated 7/5/12, was not timed or signed.

The Secondary Assessment, dated 7/5/12, was not timed.

The Ongoing Assessment, dated 7/5/12, indicated that a note was entered to indicate that Patient #17 was placed in a treatment room and was triaged in the room. The entry was not timed.

The Surveyor interviewed the ED Medical Director and the ED Nursing Director on 7/16/12 and discussed the prevalence of documentation discrepancies found in the sampled records. The ED Medical Director and ED Nursing Director said that they were aware of the documentation discrepancies through random auditing of clinical records. The ED Nursing Director presented an action plan and said that education to address documentation discrepancies would being 8/1/12.