HospitalInspections.org

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Based on interview, document review, and review of the hospital's policies and procedures, the hospital failed to ensure that emergency care was managed and provided in accordance with professional practice recommendations and hospital policy.

Failure to manage and deliver emergency care in line with professional standards can lead to unsafe and low-quality emergency care.

Findings included:

1. Failure to ensure that staff performed and documented baseline triage, risk screenings, initial assessments, and ongoing assessments according to hospital policy for patient's admitted to the hospital's Emergency Department (ED) for 4 of 5 patients reviewed.

Cross Reference: A1104

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Based on document review and interview, the hospital failed to ensure that staff performed and documented baseline triage, risk screenings, initial assessments, and ongoing assessments according to hospital policy for patient's admitted to the hospital's Emergency Department (ED) for 4 of 5 patient's reviewed (Patient #506, #507, #508, and #509).

Failure to perform baseline and ongoing assessments for patients presenting to the Emergency Department created risk that patients would not receive timely medical treatment appropriate to their care needs and could result in poor patient outcomes or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Nursing Assessment," policy number HS-423.4, revised 01/21, showed the following:

a. In outpatient settings, assessments will focus on presenting or primary problem/need/service and the following parameters may be considered for outpatient assessment as indicated by patient condition:

i. Urgent Care: as indicated by patient need varying from every 15 minutes to every four hours.

b. Patient assessment and reassessment will be documented in HealthConnect or PICIS and according to departmental documentation guidelines.

Document review of the hospital's policy and procedure titled, "Documentation Standards in Urgent Care," no policy number, approved 10/15/20 showed the following:

Triage:

a. A designated Triage Registered Nurse (RN) will record a triage assessment of all patients as they present.

b. All findings will be entered into the electronic medical record (EMR)

c. Assignment of an emergency severity index (ESI) rating occurs when triaging patient based on chief complaint and physical findings.

d. Key Points include the following:

i. Chief complaint, history of present illness/injury, subjective and objective findings.

ii. Allergies, current medications, tobacco, drug and alcohol use, immunization status, fall risk assessment and pregnancy status for women of childbearing age.

iii. Suicide Risk Assessment as indicated (based on chief complaint and patient assessment).

iv. Complete vital signs, pain rating and weight on all patients.

Nursing Care

a. Consists of physical assessment, ongoing assessments, interventions, and responses.

b. All care will be documented in the patient's medical record timely and accurately.

c. When Vistal Signs (VS) are completed these include blood pressure, respiratory rate, and oxygen saturation. Temperature will be completed based on chief complaint and as clinically indicated based on physical finding.

d. Key Points for ESI Level 2 patient include the following:

i. An initial Physical Assessment that included airway, breathing, circulation, disability, exposure/environment, and a full set of vital signs.

ii. A complete physical assessment during the visit once stabilized.

iii. Vital Signs every 15 minutes as needed based on clinical presentation but no less frequently than every hour.

e. Key Points for ESI Level 3 patient include the following:

i. A focused Physical Assessment based on chief complaint.

ii. A more thorough exam based on patient findings and status.

iii. Vital signs no less frequently than every 2 hours during the urgent care visit.

f. Ongoing assessments and reassessments are based on chief complaint, physical findings, and interventions.

g. Rounding on all patients is encouraged to be done hourly with supporting documentation.

h. Document all orders completed and performed.

i. Document patient response to interventions and treatments.

Discharge

a. All patients discharged from the urgent care will have the discharge status entered in to the EMR. including an updated set of vital signs, IV removal, and the status of the patient at discharge.

2. On 01/25/22 at 4:00 PM, Surveyor #5, the Urgent Care Manager (Staff #507) and a Registered Nurse (RN) (Staff#506), reviewed the medical record for patient #506 who was receiving care in the Emergency Room/Urgent Care. The review showed the following:

a. Patient #506 arrived at the Emergency Department on 01/24/23 at 4:20 PM, for the treatment of shortness of breath. The patient received a focused lung, cardiac and neuro assessment at that time.

b. On 01/25/23 at 5:11 PM, the patient's oxygen was increased to 3 Liters per minute via nasal canula. At 8:15 PM, the patient's oxygen was increased to 5 Liters per minute via nasal canula, and at 11:20 PM, the oxygen was decreased to 4 liters per minute via nasal canula.

c. On 01/26/23 at 6:34 AM, the patient's blood pressure was 84/50 mm/hg, and he received a fluid bolus. At 7:06 AM, his blood pressure decreased again to 75/59 mm/hg and his oxygen saturation was 85%. His oxygen was increased to 4 Liters per minute nasal canula. At 7:27 AM, his blood pressure was 106/68 and he continued on oxygen at 4 Liters.

From 01/24/23 at 4:20 PM until the time of the review 01/25/23 at 4:00 PM (a period of 23.5 hours) Surveyor #5 found no evidence the patient received an initial complete physical assessment or any reassessment when a change in status and treatment occurred, at the change of shift when a new nurse took over care of the patient on 01/24/23 on the night shift or 01/25/23 on the day shift, or per the maximum time allowed by hospital policy of every 4 hours (6/6 missing assessments/reassessments). Surveyor #5 found no evidence of suicide, infection, or fall risk screenings.

3. At the time of the review, the Urgent Care Manger confirmed the finding and stated that the staff should reassess patients each shift.

4. On 01/25/22 at 4:25 PM, Surveyor #5 and a Registered Nurse (RN) (Staff#506) reviewed the medical record for patient #507 who was receiving care in the Emergency Room/Urgent Care. The review showed the following:

a. Patient #507 arrived at the Emergency Department/Urgent Care on 01/24/23 at 1:41 PM, for the treatment of shortness of breath and left calf pain. His blood pressure was 164/87.

Surveyor #5 found no evidence the patient received a Triage Assessment or risk screenings.

b. On 01/24/23 at 4:45 PM, the patient's blood pressure increased to 127/103 mm/hg. At 5:56 PM, the patient's blood pressure increased to 154/100 mm/hg and his pulse was 118 beats per minute.

From 01/24/23 at 1:41 PM until the time of the review 01/25/23 at 4:30 PM (a period of 26 hours and 41 minutes) Surveyor #5 found no evidence the patient received a triage assessment, an initial complete physical assessment, any reassessment when a change in status and treatment occurred, reassessment at the change of shift when a new nurse took over care of the patient on 01/24/23 on the night shift or 01/25/23 on the day shift, or per the maximum time allowed by hospital policy of every 4 hours (8/8 missing assessments/reassessments).

5. At the time of the review, Staff #506 and #507 verified the finding and stated that there was a gap in practice.

6. On 01/26/23 at 2:00 PM, Surveyor #5, a Registered Nurse (RN)(Staff #506), and the Urgent Care Nurse Manager (Staff #507), reviewed the discharge medical records for Patient #508 and #509 who had received care in the hospital's Emergency Department/Urgent Care for more than 4 hours. The review showed the following:

a. Patient #508 arrived at the Emergency Department/Urgent Care on 01/20/23 at 6:37 PM, for the treatment of heartburn, dizziness and dehydration. The patient was discharged on 01/21/23 at 8:44 PM.

b. The patient received a Triage Assessment at 6:54 PM. The patient was placed in a bed and assessed by a nurse on 01/20/23 at 11:30 PM. The patient received a focused respiratory and cardiac assessment on 01/21/22 at 6:00 AM (a period of 6.5 hours)

Surveyor #5 found no evidence the patient received a complete physical assessment, the patient was reassessed per the maximum time allowed by hospital policy of every 4 hours from 01/20/23 at 11:30 PM, until a focused respiratory and cardiac assessment on 01/21/22 at 6:00 AM (a period of 6.5 hours), or received a fall risk assessment.

Surveyor found no evidence the patient received a complete physical assessment or any further reassessment after 01/21/22 at 6:00 AM (a period of 14 hours and 44 minutes).

c. Patient #509 arrived to the Emergency Room/Urgent care on 01/12/23 at 3:36 PM, for the treatment of bilateral leg cellulitis and a leg wound. The patient was discharged on 01/13/23 at 1:41 PM.

d. The patient received a focused neurologic assessment on 01/13/23 at 1:00 PM.

Surveyor #5 found no evidence the patient received a physical assessment, reassessment per hospital policy, any wound assessment, or fall risk assessment for a period of 22 hours and 5 minutes.

7. At the time of the review, Staff #506 verified the findings and verified the hospital's policy to reassess every 15 minutes to every 4 hours based on patient's clinical presentation.

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