HospitalInspections.org

Based on findings from document review and interview, nursing reassessments of a toddler (Patient A), who presented to the emergency department (ED) following a 6 foot fall onto her head, did not occur 1) within 30 minutes of the triage assessment, 2) following physician evaluation of the patient and 3) prior to discharge, as required per generally accepted standards of emergency nursing care and facility policy.

Findings include:

--Per review of the medical record (MR) of Patient A, she was triaged in the ED at 18:59 as a level III (in a system where I is most urgent and V is least urgent) following a 6 foot fall onto her head, landing on her chin, approximately 2 hours prior. Complaints included a headache, lethargy and bitten lip. Triage assessment included pulse 116, respirations 18, and temperature 97.4. She was awake, alert and oriented. The physician evaluated the patient at 20:15. A CT scan was ordered at 20:20. The CT scan revealed no acute intracranial hemorrhage, mass effect, midline shift, or acute calvarial fracture. The patient was discharged at 22:10.

--Per review of the facility policy and procedure (P&P) entitled "Triage," last revised 9/26/07, it states," ...The charge (triage) nurse is responsible for monitoring and reassessing ED patients waiting for evaluation/treatment in the waiting room ...The RN will interview ...relevant past medical history, medications, last tetanus, visual acuity and pain scale ...Complete a limited physical assessment appropriate for the complaint, including: A full set of vital signs including blood pressure on all patients 3 years and older ..."

Additionally, the P&P requires that patients identified as a level III triage category are to be reassessed by a registered nurse (RN) every 30 minutes.

--However, per review of the MR, a blood pressure was not obtained at triage and reassessment by nursing staff did not occur during the 75 minutes that elapsed from time of triage to physician assessment. Further, following the physician evaluation recorded in the MR, there is no indication that a nurse was involved in the patient's care until the time of discharge. Even then, only discharge instructions were documented. There is no indication nursing staff performed an assessment of the patient just prior to discharge.

--During interview of the Director of Quality Resources Risk Management on 9/10/10, he/she verified that there should have been, but was not, documented reassessments of the patient following triage as well as just prior to discharge. In addition, he/she could not determine from the MR what nurse had been assigned to this patient in the ED.