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Based on facility policy and procedures review, record reviews, and staff interviews, the facility failed to follow their own triage policy as evidenced by fifteen of thirty patient records reviewed in which no comprehensive assessment was performed within one (1) hour of entering emergency department.

Findings include:
Review of thirty Emergency Department (ED) records, which included a transfer, four (4)patients that left without treatment, and the 12 that had a level of three (3) or higher revealed the following: Fifteen patients' did not have a triage assessment as defined in the facility Policy #1, entitled, " PP-ED-4/Triage/Assessment/Reassessment in the ED " , with a revision date of " 01/12". Patient numbers #1, #2, #6, #7, #10, #11, #12, #17, #18, #19, # 20, #21,#23, #24, and #27 had a triage consisting of 1-4 minutes with no nursing observations. All of these patients were in the ED more than an hour and none of the fifteen received a comprehensive assessment. The other fifteen records did not go to triage, they by passed it.
Interviews with the ED staff confirmed they did not know the triage and medical screening policy. This was confirmed by the Nurse Manager of the ED during an interview on 05-04-12 at 2:20 p.m. in the presence of the Chief Nursing Officer (CNO).

Review of the aforementioned policy, (Policy #1), entitled, " PP-ED-4/Triage/Assessment/Reassessment in the ED " , with a revision date of " 01/12", revealed the definition of Triage Assessment is: "The dynamic process of sorting, prioritizing, and assessing the patient. It is performed by a qualified registered nurse at the time of presentation and before final registration."
Review of Policy #1 revealed: Patients waiting for the initiation of the Medical Screening Exam (MSE) shall be reassessed according to these guidelines: for example: Level 3/Urgent: Every 60-90 minutes.

Further review of Policy #1 revealed the following: Triage Assessment: Visual assessment will be done within 10 minutes of arrival to the Emergency department. Triage consists of information which is obtained that would enable the triage RN to determine minimal acuity. Either a rapid assessment and/or a comprehensive assessment should be performed to accomplish this function. If a rapid assessment is completed, the comprehensive assessment must be completed within one hour of the patient ' s arrival.

Based on document review, staff interview, and policy and procedure review, the facility failed to provide an appropriate triage assessment and a timely medical screening in fifteen of thirty patient records reviewed. (Patient #1, #2, #6, #7, #10, #11, #12, #17, #18, #19, #20, #21, #23, #24, and #27 )
Findings include:
Review of Policy #1, entitled, " PP-ED-4/Triage/Assessment/Reassessment in the ED " , with a revision date of " 01/12", revealed the definition of Triage Assessment is as follows: "The dynamic process of sorting, prioritizing, and assessing the patient. It is performed by a qualified Registered Nurse (RN) at the time of presentation and before final registration. If the RN does a rapid assessment, a comprehensive assessment must be done within one (1) hour of triage."
Review of Policy #1 revealed: Patients waiting for the initiation of the Medical Screening Exam (MSE) shall be reassessed according to these guidelines: for example: Level 3/Urgent: Every 60-90 minutes.

Further review of Policy #1 revealed the following: Triage Assessment: Visual assessment will be done within 10 minutes of arrival to the Emergency department. Triage consists of information which is obtained that would enable the triage RN to determine minimal acuity. Either a rapid assessment and/or a comprehensive assessment should be performed to accomplish this function. If a rapid assessment is completed, the comprehensive assessment must be completed within one hour of the patient ' s arrival.
Fifteen of thirty patients reviewed did not receive observations by the RN and also did not receive comprehensive assessments. They were all triaged as a Level 3 (three), urgent not emergent. The triage for these 15 patients lasted from 1-4 minutes as noted in the medical records.
Listed below are the findings for the aforementioned 15 patients:
Patient #1:
The patient, a 2 year old child, left the Emergency Department (ED) without treatment, Arrived at 16:04 and was triaged at 16:08, the child presented vomiting, vital signs within normal limits. There were no observations or comprehensive assessment until the patient called at 18:38. Chart states called for the third time, no answer.
Patient #2:
Patient #2 entered the hospital at 14:07 and was triaged from 14:11 to 14:13 (two minutes). The Triage RN documented vital signs again at 16:44. This was 2 (two) hours and 34 minutes after the first vital signs were taken. No observations or comprehensive assessments were noted. The patient's pain level is documented as 8/10 on both sets of vital signs. The record reflects the patient told the RN she had just had a kidney removed and was in pain and nauseated. No documentation of the wound or of bowel sounds etc. The patient was called to come to the back for a medical screening at 19:41. The patient had left the hospital at 17:30 based on a telephone interview and at 18:45 per written complaint.
Patient #6:
Triaged 16:37-16:40 and declared a Level 3 (three), with no comprehensive assessment was documented. The patient was in a motor vehicle accident. The Medical Screening Exam (MSE) was performed at 19:58. (three hours and 18 minutes from triage ) The second set of vital signs were taken at 18:42. There were no observations noted. Patient's complaint: was neck pain.
Patient # 7:
The patient was a 71 year old female who arrived on 04-20-12 at 16:27. She was in a motor vehicle accident and was triaged as a Level 3 at 16:35. There was no comprehensive assessment conducted within one (1) hour and there were no observations at triage documented. The patient's vital signs were taken at 16:35, 18:27, and 20:58. The MSE was conducted at 20:08. Diagnosis (Dx) for this patient was multiple trauma. Dx: Back sprain, chest wall contusion, liver injury, sprained or fractured extremity. Pain scale 8 of 10 . No observation of patient from 16:35 to 18:37 and saw the physician at 20:08. The patient was discharged home.
Patient #10:
The patient entered the facility at 11:04 on 04-20-12 with a pain level 10/10. She has sickle cell disease. She was triaged at 11:06 at a Level three. No observations noted other than stated pain level. There was no comprehensive assessment documented within one (1) hour after triage. Vital signs were taken additionally at 14:18 and 15:26 p.m. Patient #10 had a MSE at 18:35, Her HCT (Hematocrit) was 25.4 , WBC (White Blood Count) was 20,000, K+(potassium) was 3.1, her Segmented Neutrophils were 73 and Bands were 9 . She immediately grew out gram negative organism. Her Reticulocyte count indicated sickling cycle. She waited 6 (six) hours and nineteen minutes for a MSE and pain medication. She was admitted to the hospital.
Patient #11:
The patient arrived at 10:21 a.m. on 04-20-12 with a pain level of 5/10. The patient was triaged at 10:27 a.m. There were no observations documented. There was no comprehensive assessment documented an hour after triage. The MSE was conducted by the physician at 13:55. There was no nursing documentation or observation from 10:27 until 14:56. The patient was triaged as a Level 3 and was discharged home at 14:57.
Patient #12:
The patient arrived on 04-20-12 at 09:23 a.m. and was triaged at 09:30 a.m. Patient #12 had been vomiting for three (3) days. The patient had a MSE at 14:24. (5 hours and one minute after entering the ED) The patient was then admitted to the hospital. There were no nursing observations or comprehensive assessment within one hour documented in the record.
Patient #17
The patient arrived on 04-20-12 at 12:56 with pain of 9/10. Patient #17 was triaged from 12:59 to 13:00. (one minute), Patient #17 complained of abdominal pain, stating it had been going on for past two (2) weeks. There was no documented evidence of observation or comprehensive assessment on patient from 13:00 till 15:50. The MSE was performed at 16:07.
Patient # 18:
The Patient left without treatment after waiting for three (3) hours. She arrived at 12:27 on 04-20-12. She was triaged 12:33. Her complaint was dizziness. When she was called at 15:17 for an MSE, she was gone. No reassessment was done after one (1) hour.
Patient #19:
The patient entered the ED at 12:51 on 04-20-12. She was triaged at 12:52. Vitals were taken again at 14:23. There was no comprehensive assessment done within an hour and there were no nursing observations. The patient's pain scale listed as 10/10. The MSE was conducted at 15:49.
Patient #20
The patient arrived at 10:26 a.m. on 04-20-12. Patient #20 had been confused for five (5) days. The patient was triaged at 10:36 a.m. as a Level 3. The next RN note was at 14:19. The physician saw the patient at 15:34 for a MSE. There were no observations or comprehensive assessment performed on this patient within one (1) hour of triage. Patient #20 was admitted to the hospital.
Patient #21
The patient entered the ED at 13:19 on 04-20-12. The patient had fallen and was experiencing lower back pain. Patient #21 was triaged at 13:30 p.m. Vitals were also taken at 15:41 and 18:25. Patient had a MSE at 19:23. (6 hours and 4 minutes) No comprehensive assessment was conducted. Patient #21 received Dilaudid for pain after MSE.
Patient #23
The patient was triaged at 13:05 on 04-20-12. Complaint was swelling in left orbital area. The MSE was conducted at 16:29. No other observations were conducted prior to that time and no comprehensive assessment within one (1) hour.
Patient # 24
On 04-27-2012, the triage was conducted at 12:25. The MSE was conducted at 14:10. The patient did not have observations within one (1) hour after triage. (several charts were chosen to see if different triage nurses were following the policy for triage and medical screening exam.)
Patient #27
The patient left without treatment. Patient #27 was triaged at 13:21-13:22. The RN rechecked the patient's vitals at 15:40. The patient was called for a MSE at 18:30 p.m. but she had already left. (5 hours and 7 minutes after triage)
In an interview on 05-04-12 with the CNO, it was confirmed that the facility realized there was a systems problem and they were working with the performance improvement coordinator, who also is involved in risk management, and the ED nurse manager to get this problem resolved as quickly as possible. She stated they had recognized the problem on 05-01-12 when the surveyor was there and had started on it then.
The Performance Improvement Coordinator had performed a root cause analysis and provided a copy of those findings to the surveyor. Some of the findings were:
1. There is no specific job description for the triage nurse.
2. The ED employees did not or were not able to verbalize the facility policies for triage and medical screening.
3. No true assessment was being done at triage and when vital signs were retaken, it was two hours after the first set. No observations were noted. LPNs and technicians were taking the second set of vitals.
4. The physicians were telling the nurses they did not want any more patients brought back. (root cause analysis included in the packet)
5. Chief complaint is not driving physical assessment in triage.
6. Too long from triage time till MSE
7. Lack of communication between the meter/greeter and triage personnel
In an exit conference at 4:30 p.m. on 05-04-2012, the Administrator stated after the findings were revealed, this will be fixed. No further documentation was provided at that time.