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Based on medical record review, document review and staff interview, it was determined the facility did not: 1) ensure that systematic corrective measures were implemented to correct identified problems; 2) implement measures to evaluate the effectiveness of training provided to the Emergency Department (ED) providers; 3) ensure ongoing monitoring and evaluation of the performance improvement data collected. This finding was evident in the ED Quality Assurance (QA) report for nursing and medical staff.


Findings include:

Review of the medical record for Patient #1 identified: This 63-year-old male was triaged in the Emergency Department (ED) on 1/12/16 at 3:31 PM, with a chief complaint of left flank pain and was status post fall at home on 1/10/16. The patient's medical condition deteriorated in the ED and he expired on 1/12/16 at 9:24 PM.

The Emergency Department Quality Assurance (QA) report, dated 1/19/16, consisted of nursing and medical reviews of the case, and identified quality of care issues with the care and management of the patient while in the ED. The QA report determined that the standard of care was not met.

The Nursing QA report determined that Patient #1 was not timely evaluated by the nursing staff and changes in the patient's medical condition was not brought to the attention of the ED provider. However, nursing plan of action focused on the two registered nurses involved in the care of the patient (Staff A and Staff B).
The facility did not ensure that systematic corrective measures were implemented.

The Nursing QA notes a plan to review 10 medical records for compliance with timely nursing assessment. The review, however, was limited to February 2016 only. The nursing QA report did not establish a mechanism for ongoing monitoring and evaluation of data collected regarding timeliness of nursing assessments in the ED.


The Medical QA report determined the ED Physician Assistant did not use the "Status Board" to identify his patients and hence, he was not aware that he was assigned Patient #1.
(The Status Board is an electronic board with patients' name and provider assignment).
The facility's corrective action plan included training to the ED providers; however, the plan did not establish a mechanism to monitor the effectiveness of the training provided on the ED workflow and timeliness of medical evaluations.

During interview with Staff C, ED Site Director, on 2/18/16 at 9:00 AM, staff acknowledged these findings and stated that no monitoring activities were in place.

Based on medical record review, document review and interview, in three (3) of 23 patient records reviewed, it was determined the facility failed to ensure that patients presenting to the Emergency Department (ED) receive timely nursing assessment and timely medical evaluation, consistent with the facility's policies and procedures and acceptable standard of practice.

These failures may have placed patients at risk for delayed recognition and treatment of their medical condition, with adverse outcomes.

Findings include:

See: Tag A 1104

Based on medical record review, document review and staff interview, it was determined the facility did not ensure that each patient presenting to the Emergency Department (ED) received a timely medical evaluation and treatment, in accordance with facility's ED policy and procedure. This finding was noted in three (3) of 23 medical records reviewed. (Patient #1, Patient #2, and Patient #3).

Findings include:

Review of the medical record for Patient #1, identified: This 63-year-old male was triaged in the ED on 1/12/16 at 3:31 PM for complaints of status post fall on 1/10/16, and a left flank pain. Vital signs were as follows: Blood Pressure 90/60; Heart Rate 60; Respiratory Rate 16; Saturation 96% on Room Air: patient rated pain at "0" on a numeric pain scale of "1" to "10". The patient was assigned an Emergency Severity Index (ESI) of Level 3. (Level 3 are patients with significant medical problems requiring multiple resources).
The record revealed a late note written by Physician Assistant (PA), on 1/12/16 at 9:31 PM (after patient expired). The PA Note documented his patient evaluation at 8:30 PM. The note stated; during his evaluation of Patient #1 at 8:30 PM, he complained of nausea, vomiting, and lower abdominal pain since last night, denied fever, and chills. The patient was sitting up in bed with vomitus, and while talking to the patient, he became dyspneic, then lethargic, and apneic. A code was called at 9:00 PM; the code was unsuccessful and patient pronounced dead at 9:24 PM.

This patient was triaged by Staff A on 1/12/16 at 3:31 PM, and there is no documented evidence that Patient #1 received a nursing reassessment by Staff B, after she was given a hand- off report by Staff A.
During interview with Staff F, ED Nurse Manager, on 2/17/16 at 2:00 PM, she stated that there is an expectation that when the Primary Nurse receives a "Hand-Off" report from the Triage Nurse, the Primary Nurse should conduct a nursing assessment of the patient and document the assessment in the electronic medical record.

On 1/12/16 at 5:27 PM, approximately two (2) hours after triage, Staff A noted: "The patient is alert and oriented x3, skin cool and moist, ordered EKG (ED Standard order set) and placed on cardiac monitor with sinus rhythm. Patient denies chest pain and dizziness at this time. Vital signs: Blood Pressure 102/70; Heart Rate 66; Respirations 16; and Oxygen saturation 95%."
The EKG result dated 1/12/16 at 6:42 PM identified: Ventricular Rate 90; Normal Sinus Rhythm; Possible Left Atrial Enlargement.
There is no documented evidence that Patient #1 received a medical evaluation by the ED Attending Physician, who read and signed off on the patient's EKG (time of review of the EKG was not documented), and there is no documented communication between the ED Attending Physician and the Physician Assistant, who were responsible for the care and management of Patient #1.

During interview with Staff A (Triage Nurse) on 2/17/16 at 1:00 PM, staff stated that a "Nurse to Nurse Hand-Off report was given to the Primary Nurse (Staff B). She stated that when she observed the patient to be cold and sweating, she ordered EKG and Cardiopulmonary monitor for the patient and notified the Primary Nurse and Charge Nurse of the patient's change in condition.
Although the attending physician read and signed off on the EKG, there was no documented evidence that the patient received a medical evaluation until 8:30 PM, approximately five (5) hours after triage and three (3) hours after Staff A observed "skin cool and moist." During the medical evaluation, the patient had a cardiopulmonary arrest and expired at 9:24 PM.

During interview with Staff C, ED Site Director, on 2/18/16 at 9:00 AM, the staff stated the PA assigned to the patient had not read the Status Board and was not aware that Patient #1 was his patient, and went off duty. The incoming PA evaluated the patient at 8:30 PM.
Staff C was asked what would be the expectation for the care of a patient who is diaphoretic. Staff C stated, "It would have been preferable if the patient was seen by the provider, and the EKG result should have been brought to the attention of the PA responsible for the care of the patient."

Staff A and Staff B did not report significant changes in the patient's medical condition to the provider responsible for the care of the patient, in accordance with the facility policy titled, "Triage and Primary Nursing of Adult and Pediatric Patients in the Emergency Department," last revised 5/2014. This policy notes the following: Primary Nurse responsibility includes direct nursing care and decision-making, communication with patients, families, and members of the health care team, documentation and teaching; Once the triage process has been completed, a nurse to nurse hand-off will be completed ... Reassessment includes a full set of vital signs, a focused assessment based on the chief complaint and pain re-assessment." The policy prescribed reassessment of patient at a minimum of every four hours for ESI Levels 3, 4, and 5.


Review of the medical record for Patient #2, identified: Patient was triaged in the ED on 12/14/15 at 4:57 PM, with a chief complaint of suprapubic pain for the past three days, associated with one episode of vomiting on 12/13/15. The triage nurse noted stable vital signs, and assigned the patient an Emergency Severity Level (ESI) Level of 3.


A Nurse Practitioner (NP) on 12/14/15 at 5:18 PM, noted the patient complained of abdominal pain associated with nausea and dysuria. The NP documented at 5:17 PM an order for "urinalysis and Dipstick with microscopic exam on positive."


On 12/14/15 at 11:55 PM, approximately seven hours after arrival of the patient to the Emergency Department, nurse noted, "Patient called, no response/not in area." The final disposition of the patient on 12/15/15 at 00:29 AM noted, "walked out after medical evaluation."


The NP orders for urinalysis and Dipstick with microscopic exam for a positive result were not implemented. There was no medical evaluation of the patient prior to the time she was noted to have walked out on 12/14/15 at 11:55 PM.


There was no evidence of a nursing assessment after the triage evaluation of the patient at 4:57 PM, in accordance with facility's policy titled, "Triage and Primary Nursing of Adult and Pediatric Patients in the Emergency Department."


At interview with Staff C on 2/17/16 at 2:30 PM, Staff C acknowledged that Patient #2 did not receive a medical evaluation before her departure from the ED and the order by the NP for urinalysis and Dipstick were not implemented.




Review of the medical record for Patient #3, identified this patient was initially evaluated in the ED on 12/14/15 at 01:58 AM, with complaint of vaginal and suprapubic pain. Triage assessment revealed low-level pain, rated at 2 on a numeric pain scale of 1 to 10. The patient was discharged home at approximately 5:33 AM, after physician assessment and the provision of follow up care instructions.

Patient #3 returned to the ED on 12/14/15 at 4:52 PM, with the same complaint of suprapubic pain, but now rated pain at 9. Triage nurse noted the patient was tachycardic (rapid heart beats greater than 100 beats per minute) at 104 beats per minute. The patient was assigned an ESI Level of 3.

ED mid level provider on 12/14/15 at 5:12 PM, documented that the patient was in the ED earlier for the same complaint and was awaiting further evaluation by ED physician. On 12/14/15 at 11:55 PM, nurse noted, "Patient called, no response/not in area."

There was no documented nursing evaluation of Patient #3, after she was triaged on 12/14/15 at 4:52 PM. The ED mid level provider's assessment at 5:12 PM did not include a medical evaluation and the patient's severe suprapubic pain was not evaluated and managed.

The patient presented to the ED at 4:52 PM with severe pain rated at 9 and rapid heart rate (104 beats per minute). No further assessment of the patient is documented until at 11:55 PM when the nurse noted, "Patient called, no response/not in area." This patient left the ED approximately seven (7) hours after arrival with no evaluation or treatment for the pain.

At interview with Staff C, ED Site Director, on 2/17/16 at approximately 2:40 PM, she stated there was no nursing assessment of Patient #3, and she confirmed that a medical evaluation was not conducted.