HospitalInspections.org

Based on interviews, medical record and document review, the acute care hospital's administrative staff failed to ensure the nursing staff completed and documented ongoing assessments for 1 of 1 patients (Patient #1) who presented to the Emergency Department (ED) for an evaluation of a painful and swollen left eye. Failure of the nursing staff to complete and document ongoing assessments could potentially result in the nursing staff failing to identify changes in a patient's condition that would indicate a worsening infection or bleeding in Patient #1's eye which could potentially cause further harm. The hospital's administrative staff identified a average of approximately 71 patients per day in this ED.

Findings include:

1. Review of the policy "Emergency Department Standards of Practice Care and Documentation Guidelines", last reviewed 3/9/21, revealed in part:

--The purpose of this policy is to provide a structured and systematic method for the delivery and the documentation of ED nursing care. It is the responsibility of the ED RN to complete and accurately document nursing care provided.

--Emergency Severity Index Level 3 (ESI Level 3 defined as a stable patient, with multiple types of resources needed to investigate or treat, such as lab tests, X-ray imaging) requires the patient to have vitals at least every 2 hours and as needed. Patient face-to face interaction should occur and be documented at least every 60 minutes to assess for safety.

--Abnormal vital signs, for example a systolic blood pressure greater than 180 (systolic blood pressure refers to the pressure in the arteries when blood is pumped out of the heart, normal systolic blood pressure is 120 or lower) require follow-up assessment and should be reported to the ED provider.


2. Review of Patient #1's medical record revealed the following in part:

On 9/28/21 at 11:40 AM, Patient #1 arrived via ambulance from a skilled nursing facility. RN A noted Patient #1 had a left eye infection that had been ongoing for two weeks and was getting worse despite medications. Triage was started at 11:42 AM.

On 9/28/21 at 3:16 PM, RN B completed triage, noted Patient #1 had arrived from a skilled nursing facility, and complained of left eye pain. Their left eye was crusty and Patient #1 was unable to open that eye. Patient #1 was triaged as an ESI 3.

ED staff failed to document any vital signs, face to face interaction, or assessments between 11:40 AM arrival and 3:16 PM when triage was completed as required by policy.

On 9/28/21 at 7:42 PM, Patient #1 signed the document, "Refusal for Treatment" because Patient #1 had been waiting too long in the ED.

On 9/28/21 at 9:29 PM Patient #1 had left without being seen after triage, and RN C documented that Patient #1 had been discharged. ED staff failed to document any further vital signs, face to face interactions, or assessments for over 6 more hours (from 3:16 PM when triage was to completed, to 9:29 PM when Patient #1 left the ED) as required by policy.


3. During an interview on 10/21/21 at 9:00 AM, RN A recalled Patient #1 had been brought in by ambulance around 11:40 AM. RN A noted Patient #1's complaint, got report from ambulance staff, and had Patient #1 go to the waiting room because there were no open rooms in the ED. Triage was completed around 3:00 PM and again Patient #1 was sent to the lobby because there were no open rooms. RN A confirmed that hospital policy for ongoing monitoring of Patient #1 should include vitals signs every two hours, assessments and rounding.


4. During an interview on 10/25/21 at 10:00 AM, RN C recalled that Patient #1 was "on the board" (meaning they were waiting to be seen by the ED provider). RN C recalled printing labels for Patient #1 with an intent to go do rounds and get their vitals, but then RN C got sidetracked with other tasks. RN C could not recall policy specifically but stated their personal practice for people in the waiting room is to get vitals every two hours.

RN C stated when they came on shift around 3:00 PM they only got information on patients who were a higher acuity level but did not get specific information on every patient who was in the waiting room. RN C did not recall documenting that Patient #1 was discharged, and did not have any recollection of how Patient #1 left the ED, or where they went after leaving the ED.


5. During an interview on 10/25/21 at 11:30 AM, ED Manager and ED Executive Director confirmed that Patient #1's medical record did not contain documentation of the assessments and monitoring required while Patient #1 was in the hospital's ED.