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Based on review of documents and interview of staff, it was determined the facility failed to ensure staff monitored patients in the Emergency Department (ED) at the frequency required per policy, for nine (9) of twelve (12) medical records reviewed (Patients #2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure can lead to changes in a patient's condition going unobserved and untreated, with possible negative outcomes.


Findings include:

1. Facility policy entitled "Emergency Department/Nursing Documentation", last revised 3/15, was reviewed on 3/15/16.
It revealed, in part, different frequencies of vital sign rechecks and nursing reassessments required according to the Triage Acuity number assigned to the patient (the level of urgency determined by the complexity and/or severity of the patient's condition upon arrival to the ED, with Level 1 indicating the most serious/urgent). It states, in part, "Vital Sign & Reassessment For Triage and ER Nurses, Level 1: Continuous, Level 2: Every 15-30 min., Level 3: Every Hour, Level 4: Every 2 Hours, Level 5: Every 4 Hours."

2. Patient #2's medical record, date of service 2/4/16, was reviewed on 3/15/16, and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed vital signs were obtained at 8:00 p.m. and then at 10:01 p.m. and assessments were completed at 8:01 p.m., and then at 10:00 p.m.

3. Patient #3's medical record, service date 3/3/16, was reviewed on 3/15/16, and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed vital signs were obtained at 10:49 a.m. and then at 12:51 p.m., and assessments were completed at 12:51 p.m. and then at 2:05 p.m.

4. Patient #4's medical record, service date 3/1/16, was reviewed on 3/15/16, and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed vital signs were obtained at 3:53 a.m. and then at 5:54 a.m. A nursing assessment was documented at 4:01 a.m., and no documentation was found of a reassessment prior to the patient leaving the ED for transfer to another facility at 8:51 a.m.

5. Patient #5's medical record, date of service 3/7/16, was reviewed on 3/15/16 and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed vital signs were obtained at 1:23 p.m. and then at 7:03 p.m., and assessments were completed at 11:41 a.m., then at 2:10 p.m., and then at 5:40 p.m.

6. Patient #6's medical record, service date 3/3/16, was reviewed on 3/15/16 and revealed an Acuity Level 2 assigned. Review of Nurse's Notes revealed assessments completed at 12:33 a.m. and then at 1:13 a.m. Later assessments were noted documented at 2:01 a.m. and then at 2:46 a.m.

7. Patient #7's medical record, service date 3/9/16, was reviewed on 3/15/16 and revealed an Acuity Level 2 assigned. Review of Nurse's Notes revealed an assessment completed at 11:05 p.m., and no further documentation was found of a reassessment prior to the patient's leaving the ED for transfer to another facility at 1:38 a.m.

8. Patient #8's medical record, service date 3/7/16, was reviewed on 3/15/16 and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed an assessment documented at 5:30 p.m., and then at 7:21 p.m.

9. Patient #9's medical record, service date 3/7/16, was reviewed on 3/15/16 and revealed an Acuity Level 2 assigned. Review of Nurse's Notes revealed assessments documented at 7:23 p.m. and then at 8:45 p.m.

10. Patient #10's medical record, service date 3/2/16, was reviewed on 3/15/16 and revealed an Acuity Level 3 assigned. Review of Nurse's Notes revealed assessments documented at 5:24 a.m. and then at 7:35 a.m.

11. An interview was conducted with the Chief Nursing Officer on 3/16/16 at 10:45 a.m., at which time all of the above documentation was reviewed. She concurred with all of the above findings, and agreed the staff had not conformed to facility policy.