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Based on staff interview, clinical record review, policy and procedure review, and review of nursing schedules it was determined the facility staff failed to ensure the policy and procedure regarding triage ensured that triage assessments were provided by registered nursing (RN) staff. This affected 2 of 20 patients in the survey sample. Licensed practical nurses (LPN) documented the triage of Patients #6 and #12.

The findings include:

The facility policy and procedure titled, 'TRIAGE OF PATIENTS' was reviewed on 2/8/12. The policy had been developed in February 1994 with a most recent review/revision date of June 2009. The policy stated "All patients are assessed promptly at the triage station or exam room upon arrival in the ED to ascertain their condition and thus prioritize for treatment prior to registration." The policy did not define the qualifications of who could conduct a triage assessment. According to the policy, a "triage person" was to conduct the assessment.

The surveyors toured the emergency department (ED) on the afternoon of 2/7/12, with several hospital staff, including the nurse manager of the ED. During the tour, a surveyor asked the ED manager if nursing staff included both RNs and LPNs. The manager stated both types of nurses worked in the ED. The surveyor then asked if LPNs did triage of patients. Initially the manager stated the RNs did triage, and then clarified the statement to say that LPNs did some of the triaging of patients. The manager also explained that the majority of triage was done at the bedside, rather than in the triage room which was near the front lobby. He stated the goal was to have patients be placed in the ED department as quickly as possible.

The ED manager stated there were usually six nurses assigned to each twelve hour shift. Four nurses were usually assigned to the more acute side of the ED, with two nurses working the fast track, or less acute, area. One RN was assigned to be the charge nurse on each shift.

On 2/8/12 the surveyors received a copy of the ED nursing schedule for January 2012. The schedule included the nursing manager, twenty-one RNs, and five LPNs.

Upon review of the clinical records, the surveyors noted a legend in each record which included the initials, names, and discipline of the staff members involved with that patient. A surveyor reviewed Patient #12's ED record on the afternoon of 2/8/12. The triage of Patient #12 was documented by an LPN. The LPN's initials were on the record, on the legend, and were listed on the schedule as an LPN. Patient #12 arrived to the ED at 2:11 p.m. and was triaged at 2:25 p.m. A triage priority rating of "4", non-urgent, was assigned to the patient. The documentation of triage, listing of medications, and the physical assessment were all documented by the LPN.

Patient #12 was seen by a physician's assistant and discharged to home at 2:40 p.m. The only RN signature on the record was at 6:42 p.m., approximately four hours after the patient was discharged. The RN signed as the "dispositioning nurse".

The survey team met with the ED nursing manager on 2/8/12 at 4:05 p.m. The surveyors asked about the triage process. The manager stated the RN charge nurse was assigned to triage patients on each shift. He stated that if a patient went directly to an ED bed, rather than being triaged in the triage room, other RNs may help with triage if the charge nurse was busy. And, LPNs may triage if the RNs were all busy. If an LPN did the triage for a patient, then an RN was to check the patient to verify the triage information. The RN was to document the verification of the LPN assessment.

The ED manager and surveyors discussed the ratio of RN to LPNs on each shift. The manager stated he tried to have a maximum of two to three LPNs per shift, with a total of six nurses per shift. He stated the reality of staffing was there were times when four LPNs worked a shift with two RNs.

A surveyor asked the nursing manager to review the record for Patient #12. He verified an LPN had documented the triage and assessment for the patient. He explained the RN documentation of disposition was a review to ensure the record was complete; it was not an indication that the RN had assessed or provided care for Patient #12.

The survey team also discussed the facility policy for triage with the ED manager. According to the policy, the "triage person" was to obtain a brief history and to initiate treatment as indicated by the patient's complaints and standing orders. The policy did not indicate that triage was a function to be done by an RN. The ED manager acknowledged the policy did not clarify who was qualified to do a triage assessment. And, the manager acknowledged a triage assessment would be outside the scope of practice for LPNs in the state of Virginia.

The LPN job description for the ED included the following function or responsibility, "assists with triage and direct care of patients". The heading to this duty stated "Attends emergency patients independently and under charge nurse and/or physician direction according to established protocols. Observes and evaluates patients' symptoms, progress, and reactions to therapies, and communicates these to charge nurse or physician as indicated."

The clinical record for Patient #6 was subsequently reviewed. The patient arrived in the ED at 9:38 p.m. According to the staff legend on the record, it was an LPN who did the patient's triage. The chief complaint was chest pain. The LPN documented the priority level as a "2" - emergent, at 9:44 p.m. The physician exam began at 9:45 p.m. The first RN documentation noted on the clinical record was at 11:35 p.m. Patient #6 was admitted to the hospital.