HospitalInspections.org

Based on medical record review and interviews with hospital staff, the hospital failed to ensure the emergency services department (ED) required staff to be trained to provide complete triage assessments for patients presenting to the ED with complaints of head and eye problems. This occurred for two of five patients (Patients # 6 and 9 of Patients #5, 6, 9, 10 and 12).

Findings:

1. Patients # 6 presented to the ED on 05/16/2011 at 2026 with complaints of head/eye trauma with blurred vision. The triage assessment documentation did not reflect/demonstrate the nurse performed a neurological or vision/eye assessment on the patient. The patient left before a medical screening examination, at approximately 0229.

2. Patient #9 presented to the ED on 05/16/2011 at 1828 with complaints of head injury with a possible concussion. The triage assessment documentation did not demonstrate the nurse performed a neurological assessment on the patient. The patient left before a medical screening examination, at approximately 0135.

3. These findings were reviewed, discussed and verified with Staff E and F on 09/27/2011 at 1355.