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Based on review of hospital policy and a closed medical record review the hospital staff failed to follow the ED triage policy for 1 of 41 patients reviewed (Pt#11).

The findings included:

Review of hospital policy titled "Triage Policy for Adults" revealed an ESI (emergency severity index) triage algorithm. The algorithm revealed when a patient required immediate life-saving intervention they would get triaged as an ESI 1. When a patient presented with a high-risk situation, confused/lethargic/disoriented, or in severe pain/distress they would get triaged as an ESI 2. When patients do not fall into an ESI 1 or 2 level. The number of resources a patient required determined ESI levels 3-5. Two or more resources would get an ESI 3, one resource would get and ESI 4, and no resources would get an ESI 5. When a patient presents with dangerous vital signs, to include heart rate and respiration, further consideration should be made. For a patient 8 years and older a heart rate greater than 100, respirations greater than 20, and an SpO2 less than 92% could warrant an ESI 2.

Closed dedicated emergency department (DED) medical record review of Patient #11 revealed an 83 year old female presented to the ED via EMS on 08/24/2022 at 1956 with neck pain after sneezing. Review of the ED triage note at 2002 revealed " ...Pt (patient) reports that pain is now radiating to head and down arms. No neurological deficits noted, no blurred vision or light sensitivity." Review of the ED vital signs at 2007 revealed temperature 97.8, heart rate 99, respiration 20, blood pressure (BP) 221/113, SpO2 94%, and a neck pain score of 10. At 2009 patient assigned acuity of 4. At 2012 Tylenol 650mg (milligrams) was given orally. Review of the ED nursing note revealed the patient was offered an ice pack and heating pack, the patient declined and stated, "it probably wont work." Review of the triage note at 2104 revealed the patient became unresponsive in the waiting room. Glucose 222. BP 223/115. At 2107 patient assigned acuity 2. Review of the ED nursing note at 2110 revealed the physician assessed the patient at bedside. At 2112 the patient was roomed to ED38. At 2115 the patient status changed to Code Stroke. At 2116 labs, arterial blood gas, ECG, CT head neck angio, CT cervical, and a CT head were ordered. At 2118 an inpatient Neurology consult was placed. At 2128 a chest Xray was ordered. At 2142 NIH Stoke Scale: 27. At 2155 tele neurologist assessed the patient. At 2156 Neurosurgery consult was placed. At 2200 the patient was assigned acuity 1. At 2213 an Endotracheal tube was placed, 7.5mm (millimeter) cuffed. At 2216 ED disposition was set to transfer. At 2223 a CVC triple lumen catheter was placed in the right femoral. At 2248 Protime 10.6 seconds, INR 1.0, and aPTT 24.5 seconds. Review of ED vital signs at 2250 revealed temperature 96.8 bladder, heart rate 88, respiration 20, BP 156/81, and SpO2 94%. Review of a Physician note at 2312 revealed " ...presented initially for neck pain but developed altered mental status ...patient was made a code stroke ... CT head shows large subarachnoid hemorrhage at the skull base, likely aneurysmal ... Neurosurgery recommended airway control and transfer emergently for intervention ..." At 2319 flight crew at bedside. At 2357 high sensitivity Troponin 191. On 08/25/2022 at 0000 the patient was discharged. Review of the grievance received on 09/12/2022 revealed a resolution letter was sent out on 10/26/2022. Review of the SIR event revealed it was entered on 09/29/2022 by risk management.

NC00194349, NC00207728, NC00205597, NC00200341, NC00204911