HospitalInspections.org

Based on medical record review, documentation review and staff interviews, the surveyor determined that the hospital failed to provide sufficient staffing to meet the needs of the patients seeking services in the Emergency Department (ED) as evidenced by extended wait times exceeding greater than four (4) hours for 20 out of 179 patients that presented to the ED on October 2, 2017. (Patient #s 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64,65, and 66).

The findings include:


Hospital policy number ED 600 titled "Staffing of The Emergency Department", reviewed March 2017, section 2 policy stipulates, "The Emergency Department will have a sufficient number of personnel to provide optimal healthcare to patients ...


Personnel coverage will be a total at least 12 on all shifts

i. 7 RN's
ii. 4 EDT's [emergency room technicians]
iii. 1 Unit Coordinator."
Staffing will be adjusted according to the volume and acuity if patients presenting to the Emergency Department ..."


The surveyor reviewed the ED staffing schedule and Daily Assignment Sheets dated October 2, 2017, 7:00 AM to 7:00 PM shift on October 12, 2017 at approximately 2:00 PM.


The surveyor noted that the real-time staffing for the ED on October 2, 2017, the 7:00 AM to 7:00 PM shift reflects, six (6) Registered Nurses (RN) and three (3) ED Technicians from 7:00 AM to 11:00 AM. After 11:00 AM, there were 3.5 ED technicians until 7:00 PM. The RN assigned, as the Charge Nurse for the shift is the ED Nurse Manager. The ED technician that arrived at 11:00 AM works an eight (8) hour shift, 3:00 PM to 11:00 PM.


Further review of staffing revealed the hospital failed to provide sufficient staff on October 3, 4, 6, 7, and 8, 2017 the 7:00 PM and 7:00 AM shift. On October 3, 2017, there were 12 staff. Six (6) RNs. ON October 4, 2017, there was 10 staff, six (6) RNs and four (4) EDTs. On October 6, 2017, there was 11 staff, eight (8) RNs, and three (3) EDTs. On October 7, 2017, nine (9) staff, seven (7) RNs from 7:00 PM to 11:00 PM, at 11:00 PM, RNs eight (8) and EDTs one (1) at 11:00 PM. On October 8, 2017, there were 7 RNs until 3:30 AM, after 3:30 AM five (5) RNs and one (1) EDT for the 7:00 PM shift.


The ED total census for 24 hours, starting October 2, 2017 at 12:00 AM through October 2, 2017 2, 2017 at 11:59 PM was 179 patients. There were a total of 126 walk-in patients; 42 patients arrived by ambulance; two (2) patients arrive by metropolitan police (MPD); one (1) patient Department of Corrections (DOC); 18 patient admissions, three (3) patients left against medical advice (AMA), two (2) patients eloped, one (1) patient left without being seen and 25 patients left before triage (LBT). Eight (8) of the 25 patients that left before triage arrival modes were left blank on the ED log because the patients signed in a left the ED, no information is available on the eight (8) patients.


The surveyor reviewed the ED Patient Log that references the times of the patient's arrival, to the triage nurse, the medical staff time and disposition (discharge time). Twenty patients waited more than four (4) hours for treatment. Listed below is a random sample of ED patients that waited more that four (4) hours.


The patient's time of arrival starts, the triage, medical staff, discharge times and the total ED time (length of stay).


A. Patient 47: arrival time 10:59 AM- chief complaint: a cough, triage wait time 1.78 hours) after arrival, ESI Level 4- Fast Track (FT), medical staff (MD) wait time, 3.76 hours after arrival and discharged 2.15 hrs later (after MD time). Total ED Time: 7.69 hrs


B. Patient 48: arrival time 11:26 AM-chief complaint- Upper extremity problem. Triage wait time 1 hr. 45 min, ESI Level 4- FT, MD wait time 4 hrs. Discharge 45 minutes later. Total ED time 4 hrs. 45 min.


C. Patient 49: arrival time 11:43 AM- chief complaint-Chest pain,- Directly to Core, ESI Level, 3, MD time with patient 8.3 hrs, decision to admit 8.83 hr. Total ED time: 18 hrs. 18 min.


D. Patient 50: arrival time 11:43 AM- chief complaint-Lower Extremity problem, triage wait time 2 hrs. ESI Level 4-FT MD wait time 3.36 hrs, discharge time 39 min later. Total ED time: 5.75 hrs.


E. Patient 51: arrival time 12:05 PM- chief complaint-Assault, triage wait time 2.86 hrs. ESI Level 4- FT, MD wait time 3.61 hrs. Discharge time 2.42 hrs. later. Total ED time: 8.43 hrs.


F. Patient 52: arrival time 1:04 PM- chief complaint- Headache, triage wait time 2.2 hrs., ESI Level 4- FT, MD wait time 3.51 hrs. Discharge time 1.87 hrs. later. Total ED time: 8.38 hrs.


G. Patient 53: arrival time 1:13 PM-chief complaint- Nausea and Vomiting triage time 2.16 hrs. ESI Level 3- FT, MD Time 4.35 hrs, discharge time 1.87 hrs. Total ED time: 8.38 hrs.


H. Patient 54: arrival time: 1:36 PM- chief complaint- Male GU problem. Triage wait time 2.2 hrs., ESI Level 3-FT, MD time 3.88 hrs , Discharge time; 2.43 hrs. Total ED time 8.51 hrs. '


I. Patient 55: arrival time 6:16 PM-chief complaint- Back Pain, Triage time 55 min, ESI Level 4- FT, MD time 3.48 hrs, Discharge time 2.4 hrs. Total ED Time: 6.43 hrs.


J. Patient 56: arrival time 10:45 PM- chief complaint- Medication refill, Triage time 51 min, ESI Level 4- FT, MD time 5.23 hrs, Discharge time, 23 minutes. Total ED time: 5.5 hrs.


K. Patient 57: arrival time 12:30 PM- chief complaint- Motor Vehicle Crash, Triage time: 1.9 hr. ESI Level 4- FT, MD time 2.22 hrs. Discharge Time 1.19 hr. Total ED Time: 5.3 hrs.


L. Patient 58: arrival time: 1:31 PM- chief complaint- Neck Pain, Triage Time 2.11 hrs, ESI Level 4- FT, MD time, 3.77 hrs. Discharge 1.38 hr. Total ED Time: 7.26 hrs.


M. Patient # 59: arrival time: 2:06 PM- chief complaint-Wound Check, Triage Time 2.55 hrs. ESI Level 4-FT, MD time 3.06 hrs. Discharge Time: 37 min, Total ED Time: 6 hrs.


N. Patient #60: arrival time: 2:03 PM- chief complaint-Abscess, Triage Time 2.6 hrs, ESI Level - FT, MD time 2.9 hrs. Discharge time: 3.6 hrs. Total ED Time: 9.1 hrs.


O. Patient #61: arrival time: 2:26 PM- chief complaint- Nausea/Vomiting - Triage Time 2.56 hrs.
ESI Level 4- Core. MD time 3.3 hrs. Discharge Time 5.39 hrs, Total Ed time 11.25 hrs.


P. Patient #62: arrival time: 3:06 PM-chief complaint-Motor Vehicle Crash- Triage Time 2.33 hrs. ESI Level 3 -FT, MD time 2.88 hrs Discharge time 2.02 hrs. Total ED time 7.23 hrs.


Q. Patient #63: arrival time: 4:27 PM- chief complaint-Upper Extremity Problem. Triage time 1.83 hrs. ESI Level 3- Core, MD time 2.2 hrs, Discharge Time 1.72 hrs Total ED Time: 5.75 hrs.


R. Patient #64: arrival time: 4:57 PM-chief complaint-Upper extremity Problem, Triage time 1.48 hrs. ESI Level 3-FT. MD time 2.72hrs. Discharge Time 1.55 hrs .Total ED time 5.95 hrs.


S. Patient #65: arrival time 8:46 PM-chief complaint-Constipation, Triage time eleven (11) minutes. ESI Level 5-Core, Med time 4.4 Hrs. Decision to Admit 10.05 minutes. Total ED time.


T. Patient #66: arrival time: 8:53 PM- chief complaint-Flu Symptoms, Triage Time 19 minutes, ESI Level 4-FT, MD time 3.99 hrs. Discharge Time 2.67 hrs. Total ED Time 2.67 hrs.


All patients were "Walk-ins" except Patient #49 (8870). Patient #49 arrived by ambulance and admitted to UMC.

All patients were "Walk-ins" except Patient 8870. Patient 8870 arrived by ambulance.


The surveyor reviewed the ED Patient Disposition Log on October 12, 2017, at approximately 1:00 PM, which revealed 25 patients left before triage, which means the patient went through a quick registration process or the patient completed the pre-triage form and left before registration.


A pre-triage form is a form that patients complete on entry into the ED. The staff keeps the form on the Patient Concierge's Desk. The ED staff ask the patients to complete the form. The form contains the necessary information, name, date of birth, chief complaint. The registration staff calls the patient to obtain data required to generate a medical record and hospital armband. Once the patient completes quick registration, the ED nurse triages the patient.


The surveyor reviewed the disposition name titled "Left prior to triage" (LPT) which revealed, eight (8) patients have medical records numbers, encounter numbers and arrival times, however, the chief complaint is "To Be Determined", arrival mode not documented and no documented evidence of a ESI Level. The patients LPT.


Further review revealed 12 patients were walk-ins, 10 of the 12 patients were assigned to "Core" [main emergency department] and two (2) patients assigned to Fast Track [section in the emergency room for the treatment of patients with minor illnesses/injuries]. One (1) patient arrived by ambulance, assigned to "Core" and chief complaint "To Be Determined". The patient's chief complaints included Abdominal Pain (two patients), Back Pain, Chest Pain, Female GU Problem, General Problem, Rash, Shortness of Breath, Toothache, Upper Extremity Pain, Sexually Transmitted Infection (STI) and Wound Check. All the patients Left Prior to Triage.


Nursing Services failed to provide sufficient staffing per hospital policy to meet the needs of the patients as evident by twenty patients waiting more than four hours for treatment, 25 patients leaving prior to triage, and two (2) patients eloping.

The surveyor conducted a face-to-face interview with Employee #6 on October 12, 2017, at approximately 11:00 AM and Employee #7 on October 12, 2017, around 2:30 PM.


Employee #6 stated, "The ED was short of staff on October 2, 2017, the 7:00 AM to 7:00 PM shift. The shift was three (3), nurses short. The Nurse Manager was the Charge Nurse, and I floated in and out to assist. I did not take a team because of other obligations. We closed Team B in the Core."


The surveyor asked Employee #6 the number of bays (beds) that is Team B. Employee #6 stated four (4).


The surveyor reviewed the ED staffing policy with Employee #7 on October 12, 2017, at approximately 2:30 PM. Employee #7 stated the current practice is to have a minimum of eight (8) RNs and five (5) ED technicians, especially on Mondays. Monday is the ED's busiest day.


The surveyor questioned Employee #7 about the three (3) nurses that were out. Employee #7 stated the three (3) slots were vacant from the staffing schedule. Three (3) RN's did not call out. One (1) RN and one (1) ED technician called out on a day that the schedule was short of people (October 2, 2017).


The surveyor reviewed the ED staffing policy with Employee #7 on October 12, 2017, at approximately 2:30 PM. Employee #7 stated the current practice is to have a minimum of eight (8) RNs and five (5) ED technicians, especially on Mondays. Monday is the ED's busiest day.


The surveyor questioned Employee #7 about the three (3) staff members that were out. Employee #7 stated the three (3) slots were vacant from the staffing schedule. Three (3) RN's did not call out. One (1) RN and one (1) ED technician called out on a day that the schedule was short of people.


Employees #6 and 7 reviewed and acknowledged the findings on October 12, 2017 at 11:00 AM and 2:30 PM respectively.