HospitalInspections.org

Based on a review of documentation, clinical records and an interview with staff, the director of nursing failed to be responsible for the operation of the nursing service.

Findings were:

Patient #1 presented to the emergency department of SMC on 12-31-18 at 5:48 pm. Her arrival complaint was "post op complaint". An update to her chief complaint stated simply "+ neck pain (ran out of her pain meds)". Patient #1 was triaged beginning at 5:49 pm. The clinical record for patient #1 contained no other documentation regarding the patient's complaint to include such information as the date of her surgery or what type of surgery the patient had undergone. Her vital signs (taken at 5:54 pm) were within normal limits with the exception of her temperature, which measured 99.6 Fahrenheit, orally. Patient #1 stated that her pain level was an 8 on a 0-10 pain scale. Patient #1 was assigned an ESI (emergency severity index) level V and placed in the waiting room.

**In email correspondence with patient #1, patient #1 stated that she had undergone surgery on 12-8-18.**

Patient #2, a 2-year-old male, presented to the emergency department of SMC on 12-31-18 at 7:12 pm. He was triaged immediately with an arrival complaint of "cough, congestion". The triage process was completed at 7:23 pm and patient #2 was assigned an ESI level V and placed in the waiting room. Patient #2 was then placed in a triage room at 7:45 pm and seen by the physician assistant at 7:52 pm. A rapid strep[tococcus] screen and flu screen were ordered. Patient #2 was discharged from the emergency department at 7:58 pm.

Patient #1 left the emergency department without being seen at 8:50 pm, approximately 3 hours after being triaged.

In an interview with staff #1 on 2-26-19, staff #1 was asked if the electronic health record for patient #1 contained any additional documentation by the triage nurse to include any further assessment of patient #1's chief complaint other than "post op complaint ...+neck pain (ran out of her pain meds". After a search through the electronic record, staff #1 stated that no additional documentation was present.

Facility policy 6231-030 titled "Triage Protocols in the Emergency Department" states, in part:
"Policy:
All patients presenting in the Emergency Department shall be evaluated and triaged by a registered nurse to determine their complaint, assess their condition, determine the priority for receiving a medical screening examination, assign a triage priority, initiate treatment when appropriate and monitor according to the standards set forth by the triage priorities."

Facility policy 6231-038 titled "ED Nursing Assessment Documentation" states, in part:
"Policy:
...All patients will have a Nursing Assessment completed during their ED stay ..."

Facility policy 6231-020 titled "Classification of Patients" states, in part:
"Procedures:
A patient is classified through the process of triage. Triage is a brief clinical assessment that is used to determine the time order sequence and area of the Emergency Department in which the patient will be seen. This is generally based on a brief evaluation of the patient and assessment of the vital signs. In addition the patient's overall appearance, history of illness/injury and mental status are considered in the triage decision.
...
Level IV Less Urgent (Semi urgent)
Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours.

Level V Non Urgent
Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration. The investigation or interventions for some of these illnesses or injuries could be delayed."

The above was confirmed in an interview with the Quality Resources nurse and the Assistant Quality Director on the afternoon of
2-26-19.