HospitalInspections.org

Based on facility document review, policy review, medical record review, and interview, the facility failed to ensure a patient received ethical, high-quality, safe and professional care when presenting to the emergency department for medical treatment for 5 of 5 (Patient #1, 2, 3, 4, and 5) sampled patients.

The findings included:

1. Review of the facility "Patient Guide," revealed, "...Rights & [and] responsibilities...Considerate and respectful care...To receive ethical, high-quality, safe and professional care without discrimination..."

2. Review of the facility policy, "Triage Assessment, Acuity Levels and ED [Emergency Department] Reassessment Guidelines," revealed, "...All patients presenting to the emergency room are assessed using a RAPID Triage methodology to determine the severity of the presenting chief complaint. A Triage Acuity Level is assessed to each patient using the Emergency Severity Index 5 Level (ESI) during the initial assessment...Rapid Triage Assessment-The Rapid Triage Assessment is a dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN [registered nurse] at the time of presentation and before registration. Rapid Triage Assessment should be done within 10 minutes of arrival to the emergency department. Rapid Triage consists of information that would enable the Triage RN to determine a minimal acuity. The rapid triage assessment includes airway, breathing, circulation and disability, general appearance, symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent/caregiver ...The Rapid Triage Assessment includes, but is not limited to...Date/Time of Arrival in the ED...Reason for Visit as STATED BY THE PATIENT...Pertinent subjective and objective data collection...Airway, Breathing, Circulation, Disability...Any vital sign(s) and pain evaluation needed to determine acuity level...Chief Complaint...Acuity Assignment..."

3. Medical record review revealed Patient #1 presented to the ED on 5/18/2022 at 8:31 AM with a stated complaint of flu symptoms for the past 5 days.

RN #1 documented on 5/18/2022 at 8:34 AM that Patient #1 reported fever greater than 100.4 degrees Fahrenheit (F), cough not related to allergy or chronic obstructive pulmonary disease (COPD), cough with blood produced, sore throat, night sweats, unexplained weight loss, fatigue, body aches, rash, and nasal congestion unrelated to allergies or sinus infections in the last 7 days. RN #1 documented Patient #1 reported persistent cough greater than 3 weeks and having a fever and shortness of breath.

Patient #1 left the ED on 5/18/2022 at 9:44 AM (1 hour 13 minutes after arrival) prior to triage.

Patient #1 presented to a free-standing ED of Hospital #2 on 5/18/2022 at 10:08 AM with chief complaints of upper respiratory congestion, cough, headache, general malaise, ear pain, and throat pain since 5/14/2022. Patient #1 was diagnosed with Otitis Media and Upper Respiratory Infection and was discharged home on 5/18/2022 at 11:24 AM. Patient #1 was given a prescription for Azithromycin 250 milligrams tablet and instructions to take 2 tablets daily for 1 day and then 1 tablet daily for 4 days.

There was no documentation an RN conducted a rapid triage assessment including pertinent subjective and objective data collection, airway, breathing, circulation, disability, vital signs, pain evaluation, chief complaint, or acuity assignment for Patient #1 during the ED visit.

4. Medical record review revealed Patient #2 presented to the ED on 5/18/2022 at 8:52 AM with a stated complaint of positive test for the flu, vomiting blood, and blood coming out of both his ears.

RN #1 documented on 5/18/2022 at 8:53 AM that Patient #2 reported fever greater than 100.4 degrees Fahrenheit (F), sore throat, night sweats, unexplained weight loss, fatigue, body aches, rash, and nasal congestion unrelated to allergies or sinus infections in the last 7 days. RN #1 documented Patient #2 reported having a fever and shortness of breath.

RN #2 documented a blood pressure (124/72) at 9:46 AM (54 minutes after arrival to the ED), vital signs (temperature 99.1 degrees F, pulse 99, respiratory rate 16, blood pressure 116/67, and oxygen saturation 97%) at 9:48 AM (56 minutes after arrival to the ED) and the rapid initial assessment at 10:01 AM (1 hour 9 minutes after arrival to the ED).

There was no documentation an RN conducted a rapid triage assessment including pertinent objective data collection, airway, breathing, circulation, disability, vital signs, pain evaluation, chief complaint, or acuity assignment for Patient #2 within 10 minutes of arrival to the emergency department.

5. Medical record review revealed Patient #3 presented to the ED on 5/18/2022 at 8:57 AM with a stated complaint of left rib pain from a motorcycle accident 2 days ago.

Patient #3 left the ED on 5/18/2022 at 10:22 AM (1 hour 25 minutes after arrival to the ED) prior to triage.

There was no documentation an RN conducted a rapid triage assessment including pertinent subjective and objective data collection, airway, breathing, circulation, disability, vital signs, pain evaluation, chief complaint, or acuity assignment for Patient #3 during the ED visit.

6. Medical record review revealed Patient #4 presented to the ED on 5/18/2022 at 9:04 AM with a stated complaint of abdominal pain for 2 days.

RN #3 documented the rapid initial assessment on 5/18/2022 at 10:03 AM (59 minutes after arrival to the ED) including a pain assessment (Patient #4 rated the pain as a 10 on a 0-10 pain scale), acuity assignment of ESI 3/Urgent, and vital signs (temperature 98.5 degrees F, pulse 71, respiratory rate 18, blood pressure 139/102, and oxygen saturation 100%).

There was no documentation an RN conducted a rapid triage assessment including pertinent subjective and objective data collection, airway, breathing, circulation, disability, vital signs, pain evaluation, chief complaint, or acuity assignment for Patient #4 within 10 minutes of arrival to the emergency department.

7. Medical record review revealed Patient #5 presented to the ED on 5/18/2022 at 9:15 AM with a stated complaint of flu symptoms for the past week.

RN #1 documented on 5/18/2022 at 9:16 AM that Patient #5 reported fever greater than 100.4 degrees Fahrenheit (F), cough not related to allergy or chronic obstructive pulmonary disease (COPD), cough with blood produced, sore throat, night sweats, unexplained weight loss, fatigue, body aches, rash, and nasal congestion unrelated to allergies or sinus infections in the last 7 days. RN #1 documented Patient #1 reported persistent cough greater than 3 weeks and having a fever and shortness of breath.

Patient #5 left the ED on 5/18/2022 at 9:45 AM (30 minutes after arrival) prior to triage.

There was no documentation an RN conducted a rapid triage assessment including pertinent subjective and objective data collection, airway, breathing, circulation, disability, vital signs, pain evaluation, chief complaint, or acuity assignment for Patient #5 during the ED visit.

8. During an interview on 7/6/2022 at 8:41 AM, the ED Director stated the ED had a trained medic or nurse assigned to the ED lobby who would get vital signs on the patients who were not immediately brought back to a room. The ED Director stated the person assigned to the ED lobby would typically get vital signs within 15 minutes of arrival to the ED. When shown the medical record for Patient #1 who was in the ED for 1 hour 13 minutes before leaving and had no vital signs or rapid triage assessment documented, the ED Director stated, "this is not typical."