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Based on medical record review, policy review and staff interview, the facility failed to ensure the policies and procedures governing medical care provided in the emergency department are a continuing responsibility of the medical staff for four of nine emergency department records reviewed (Patient #1, #7, #8, and #9). The total patient sample was 17.

Findings include:

Review of the facility policy titled, Emergency Department Assessment and Reassessment Interval, effective 09/23/21, revealed staff were to complete vital signs (VS) and assessments in accordance with the Emergency Severity Index (ESI) acuity classification. Listed under IV of this policy is vital signs are recommended to be taken according to the nurse's discretion or physician's request as follows for ESI 1-5.
ESI 1 patients: recommend to repeat vital signs every 15 minutes or more frequent depending upon condition.
ESI 2 patients: recommended to repeat VS every one hour or more frequent depending upon condition.
ESI 3 patients: recommended to repeat vital signs every two hours or more frequent depending upon condition.
ESI 4 patients: recommended to repeat vital signs if abnormal prior to being discharged.
ESI 5 patients: recommended to repeat vital signs if abnormal prior to being discharged.

Listed under H of this policy it states that regardless of triage level, all patients with abnormal vital signs should have them repeated prior to discharge and all abnormal VS will be communicated to the Emergency Department (ED) Physician or designee.

1. The medical record for Patient #1 was reviewed on 09/06/23. Patient #1 came to the ED on 07/25/23 at 7:56 AM with complaints of chest pain and dizziness which started this morning. The chest pain was described as pressure in the central chest with no radiation. Patient #1 was moved to triage 1 at 7:57 AM with a patient acuity level of a 2 documented.

Vital signs (VS) were completed at 8:01 AM with a blood pressure (BP) of 191/99, temperature of 97.7, heart rate (HR) of 69, respirations of 18 and oxygen saturation of 95%. Nursing notes at 8:04 AM indicated lab work was ordered with a Troponin (a protein that's released into the bloodstream during a heart attack) now and repeat in three hours, chest x-ray and 12 lead electrocardiogram (ECG) ordered. An ECG was completed 8:07 AM, intravenous started at 8:08 AM with lab work obtained and a chest x-ray completed at 8:20 AM. This patient was transferred back to the waiting room. The Troponin level came back within normal limits at 8:31 AM.

No physician order for frequency of vital signs were found in the medical record and no documentation was found the abnormal BP of 191/99 was reported to the physician or repeated hourly as this policy instructed.

Nursing notes at 8:47 AM listed ED destination: normal sinus rhythm, negative Troponin and chest x-ray. The next note was at 10:39 AM indicating registration started and was completed at 11:00 AM.

Nursing notes at 1:31 PM stated this patient was up to the intake desk multiple times upset with her wait time. This patient was growing increasingly frustrated, was informed of the bed situation and requested to have her IV removed and leave at this time. Patient #1 was discharged home without being seen by a physician at 1:32 PM. No documentation was found a second Troponin was completed per the three hour order and no documentation of VS completed hourly as policy instructs or prior to discharge since the BP was abnormal.

The findings of not following the facility policy titled, Emergency Department Assessment and Reassessment Interval in regard to completing VS hourly or reporting an elevated BP of 191/99 to the physician was verified with Staff A on 09/21/23 at 3:15 PM.


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2. Review of the medical record for Patient #7 revealed admission to the ED on 08/23/23 from 10:41 PM to 08/24/23 at 1:55 AM. Patient #7 had an ESI of 3. The patient's chief complaint was back and abdominal pain. An initial set of vital signs were obtained on 08/23/23 at 10:43 PM. Patient #7's temperature was 97.9, pulse was 56, respirations were 16, and blood pressure was 134/88. The medical record lacked documentation of additional vital signs. These findings were verified on 09/11/23 at 2:00 PM by Staff A.

3. Review of the medical record for Patient #8 revealed admission to the ED on 09/05/23 from 7:47 AM to 1:59 PM. Patient #8 had an ESI of 2. The patient had a chief complaint of chest pain. An initial set of vital signs were obtained on 09/05/23 at 7:51 AM. Patient #8's temperature was 98.4, pulse was 88, respirations were 18, and blood pressure was 137/88. Patient #8 had an ECG which was within normal limits on 09/05/23 at 7:59 AM. The Patient's Troponin level was within normal limits. The medical record lacked documentation of additional vital signs. Patient #8 left without being seen after triage at 1:59 PM. These findings were verified on 09/11/23 at 2:00 PM by Staff A.

4. Review of the medical record for Patient #9 revealed admission to the ED on 09/03/23 from 11:08 PM through 09/04/23 at 4:41 PM. Patient #9 had an ESI of 2. The patient was brought in by police for suicidal ideation. An initial set of vital signs were obtained on 09/03/23 at 11:17 PM. Patient #9's temperature was 98.5, pulse was 83, respirations were 16, and blood pressure was 133/92. Additional vital signs were obtained on 09/04/23 at 6:30 AM and 11:49 AM. These findings were verified on 09/11/23 at 2:00 PM by Staff A.

This deficiency represents non-compliance investigated under Substantial Allegation OH00144963.