HospitalInspections.org

Based on policy review and medical record review, the facility does not ensure Emergency Department (ED) patients are reassessed following triage in accordance with facility policy in 3 of 34 patients reviewed (Patients #32, #33 and #34).

Findings Include:

Review on 10/11/18 of policy "Patient ESI/Triage Process: ED.1123" last revised 08/2017 revealed the goal is to evaluate 100% of patients with Emergency Severity Index (ESI) 3/yellow within one (1) hour of arrival. Patients that are not evaluated by a provider within the target time for that triage category need to have a reassessment done by the emergency department Registered Nurse and have that reassessment documented.

Review on 10/11/18 of ED medical records revealed no documentation to indicate the following ESI 3 patients whose provider evaluation exceeded the one hour target time for the ESI 3 triage category were reassessed by the ED nurse in accordance with facility policy.

- Patient #32 presented to the ED and was triaged on 07/12/18 at 3:05 PM. The patient was not reassessed by nursing until 6:35 PM and at 7:22 PM the patient was evaluated by the provider.
- Patient # 33 presented to the ED and was triaged on 09/29/18 at 4:47 PM. At 7:38 PM an electrocardiogram and labs were obtained and at 7:57 PM the patient was evaluated by the provider. There is no documentation to indicate the patient was reassessed by nursing prior to the provider evaluation.
- Patient #34 presented to the ED and was triaged on 07/23/18 at 10:55 AM. At 1:10 PM the patient was evaluated by the provider.There is no documentation to indicate the patient was reassessed by nursing prior to the provider evaluation.

Interview on 10/11/18 at 1:30 PM with Staff (B), Nursing Quality, and Staff (Z), Regulatory Affairs confirmed the above noted findings.