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Based on document review and interview, the facility failed to provide emergent care for 1 of 10 medical records reviewed (Patient 3).

The cumulative effect resulted in the hospital's inability to ensure a safe response in an emergent situation.

Based on document review and interview, the facility failed to ensure communication between facility services in 1 out of 10 (Patient 3) medical records reviewed.

1. Review of Patient 3's medical record indicated the provider ordered a computed tomography (CT) scan at 2:20 p.m. on 08/14/2024 as the provider note indicated the primary concern was a possible ruptured abdominal aortic aneurysm. An additional CT scan was ordered by the provider at 4:44 p.m.; provider note summary indicated that radiology requested a change in the CT order and discussed this change with the nurse. This change was not communicated with the provider resulting in a significant delay in patient obtaining a CT scan. At 5:13 p.m. on 08/14/2024, medical record indicated the radiologist notified the provider the results of the CT scan which indicated a ruptured abdominal aortic aneurysm with retroperitoneal hemorrhage.

2. Interview with P1 (Emergency Department Provider) on 10/09/2024 at approximately 8:00 a.m. confirmed that patient 3's initial computed tomography scan was delayed by approximately two hours as provider was not notified of the request; indicated radiology should have notified a Provider and not the Registered Nurse.

3. Interview with A1 (Director of Acute Quality and Safety), on 10/07/2024 at approximately 2:00 p.m., confirmed patient 3's medical record lacked documentation of communication for a request for change in computed tomography scan order and confirmed provider notes indicated radiology spoke with nursing and the information was not relayed to the provider causing a delay in care.

Based on document review and interview, emergency services failed to ensure complete documentation of patient assessment in 1 out of 10 (Patient 3) medical records reviewed.

1. Facility policy titled, Triage, Emergency Department, PolicyStat ID 12366763, last approved, 11/2022, indicated under Policy Statements: A. Patients presenting to the Emergency Department are assessed and prioritize by an RN based on the severity of their stated chief complaint, RN's assessment of physical, developmental, and psychosocial needs. These patients are then assigned a level of triage acuity. Under General Information, A. A five tiered triage system is utilized. The following examples are probable but not absolute or all inclusive: 2. Is the patient high-risk, confused, lethargic, disoriented, or exhibiting severe pain or distress? Level 2. Under Procedure: E. RN conducts an assessment of the patient which may include: 1. Focused assessment of chief complaint 2. Vital Signs which may be collected by a non-licensed team member, including a. Temperature b. Pulse c. Respirations d. Blood pressure for all patients age 2 and above or as warranted by complaint on those younger patients e. Weight/Height - actual weight on patients age 10 and younger, and whenever able to complete on adult patients. Weight based tape (eg Broselow) may be used to estimate pediatric weight in emergent or code situations. 3. Pain assessment 4. Fall Risk Screening 5. Suicide Screening 6. Initiation of RN protocols. Under Documentation: C. Document nursing assessment done to determine triage acuity level.

2. Review of Patient 3's medical record indicated the patient arrived on 08/14/2024 at 1:41 p.m. to the Emergency Department with a chief complaint of right flank pain across their abdomen for one hour, reported a history of aortic aneurysm, and stated the pain felt like the patient's past aneurysm. Medical Record indicated the patient's emergency severity index (ESI) acuity level as a 3/5 at 1:41 p.m. Patient's vital signs at 1:44 p.m. were as follows: temperature of 97.6 Fahrenheit (F) (normal 97.7-99.5 F), pulse of 72 (normal range 60-100), respirations of 26 (normal range 12-20), and blood pressure of 174/107 (normal range <120 systolic; < 80 diastolic); patient rated their pain level at a 10 based on a scale of 0 being no pain at all and 10 being the worst pain. MR lacked documentation that nursing reviewed patient's vital signs or completed initial assessment upon presentation to the Emergency Department.

3. Interview with A1 (Director of Acute Quality and Safety), on 10/07/2024 at approximately 2:00 p.m., confirmed the following for patient 3's medical record lacked nursing documentation of the initial nursing assessment upon patient 3's arrival at 1:41 p.m.; nursing assessment was documented at 2:20 p.m. after patient was taken to patient room. MR lacked nursing documentation of completed assessment and review of initial vital signs taken at 1:44 p.m.

4. Interview with A6 (Network Emergency Department Clinical Nurse Specialist), on 10/07/2024 at approximately 2:10 p.m., indicated that upon arrival patients are assessed by the pivot Registered Nurse (RN) and the RN reviews airway, breathing, and circulation and then assigns ESI level. A6 confirmed patient 3's medical record lacked documentation of this assessment upon patient's arrival and was not documented until 2:20 p.m. A6 indicated that pivot RN should review vital signs and is able to change ESI level at any time.

5. Interview with A7 (Emergency Department Nurse Educator) on 10/07/2024 at approximately 3:30 p.m. indicated that the initial RN is the pivot RN, and their role is to assess airway, breathing, and circulation and determine the patient's ESI upon presentation; patients with an ESI of 1 or 2 need to be seen immediately, and 3, 4, 5 can wait. A7 indicated the technician is to inform the pivot RN if any vital signs are abnormal. A7 indicated that the pivot RN is to review the patient vitals and confirmed that the review of vitals is not documented within patient 3's medical record.