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Based on record review and interview the facility failed to ensure the (triage acuity assessment) policies and procedures governing the medical care provided in the emergency department (ED) are enforced in 1 sampled patient (SP) #1 of 11 sampled ED patients.


The findings:

Medical record review showed sampled patient #1 was brought to the emergency department (ED) on 8/16/15 by fire rescue. The fire rescue report SP #1 was in a bicycle accident with an impact type: head-on; Patient vehicle speed: 20 MPH; other vehicle type: pedestrian. The patient was found lying on his back. The last rescue vitals taken at 18:03 PM show the pulse 94, B/P 114/P, and respiration 18. The HPI-General Trauma notes report on 08/16/2015 at 18:13 PM the patient complaint is a bicycle crash. The location is a head injury. The notes then state the patient stated he was thrown from his bicycle going approximately 20 miles per hour. There is a possible loss or suspected loss of consciousness. The patient was brought on a back board and a C-collar. The assessment also showed a hematoma of the left thigh.

Review of the Emergency Patient Record also showed that on 08/16/2015 the patient was not triaged until 20:06 PM. The ED rapid assessment showed SP #1 complained of a bicycle accident, plus loss of consciousness (LOC), plus headache, and a left nose road rash. The patient was assigned an acuity level ESI (Emergency Severity Index) priority level 3/ urgent.

Review of the emergency triage ESI (Emergency Severity Index) show that the vital signs is included in the assessment when assigning an acuity level. If level 3 and (equal) = 2 or more resources (consider danger zone vitals for possible escalation to level 2). There were no vitals taken on arrival for SP #1. Sampled patient #1 also required more than 2 resources, he required Labs (X-rays, IM medications, and specialty consultations (Neurologist consult was called on 08/16/2015 at 22:13 PM).

Review of the policy " Trauma Alert Patients, " (effective 01/15) state the following patients will be identified as Trauma Alert patients, as per Florida Trauma Score Care Methodology- the following criteria are considered an Adult Trauma Alert when two criteria listed below are met: (F) the patient is greater than or equal to 55 years of age. (G) Mechanism of injury: the patient has been ejected from a bicycle.

Sampled patient #1 met both criteria for trauma alert patients.

There were no vital signs taken immediately upon arrival to the ED.

The initial vital signs were taken on 08/16/2015 at 20:06 PM one hour and forty-seven minutes later. The readings were 158/ 94 blood pressure, temperature 98.0 (Fahrenheit), 80 pulses, 18 respirations, pulse oximetry 100. There was no telemetry monitor strips documented. The next vital signs were taken at 23:00 PM. The readings were: 150/92 blood pressure, 90 pulse, 18 respirations. There was no telemetry monitor documented. The vital signs taken on 08/16/2015 at 23:31 PM were: 160/89 blood pressure, 102 pulse, 18 respirations, pulse oximetry 100. There were no telemetry monitors reading documented. The vital signs taken on 08/17/2015 at 01:27 AM were: 149/ 87 blood pressure, 67 pulse, 18 respiration. There were telemetry monitor reading was documented.

Review of the Clinical Review audit of sampled patient physician and consultation visits showed the patient was seen by the ED provider on 08/16/2015 at 18:13 PM, a trauma consult was ordered on 08/16/2015 at 21:30 PM, and the patient was then seen by the trauma physician on 08/16/2015 at 22:54 PM.

Review of the discharge summary showed the patient was admitted with an isolated C6 spinous (Clay) fracture, multiple facial and nasal abrasions, and abrasion ' s with contusions, hematoma, to left mid distal thigh, rule out syncope, and closed head injury-mild concussion.


On 10/5/2015 at 3:43 PM, Staff Nurse F (the Registered Nurse who triaged sampled patient #1) stated that we get a report from the ambulance staff. She stated that I had a pretty sick septic patient occupying my time. I saw his vitals on the EMS run sheet. When the patient came in I did an initial assessment, I eyeballed him. The doctor saw the patient at 18:13 PM. At 21:31 PM I got a detailed assessment, his previous medical condition, nursing assessment, he was assigned a priority 3. She also stated that the initial vital signs were completed at 20:06 PM. She further stated that the patient was on the monitor but she did not record any telemetry strips. During the same interview, the Director of the Emergency Services stated that a rapid initial was completed by Staff Nurse E, a rapid initial assessment. The initial vital signs were completed at 20:06 PM. She further stated that the vital signs are usually done within 10-15 minutes.