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Based on a review of clinical records, staff interviews and a review of the Emergency Department's policies and procedures for one of four patient's reviewed for reassessments in the emergency department (Patient #99), the facility failed to conduct reassessments in accordance with the hospital's policies and procedures. The findings included:

a. Patient #41 was admitted to the hospital on 12/28/16 at 10:41 AM with complaint of abdominal pain, elevated blood sugar, nausea and vomiting. The patient was triaged at 10:42 AM. The numeric pain scale was identified by the patient as a level nine (9) on a scale of 1 to 10. The triage level was assigned as a level two and the patient was admitted to an ED room 11: 02 AM. The initial assessment by the RN identified that the assessment was entered at 3:21 PM and was performed on 3:19 PM. Interview and review of the clinical record with the Assistant Director of the ED on 12/28/16 at 2:45 PM noted that he/she spoke with the RN who cared for Patient #99 on 12/28/16 and he/she identified that although the assessment was conducted within an hour of patient arrival to the ED room, he/she forgot to change the assessment performance time in the patient ' s electronic medical record. In addition, a reassessment of the chief complaint was documented at 2:28 PM and should have been completed no later than 2:02 PM.
The hospital policy entitled Emergency Department Nursing Documentation Guidelines directed in part that all patients would have documentation that included a chief complaint, pain level, vital signs, a triage level, allergies and a past medical history. After arrival to a treatment room a general primary assessment focusing on the patient's chief complaint would be conducted. Throughout the patient's course in the ED medications, procedures, vital signs and pain reassessments would need to be documented to accurately reflect the patient's condition or changes in condition. Clinical and/or narrative documentation would also include a focused reassessment in accordance with the patient categorization. A reassessment for a level two acuity would be conducted every two hours unless otherwise indicated by the patient's clinical status and need to be conducted more frequently.



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Based on a tour of the facility, review of facility policies, observations and interviews the facility failed to ensure that glucometer controls were dated according to policy in 1of 3 clinical areas. The finding includes:
Tours of the preoperative area was conducted with the Assistant Director of perioperative Services on 12/28/16 at 1:15 PM. A review of the two glucometer control solutions failed to contain/identify a clear date indicating when the control solutions would expire and/or were opened. Interview with the Assistant Director of perioperative Services on 12/28/16 at 1:30 PM noted that he/she learned that the control solutions were opened on 9/27/16 and should have been discarded on 12/27/16.The glucose control solutions were discarded and replaced. According to Facility entitled POC Whole Blood Glucose, Using the Nova Statstrip Glucose Meter once opened, control solutions are stable when stored as indicated for up to three months or until the expiration date printed on the vials, whichever comes first.



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