HospitalInspections.org

Based on policy review, record review and interview, the facility failed to ensure nursing staff reassessed patients' statuses housed in the Emergency Department (ED) waiting room for 1 of 1 (Patient #1) waiting room patients reviewed.

The findings included:

1. Review of the facility's "Organization Plan for Assessment and Reassessment" policy (approved 11/2015) revealed, "... Reassessments are performed by registered nurses and physicians when...As indicated by patient condition and/or treatment. The reassessment includes appropriate vital signs and a review of the focus systems...A delay of greater than 2 hours is expected, patients may be reassessed as indicated..."

2. Medical record review for Patient #1 revealed the patient entered the ED at 4:19 PM on 8/21/2023. Patient #1 was triaged beginning at 4:19 PM and placed in the waiting room at 4:47 PM. Patient #1 signed an Against Medical Advice (AMA) form at 6:46 PM and was documented as leaving the ED at 7:00 PM.

There was no documentation Patient #1 was reassessed while in the waiting room for over 2 hours, between 4:47 PM and 7:00 PM.

In an interview on 9/11/2023 at 11:30 AM, the facility's Director of Nursing (DON) stated the expectation is that any patient waiting in the waiting room for an hour will then be reassessed every hour. The DON stated she knew staff had reassessed the patient, but verified there was no documentation in Patient #1's medical record of reassessment while in the waiting room.