HospitalInspections.org

Based on medical record review, documentation review, and interview, it was revealed the facility failed to follow their policy for re-assessing patients in the Emergency Department (ED) for one (1) of (10) patients presenting for care; Patient #4. This failure has the potential to negatively impact all patients presenting to the ED for treatment.

Findings include:

A record review was conducted for Patient #4. The Patient presented to the Emergency Department (ED) on 2/16/25 and triaged at 3:37 p.m. with respiratory issues. The emergency severity index (ESI) level was Urgent 3. Triage assessment documentation was completed with no additional reassessments noted until 2/17/25 at 12:11 a.m. The Patient was admitted to the facility on 2/17/25 at 3:50 a.m.

An interview was conducted with Staff #4 on 3/5/25 at 1:00 p.m. Staff #4 was presented with the electronic medical record (EMR) documentation of Patient #4's assessments. Staff #4 stated, "That's a huge problem." Staff #4 was asked if they agreed that the lack of reassessment for this Patient was a serious issue. Staff #4 stated, "I absolutely agree. I had no idea."