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Based on medical record review, document review, and staff interviews it was determined the facility failed to follow nursing care policy due to not following directed time constraints for the re-assessment of patients waiting to be seen in the Emergency Department (ED). This failure is likely to cause serious injury, serious harm, serious impairment or death (See Tag A 398). As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on 03/09/23 at 5:00 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency. The IJ was abated on 03/09/23 at 8:40 p.m.

The following interventions were implemented to resolve the IJ: a policy change to the policy titled "Triage in the Emergency Department". Triage will assign an emergency severity index (ESI) level during triage and the corresponding re-assessment intervals will be maintained. All ED staff will be educated prior to starting their next scheduled shift. A random audit of thirty (30) charts will be conducted monthly to assure compliance with the new policy.

Based on medical record review, document review, and staff interview, it was determined the facility failed to follow their policy for re-assessing patients in the Emergency Department (ED) for seven (7) of ten (10) patients presenting for care; Patients #1, 2, 6, 7, 8, 9, and 10. 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 #1. The patient presented to the Emergency Department (ED) on 12/26/22 at 12:09 p.m. with psychiatric symptoms. The emergency severity index (ESI) level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 12:33 p.m. No ED Waiting Room Re-Assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 11:46 a.m.

A record review was conducted for patient #2. The patient presented to the ED on 12/26/22 at 1:49 p.m. with difficulty breathing. The ESI level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 1:49 p.m. No ED Waiting Room Re-assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 5:42 a.m.

A record review was conducted for patient #6. The patient presented to the ED on 12/26/22 at 8:50 p.m. with weakness. The ESI level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 8:51 p.m. An ED Waiting Room Re-assessment was completed on 12/27/22 at 2:49 a.m. No additional ED Waiting Room Re-assessment was completed. The patient was admitted to the facility on 12/28/22 at 12:32 a.m.

A record review was conducted for patient #7. The patient presented to the ED on 12/26/22 at 1:07 p.m. with seizure. The ESI level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 1:08 p.m. No ED Waiting Room Re-assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 2:02 a.m.

A record review was conducted for patient #8. The patient presented to the ED on 12/26/22 at 3:29 p.m. with nausea and vomiting. The ESI level was documented as four (4). Triage assessment documentation was completed on 12/26/22 at 3:30 p.m. No ED Waiting Room Re-assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 6:27 a.m.

A record review was conducted for patient #9. The patient presented to the ED on 12/26/22 at 4:31 p.m. with weakness. The ESI level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 4:59 p.m. No ED Waiting Room Re-assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 6:31 a.m.

A record review was conducted for patient #10. The patient presented to the ED on 12/26/22 at 1:43 p.m. with difficulty breathing. The ESI level was documented as three (3). Triage assessment documentation was completed on 12/26/22 at 1:44 p.m. No ED Waiting Room Re-assessment documentation was noted. The patient was admitted to the facility on 12/27/22 at 5:40 a.m.

The policy titled "Triage in the Emergency Department," approved 07/13/22, was reviewed. The policy states in part: "Procedure: 4. When data collection is complete, the RN will classify the patient according to treatment priority, based on the ESI. a. Resuscitation (1) - Requires immediate lifesaving intervention. b. Emergent (2) - High risk situation, confused/lethargic/disoriented or severe pain / distress, danger zone vitals. c. Urgent (3) - Requires many resources, would need immediate or quick placement into an emergency room treatment area. d. Less Urgent (4) - Requires no more than one of the hospitals resources. Typically need minor treatment. e. Non-Urgent (5) - Requires none of the hospital resources. For these patients, the triage nurse has determined they need little or no treatment. (6) Qualified personnel shall continually monitor the patients who have been triaged and deemed stable enough to wait for admission to the Emergency Department. The triage nurse shall frequently scan the waiting room and look at each patient to evaluate their status for deterioration. (7) If a patient's condition has deteriorated, the triage nurse or designee shall take the patient back into the triage room to re-evaluate the patient and reassign an acuity level and notify the physician." No re-assessment time parameters were listed in the policy.

Review of document titled, "Employee Training Progress Summary" indicated that one hundred percent (100%) of licensed ED staff had completed training titled, "ESI Waiting Room Re-Assessment".

An interview was conducted with the Director of Emergency Services (DES) on 03/06/23 at 11:05 a.m. DES stated, "No mid-level provider was working on 12/26/23 to cover Medical Screening Examinations (MSE) and the Emergency Department (ED) was on diversion all day. We also called an Internal Disaster because of a lack of providers that day. Vital signs and re-assessments were missed." DES explained that changes are planned including adding an additional Licensed Practical Nurse (LPN) to assist with vital sign collection and re-assessments and additional stations have been added in the ED for Emergency Medical Services (EMS) arrivals.

An interview was conducted with RN #3 on 03/06/23 at 3:40 p.m. RN #3 was asked about the triage process. RN #3 stated. When asked about re-assessing patients in the waiting room, RN #3 stated, "Normally you just scan the waiting room and see if there are any problems. If there is a problem someone will let you know." Asked about this, RN #3 clarified that a family member would alert staff if a waiting patient were having increased problems.

An interview was conducted with the Emergency Department Clinical Nurse Manager (CNM) #1 on 03/07/23 at 11:00 a.m. CNM #1 was asked about assessing and re-assessing ED patients. CNM #1 stated, "They are supposed to do re-assessment and vital check every hour based on acuity." CNM #1 explained that the Medical Assistant (MA) or an RN is supposed to do the re-assessment and vital checks. CNM #1 explained that during the re-assessment the waiting patient would be assessed for change in symptoms and if the patient's pain level had increased or decreased. CNM #1 was asked if these checks were suspended due to the ED being on diversion. CNM #1 stated, "I'm not sure if diversion status suspends those or not."

A second interview was conducted with the DES on 03/08/23 at 1:50 p.m. DES was asked about the timing of re-assessments. DES stated, "Our acuity is tied in with Electronic Medical Record (EMR) system (Meditech). For an Emergency Severity Index (ESI) level three (3), the patient should be re-assessed every two (2) hours, for an ESI level four (4) it would be every four (4) hours." DES was asked why these were missed if Meditech is setting the frequency? DES stated, "I cannot explain it, it is highly inappropriate and should have never happened. We try to educate on everything." DES was asked about the impact of diversion on the provision of care, DES stated, "Diversion is not supposed to impact operations a surge of patients would impact differently." DES added, "Our new LPN position is going to be assigned to the waiting room for reassessments and that LPN is currently in orientation." Asked about daily ED volume, DES stated, "Our January average daily census was fifty point one (50.1) and forty-seven point five (47.5) for February." The ED census on 12/26/23 was forty-seven (47).

A telephone interview was conducted with the Chief Nursing Officer (CNO) on 03/08/23 at 1:58 p.m. CNO was asked to concur that patient #1 had an excessive wait time with no re-assessment. CNO stated, "I do concur that it is too much time." CNO was asked about the ESI level and the assignment of re-assessment intervals. CNO stated, "I'm not really sure where those levels come from."

A second interview was conducted with RN #5 on 03/08/23 at 3:06 p.m. RN #5 was asked about the ESI levels and the associated re-assessment intervals. RN #5 stated, "The triage nurse puts in the ESI level and Meditech populates this into the record. An ESI level two (2) would be re-assessed every hour and a level three (3) would be every two (2) hours for re-assessment and vitals."

A second interview was conducted with RN #3 on 03/08/23 at 3:10 p.m. RN #3 was asked about the ESI levels and the associated re-assessment intervals. RN #3 stated, "The ESI level is based on triage. Meditech defaults to every hour for re-assessments and vitals. I don't know if that can be changed." RN #3 explained that the EMR has a section titled "Next Intervention" which indicates what interventions are due including labs, vitals, and re-assessments.

An interview was conducted with the DES on 03/08/23 at 1:50 p.m. they concurred that the facility failed to follow their procedure for assessments and reassessments of patient's in the ED waiting room.