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Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to follow policy and procedures for assessment of a patient in the Emergency Department for three (#3, #9, #10) of ten sampled patients and failed to ensure nursing assessed a patient for a reported change in condition for one (#3) of ten patients sampled.

Findings include:

1. Patient #3 presented to the ED (Emergency Department) on 8/13/2013 and was triaged at 9:07 p.m. The patient reported having coordination issues, right sided vision disturbance, that had resolved, and the patient's family reported his speech was slurred and slow. Documentation by the nurse revealed the patient was assigned an acuity of 3 on a scale of 1 to 5 with 1 being the most critical.

Review of the record revealed at 9:19 p.m. the RN reported the patient's symptoms and triage assessment to the ED physician. Documentation revealed orders for an EKG (Electrocardiogram), laboratory tests, and an IV (Intravenous) catheter were ordered at that time. Review of the record revealed at 9:49 p.m. a CT scan of the brain was ordered. Documentation by nursing revealed the EKG, laboratory tests, and IV orders were completed and the patient was placed back in the ED lobby to wait.

Documentation at 10:08 p.m. by an LPN (Licensed Practical Nurse) stated the patient's family reported the patient was having right eye disturbance again and the RN (Registered Nurse) was made aware. Review of the record revealed no evidence the RN reassessed the patient for a change in condition.

Documentation revealed at 1:32 a.m. on 8/14/2013 a PCT (Patient Care Technician) measured the patient's vital signs. The vital signs were within normal limits. There was no evidence the patient was reassessed according to the facility's policy of every 2-3 hours and no evidence the RN assessed the patient's reported change in condition as reported by the LPN at 10:08 p.m.

Review of the record with the CNO (Chief Nursing Officer), Nurse Director of the ED and Nurse Manager of the ED on 10/18/2013 at approximately 2:30 p.m. confirmed the above findings in the record.

2. Patient #9 presented to the ED on 10/17/13 at 12:48 p.m. and triage was started at 2:05 p.m. The patient was triaged with the complaint of having AV fistula site problems over the last several dialysis sessions. The patient's vital signs were completed 2:08 p.m. and he was assigned an acuity level 3. The patient was placed back into the ED waiting room at 2:10 p.m. The next set of vital signs was at 9:02 p.m. approximately 7 hours after the first set was completed.

3. Patient #10 presented to the ED on 10/17/13 at 5:34 p.m. and was triage at 5:41 p.m. with a complaint of bilateral leg pain. The patient's vital signs were completed at 5:44 p.m. and assigned an acuity level 3. At 9:41 p.m. the patient approached the desk and complained of chest pain. The patient's next set of vital signs were completed at 10:37 p.m., approximately 5 hours from the first set completed.

An interview was conducted with the ED Nurse Manager on 10/18/13 during the chart reviews and the above was confirmed.

Review of the facility policy, "Plan of Care for Emergency Department", policy # ET-4, last revised 11/2011, was reviewed and states on page 2, level 3 acuity is considered urgent and would require a reassessment every 2-3 hours.

An interview was conducted with the ED Director on 10/18/13 at approximately 4:30 p.m. The Director was questioned what was considered an assessment. The Director responded that if there is an abnormal assessment it would be documented; otherwise the vital signs are considered as part of the assessment.