HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure the Emergency Department (ED) staff provided care per the facility's policies and procedures. This deficient practice was identified in six (6) of twenty (20) medical records reviewed (patients #1, 15, 16, 17, 19 and 20). This failure has the potential to negatively impact the care given to all patients in an emergency situation.

Findings include:

1. Review of facility policy titled "Triage, NUR-SPP-95-8070", approved 4/13, revealed it states, in part: "Triage is not a medical screening...The medical screening is completed by the physician, physician assistant or nurse practitioner."

2. Review of facility policy titled "CO 008, Assessment-Reassessment", last reviewed 3/31/16, revealed it states, in part: "To ensure patients who enter the Emergency Department seeking care and attention will receive an assessment and reassessment regardless of the location in the Emergency Department...All efforts made will be to gain access to a qualified medical provider. Should there be a delay, the triage nurse will communicate any concerns to the provider and charge nurse for evaluation in obtaining orders while waiting...All patients waiting greater than one (1) hour- regardless of location in the Emergency Department-will be reassessed at least hourly or more often as indicated following the Rapid Initial (Triage) Assessment."

3. Review of facility policy titled "Medical Screening, NUR-SPP-04-8098, NUR-SPP-05-6105", approved 11/11, revealed it states, in part: "Leaving Dedicated Emergency Department (DED) after Triage but before an Medical Screening Examination (MSE)...If an individual presents to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE ("LPMSE"), the facility should use its best efforts to:..offer the individual further medical examination and treatment as may be required to identify and stabilize an Emergency Medical Condition (EMC);...discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same;...take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the Refusal of MSE and/or Consent to Treatment form, if possible;...document the individual's refusal of MSE or the attempts to locate the individual if he or she left without notifying someone."

4. Review of patient #1's medical record revealed a sixty-nine (69) year old female who presented to the ED on 2/28/17 at 11:24 p.m. with complaints of an elevated blood sugar of six hundred (600). The patient was triaged by RN #1 at 11:33 p.m. Laboratory orders were initiated in triage for an Abdominal protocol and an acetone. The patient was given a priority level three (3) and placed in the ED waiting area. At 12:51 a.m. on 3/1/17 the laboratory called a critical value result, for Glucose five hundred seventy-seven (577), to the ED Licensed Practical Nurse (LPN) who documented the physician was notified (Doctor of Osteopathic Medicine; DO #1). The patient left the facility at 2:46 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, repeat glucose level, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

5. Review of patient #15's medical record revealed a forty-two (42) year old male who presented to the ED on 2/28/17 at 5:12 p.m. with complaints of chest pain. The patient was triaged at 5:14 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and electrocardiogram (EKG) were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:07 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

6. Review of patient #16's medical record revealed a forty-two (42) year old male who presented to the ED on 2/28/17 at 3:43 p.m. with complaints of chest pain. The patient was triaged at 3:49 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 7:55 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

7. Review of patient #17's medical record revealed a twenty-six year (26) old female who presented to the ED on 4/1/17 at 5:09 a.m. with complaints of swelling to the left hand/fingers. The patient was triaged at 5:18 a.m., given a priority level four (4) and was placed in the ED waiting area. The patient left the facility at 9:37 a.m. on 4/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

8. Review of patient #19's medical record revealed a seventy-eight (78) year old male who presented to the ED on 2/28/17 at 7:08 p.m. with complaints of shortness of breath. The patient was triaged by RN #1 at 7:20 p.m. Documentation revealed the patient had a history of Congestive heart failure (CHF), cardiac, pacemaker and hypertension. Cardiac orders were initiated in triage. Blood work was obtained and an EKG was completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:04 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

9. Review of patient #20's medical record revealed a fifty-six (56) year old female who presented to the ED on 2/28/17 at 10:23 p.m. with complaints of chest pain. The patient was triaged by RN #1 at 10:26 p.m. Cardiac orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 2:31 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance.

10. An interview was conducted on 4/3/17 at 11:12 a.m. with the RN Director of Emergency Services. When asked how often vital signs are reassessed, she replied, "Every two (2) hours."

11. An interview was conducted on 4/3/17 at 11:20 a.m. with RN #3 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Vital signs are repeated every two (2) hours by the ED Tech or the triage nurse.

12. An interview was conducted on 4/4/17 at 9:07 a.m. with the LPN. When asked how often vital signs are reassessed, she replied, "Each nurse does their own vital signs every two (2) hours unless the patient is critical."

13. A telephone interview was conducted on 4/4/17 at 8:10 a.m. with RN #2 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Repeat vital signs are done every two (2) hours; that's the expectation."

14. A telephone interview was conducted on 4/5/17 at 1:41 p.m. with RN #1 (Triage Nurse). When asked how often vital signs are reassessed, she replied, "Every two (2) hours if we can." She also stated, "I do reassess patients and make them a higher level if necessary."