HospitalInspections.org

Based on staff interviews and facility document reviews, it was determined the facility staff failed to comply with 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases.

The findings include:

A. The facility staff failed to ensure the facility's written policies and procedures for on call physicians addressed: (a) if an on-call physician is allowed to schedule elective survey during the time he/she is on call, and (b) if an on-call physician is allowed to have simultaneous on-call duties.

Please see Tag A-2404 for additional information.


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B. The facility staff failed to ensure the facility's written policies and procedures were followed related to triage in the emergency department.

Please see Tag A-2406 for additional information.

Based on interviews and facility document review it was determined the facility staff failed to ensure the facility's written policy and procedures for on-call physicians addressed: (a) if an on-call physician is allowed to schedule elective surgeries during the time he/she is on call, and (b) if an on-call physician is allowed to have simultaneous on-call duties.

The findings include:

The facility's Medical Staff Bylaws and their Rules and Regulations were reviewed on 11/17/16 beginning at approximately 11:30 AM. The documents did not address whether on-call physicians would be allowed to schedule elective surgeries while they are on-call or whether on-call physicians would be allowed to have simultaneous on-call duties.

On 11/17/16 at 4:20 PM, a surveyor discussed the missing policies with the facility's Chief Medical Officer (CMO) and the facility's Director of Quality. The CMO stated the facility does allow their on-call physicians to schedule elective surgeries during the time they are on-call. He/She also said their vascular surgeons were the only physicians that take call at a second facility in a nearby city. The CMO acknowledged he/she was not sure if there were policies and/or procedures related to those specific issues but would find out.

On 11/18/16 at 1:55 PM, the Director of Quality stated these policies do not exist in writing.

Based on interviews and document review, it was determined the facility staff failed to follow facility written policies and procedures related to the triage of emergency department (ED) patients for 1 of 24 sampled ED patients (Patient #6).

The findings include:

Patient #6's clinical documentation, for his/her emergency department visit which occurred on 11/6/16 indicated: at 6:22PM, Patient #6 arrived at the Triage Nurse/Registration Desk and at 7:27PM, Patient #6 was placed in a room in the ED (emergency department).

Patient #6's clinical documentation indicated, on 11/6/16 at 6:23PM, Patient #6 was triaged by a registered nurse (RN) (Staff Member (SM) #11). SM #11 documented that Patient #6 arrived ambulatory. Patient #6 was given a triage 'priority' of '3 - urgent'. Patient #6's chief complaint was documented as "C/O (complained of) RLQ (right lower quadrant) PAIN, N/V/D (nausea/vomiting/diarrhea), FEVERS THAT BEGAN YESTERDAY. PT STILL HAS APPENDIX." [sic] No further assessment of Patient #6's pain was documented during the triage assessment; no 0 - 10 patient self-reported pain scale was documented at the time of the triage assessment. No vital signs were documented at triage. Patient #6 was in the waiting room from the time of triage (11/6/16 at 6:22 PM) until being placed in a room in the ED (11/6/16 at 7:27 PM).

Patient #6's clinical documentation indicated on 11/6/16 at 7:40PM the patient was assessed by an ED registered nurse (SM #14). The patient was documented as having 'Right Lower Quadrant' abdominal pain described as 'TENDERNESS ON PALPATION, AND REBOUND TENDERNESS'. This pain was documented as an 8 on a 0 - 10 pain scale and described as "SHARP, 'FEELS LIKE A GOLF BALL' " with a 'duration' of eight (8) hours. Documentation indicated the pain had been "INCREASING THROUGHOUT THE DAY".

The nurse (SM #11) who triaged Patient #6 on 11/6/16 was interviewed on 11/18/16 at 10:10AM; the ED Quality Coordinator (SM #12) was present during this interview. After reviewing Patient #6's clinical documentation, SM #11 confirmed that a patient self-reported pain scale was not completed at triage. SM #11 stated vital signs are not generally obtained at triage; SM #11 reported that if the patient wasn't going straight to the treatment area he/she would obtain a heartrate and a pulse oximetry reading. SM #12 stated that at triage the nurse should obtain a chief complaint and assign the patient a triage level. SM #12 was asked if the facility has a policy and procedure addressing triage for when a patient is unable to be taken directly to the ED treatment area; SM #12 reported there was no policy specifically addressing triage when a patient is unable to be immediately placed in the ED treatment area.

The facility's EMTALA Policy and Procedure (Last review/revision date of December 2009) included the following statement: "Every individual presenting to (facility name omitted) Emergency Department shall first be triaged by the appropriate medical personnel in accordance with (facility name omitted) Emergency Department triage Policies and Procedures."

The facility's 'Vital Sign Policy - Emergency Room' (Last revision date of November 2015) included the following statement: "Vital Signs at Triage/Intake: A full set of vital signs should be acquired on a patient presenting to Intake/Triage if there is an anticipated delay in the treatment area, or if the patient must wait in the waiting area. Otherwise, the patient can be taken directory to the treatment area and VS obtained by the care team in the treatment area." This policy defined a 'full set of vital signs' as: temperature, pulse (heart rate), blood pressure, respiratory rate, and oxygen saturation (pulse oximetry).

The facility's 'Triage Policy' (Last revision date of January 2014) was reviewed. This policy stated that "(a)ll patients that present to the ED will be assigned a triage level" by a RN. This policy also stated that all "ED patients will be triaged using the Emergency Severity Index (ESI) five level triage system." The ESI Triage Algorithm, included with the facility's 'Triage Policy' indicated that a level '3' would be assigned to a patient that was expected to require "many different resources" but was: not a 'high risk situation', not 'confused / lethargic / disoriented', and not in 'severe pain / distress'. (The algorithm included the following: "Severe pain / distress is determined by clinical observation and / or patient rating greater than or equal to 7 on 1 - 10 pain scale.") This algorithm indicated a patient that was 'high risk situation' or 'confused / lethargic / disoriented' or in 'severe pain / distress' would be triaged as a '2'. (This facility's triage level system goes from 1 to 5; 1 being most severe and 5 being least severe.)

The facility's Director of the Emergency Department (SM #1) was interviewed on 11/17/16 at 10:15AM. SM #1 reported that patients are taken straight back to a bed to get a complete set of vital signs. SM #1 stated, if not being taken straight back to the treatment area, a complete set of vital signs would be completed at triage unless there was a line of people waiting to be triaged.

The triage / intake / registration area was observed on the morning of 11/17/16. The patients were observed to be triaged by a registered nurse. The patients were taken back to the ED treatment area within minutes of being triaged therefore complete sets of vital signs were obtained in the treatment area instead of in the triage area. On 11/17/16 at 10:35AM, the triage registered nurse, SM #3 was interviewed about the triage process. SM #3 stated that vital signs were obtained on patients in the treatment area; SM #3 stated that if a patient was unable to be immediately taken back to the treatment area that a heart rate and pulse oximetry reading was obtained. SM #3 stated the triage nurse would be continuously monitoring the ED waiting area to see if changes were occurring in patients that were waiting to be taken back to the treatment area.

This is a complaint deficiency.