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Based on medical record review, policy review and interview, the facility failed to ensure a registered nurse evaluated the nursing care for each patient for one of 10 patients reviewed (Patient #1). The facility's active census was 396.

Findings include:

Review of the facility policy titled, Routine Care, Emergency Department Protocol (Version 8 Effective 07/12/23), revealed a complete initial triage/assessment is performed by a registered nurse (RN) on arrival. An RN under the direction of an ED physician may delegate to an ED paramedic tasks allowed in the Emergency Department scope of a paramedic. Licensed practical nurses, paramedics, clinical technicians and/or nursing assistants may begin patient care, data collection and application of physiologic monitoring devices on arrival as directed by an RN. Measure and document vital signs: Temperature (T), pulse (P), respirations (R), blood pressure (BP), pain level (using appropriate pain scale and SpO2 as indicated) during initial assessment. Recommendation in the electronic health record (EHR) for vital sign alert reminders are based on the following nursing/physician leadership recommendations which are based on the Emergency Severity Index (ESI) Score: 1 = 15 minutes; 2= 30 minutes; 3= 60 minutes; 4= 240 minutes; 5= 300 minutes. Patient placement post triage: patients are assigned to exam spaces based on their assessed needs and the capabilities of areas within the ED. When space is not immediately available, patients will be monitored in Intake/Triage area. Nurse initiated protocols may be ordered and the patient returned to lobby to wait for the next appropriate bed. Patients returned to the ED lobby will be instructed to notify caregivers of any change in condition (signs/symptoms) immediately. Patients will be reevaluated based on their initial acuity. A full set of vital signs should be taken on patients with an ESI level of 2 every hour. ESI level 3, 4, and 5 should have a repeat set of vital signs every two hours. Any abnormal vital signs should be communicated to the triage or charge nurse. Patients should be communicated with frequently and kept informed of updates.

Review of Patient #1's medical record revealed he arrived at the facility's emergency department on 07/28/23 at 11:54 PM with complaints of abdominal pain. Pain was assessed as 10 (zero to 10 scale with 10 being the worst pain) on 07/28/23 at 11:58 PM. Patient #1 was triaged as ESI (emergency severity index)-3H (intermediate, will require two or more resources) and then placed back in the lobby to await an emergency department bed/room. Patient #1 was placed in an emergency department room on 07/29/23 at 5:27 AM. Patient #1's pain was not reassessed until 07/29/23 at 5:48 AM and Patient #1's pain level was a 10 during the reassessment. Patient #1 had an appendectomy on 07/29/23 at 1:35 PM.

The medical record did not contain a reassessment of pain every 60 minutes and/or every two hours as per the policy.

The findings were shared in an interview with Staff D on 11/02/23 at 11:08 AM and confirmed.