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Based on interview, the review of medical record and other documents, it was determined the facility did not ensure the implementation of its policy to assure that (1) each patient evaluated in the Emergency department receives a written discharge plan for continued treatment and follow-up care; and (2) abnormal vital signs are repeated and stabilized prior to discharge. These findings were noted in 3 of 30 applicable records reviewed (Patient #5 and #6 and #7).

Findings include:

1 (a). Patient #5 is a 23-year-old female, Gravida 1 (a woman's first pregnancy) , Para (number of pregnancies of a duration greater than 20 weeks) 0, at 24 weeks gestation who presented to the Emergency Department on 10/2/14 at 9:30 AM with complaint of "low abdominal pain since yesterday". The patient had a Trans-abdominal sonographic examination that was within normal limit and physical examination was unremarkable. A reassessment of the patient by the nurse on 10/2/14 at 11:00 AM, notes the patient's abdominal pain had completely subsided. The physician diagnostic impression was "Pregnancy". The patient was discharged home on 10/2/14 at 11:15 AM with instructions to follow up with an obstetrician.

The registration information provided by the patient on 10/2/14, during the ED visit notes, "NO Primary Care Physician AT ALL". However, the patient's discharge instruction did not indicate information necessary for the patient to make a follow up appointment; the name of the obstetrician, office location, and contact number were not noted.

The Emergency Department Manual titled "Discharge Planning and Instructions", last reviewed in November 2011, notes that upon completion of each patient's visit, "The physician documents the plan for continued treatment and or follow-up care in the Emergency Department record. The physician or Registered Nurse completes the patient's Discharge Instructions and Follow-up section of the ED record".

1 (b). Patient #6 is a 48 -year-old female who presented to triage on 9/10/14 with a chief complaint of chest pain for three hours radiating to the left shoulder. The patient's past medical history included pulmonary fibrosis (Scarring in the lungs that ca be caused by many conditions) and heart palpitations. Following medical screening evaluation and diagnostic tests, the physician's diagnostic impression was "Atypical chest pain". The patient was discharged on 9/10/14 at 6:10 PM with instruction for follow up care with Primary Care Physician (PCP) in one week.

Although the patient's ED registration record on 9/10/14 indicated, the patient had no PCP, the physician failed to document a plan for continued treatment and follow-up care of the patient in accordance with the discharge policy.

At interview with Staff #3 on 2/5/15 at 11:30 AM, she stated that when a patient reports not having a PCP, the treating physician will make appropriate referral depending on the services needed.


2. Patient #7, a 61-year-old female was triaged in the Emergency Department on 1/21/15 with a complaint of cough and yellow phlegm for three weeks. The patient had multiple medical conditions including hypertension, asthma, Multiple Sclerosis, hypothyroidism, and renal failure. Vital signs obtained at triage at 10:00 PM were as follows: Temperature - 98.5, Blood pressure - 162/99 millimeter of mercury (mm/Hg), Pulse - 100 and Respirations - 12. The triage classification was Emergency Severity Index (ESI) IV (4).

ESI is a five level emergency department triage based on the acuity of patients' health care problems and the number of resources (complex interventions or diagnostic tools) their care is anticipated to require. ESI Level 1 - Resuscitation - Immediate, life-saving intervention required without delay; Level 2 - Emergent - High risk of deterioration, or signs of a time-critical problem; Level 3 - Urgent - Stable, with multiple types of resources needed to investigate or treat; Level 4 - Less Urgent Stable, with only one type of resource anticipated; and Level 5 - Nonurgent - Stable, with no resources anticipated except oral or topical medications, or prescriptions.

The physician's diagnostic impression following a chest x-ray was Upper Respiratory Infection. The patient was discharged home with prescription for Robitussin for management of cough/cold and was instructed to follow up with her PCP.

Although the patient's current medications included antihypertensive medications, Clonidine and Diovan, the nurse failed to include in the triage assessment when these medications were last taken. In addition, the treating physician in his assessment failed to acknowledge the patient's elevated blood pressure and document a plan for treatment. The patient was discharged home without a reassessment of her blood pressure and instructions for prompt management.

At interview with Staff #4 on 2/4/15 at 3:45 PM, he stated the patient had a history of hypertension and was on medications. He added that the recent administration of bronchodilators to the patient prior to her arrival in the ED might have caused elevation in her blood pressure.

The review of the Emergency Department Manual titled "Assessment of Patients in the Emergency Department" last revised in March, 2012 notes "All patients including psychiatric who are determined to be Level IV or Level V will be reassessed and have vital signs recorded: (a) The primary RN should repeat vital signs immediately if abnormal in triage."

The patient's triage blood pressure was 162/99 mm/Hg on 1/21/15 at 10:00 PM. The primary nurse did not reassess the patient's blood pressure prior to her discharge on 1/22/15 at 2:40 AM.