The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAN JOAQUIN GENERAL HOSPITAL 500 W HOSPITAL ROAD FRENCH CAMP, CA 95231 Nov. 15, 2012
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, Emergency Department (ED) record and policies and procedures (P&P) review, the hospital failed to provide an appropriate medical screening examination conducted by an individual(s) who was determined qualified by hospital bylaws or rules and regulations, to determine whether or not an emergency medical condition existed for 6 of 28 ED patients reviewed (Patients 1, 2, 3, 4, 5, and 13).
Patient 1, who presented to the ED three times within 13 hours did not receive a medical screening exam on the third visit.
Patient 2 was triaged urgent (should have been emergent) and then was not reassessed timely for either emergent or urgent triage category. Staff noted two and half hours later that the patient had left without being seen (LWBS).
Patient 3 was triaged as non-urgent (should have been urgent) and then was not reassessed timely for either triage category.
Patient 4 was triaged as urgent and no reassessment were attempted for six and half hours where the patient was noted as LWBS.
Patient 5 was triaged as non-urgent and no reassessment was attempted for five hours where patient was noted as LWBS.
The ED nurses failed to appropriately assess and prioritized patients during triage in accordance with established hospital policies and standards which resulted delays or no medical screening examinations of patients.

Findings:

Review of the Hospital Medical Staff Rules and Regulations (dated September 2008), indicated in Article 11 titled "Emergency Medical Treatment and Active Labor Act (EMTALA)", that "The medical staff of (hospital's name) will define those classifications of staff who may conduct medical screening examinations in accordance with EMTALA provisions, to include Emergency Department licensed physicians, nurse practitioners, and physician assistants in accordance with their privileges; and in the Family Maternity Center licensed physicians and certified nurse midwives in accordance with their privileges. Appropriate criteria for the medical screening examination is set by policy; 'Compliance with EMTALA'. "

Review of the policy titled "Compliance with EMTALA" (5/1/08) indicated that: "...A medical screening examination must be offered to any individual who comes to the emergency department... The scope of medical screening examination must be tailored to the presenting complaint and the medical history of the individual... Triage is not equivalent to a medical screening examination. Triage merely determines the 'order' in which patients will be seen, not the presence or absence of an emergency medical condition... The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individual's needs... Each department of the hospital that provides emergency medical services shall adopt policies and procedures describing the conduct of the medical screening examination in the department and the documentation of patient records, and conduct ongoing inservice training of the department staff and quality management review of medical screening examinations..."

Review of the policy #1202 "Initial Nursing Assessment- Triage" (5/1/2008) indicated that "All patients will have an initial screening assessment performed by a qualified registered nurse (RN)... A subsequent medical screening exam (MSE) will be performed as appropriate by a provider to determine if an emergency medical condition exists...
1. The Registered Nurse (RN) will evaluate and categorize each patient upon arrival to the Emergency Department into emergent, urgent or non-urgent categories.
> Emergent: patient should be brought into the Emergency Department for care without delay because of the acuity of the injury or illness and the increased risk for loss of life or limb or profound disability if waiting is required.
> Urgent: patient must be seen in the Emergency Department and should be re-evaluated during the waiting period.
> Non-Urgent: Patient may safely wait for an extended period of time to be seen or sent to clinic for care."
The policy further indicated that the initial evaluation shall include medical history, subjective- chief complaint including a pain assessment utilizing the 0-10 pain scale, objective-nursing assessment and full set of vital signs including pulse oximetry (a measurement of the amount of oxygen in the blood system) on patients with respiratory/cardiac complaints. The P&P listed examples of conditions for each classification (emergent, urgent, non-urgent) and indicated that "...The nurse's assessment shall be the main guiding factor in determining the appropriate classification for a patient..."

A review of policy # 1203 titled "Assessments of the Emergency Department Patient" (7/30/05) indicated that "The goal of ongoing vital signs shall be obtained based on patient's triage category:
> emergent or critical patients every 5-15 minutes until stable; then every 1 hour, or sooner if needed, and prior to admission or transfer;
> urgent patients every 2 hours, and prior to admission, transfer or discharge;
> non-urgent patients every 4 hours and prior to discharge."

The following are summary of findings after ED records review conducted during EMTALA survey from 11/13/12 to 11/15/12:

1. Review of the ER (emergency room ) Daily Log showed that on 9/25/11 Patient 1 had three (3) visits to the ED, each time presenting to the ED by an ambulance: at 1:35 a.m., 10:15 a.m., and 2:28 p.m. The ED Log recorded that Patient 1 was discharged following visits 1 and 2. Patient 1 expired in the ED on the third visit before nursing assessment was completed and before receiving MSE. According to the administrative ED staff, Patient 1 was not known to staff prior to initially presenting to the ED on 9/25/11.

Review of Patient 1's autopsy report, performed on 9/26/11, showed immediate cause of death as cardiac tamponade (pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac of the heart) caused by hemopericardium (blood around the heart) due to dissection of thoracic aorta. Aortic dissection is a serious condition in which there is a separation of the aorta walls. The small tear can come larger. It can lead to bleeding into and along the wall of the aorta, the major artery carrying blood out of the heart. (http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm)

Review of the 1st ED visit records showed that Patient 1, a [AGE] year old male, arrived at the ED on 9/25/11 at 1:35 a.m. by an ambulance with chief complaint of "possible ground level fall." The ambulance record on 9/25/11 starting at 1 a.m. documented that upon arrival on scene Patient 1 stated he was not able to feel legs and suffered a ground level fall. The patient was also noted complaining of sharp pain in his legs and lower back. During transport to the ED Patient 1 was noted agitated and unable to hold still, complaining of having abdominal pain and increased leg pain. Vital signs were noted stable with Blood Pressure (BP) 130/70; Pulse (P) 60, Respirations (R) 16.

Review of the Medical Screening Exam/Triage form (1 page) by the triage nurse (RN 2) on 9/25/11 at 1:35 a.m. documented Patient 1's vital sign measurements of: BP 180/109 (high, normal average is 120/80); P 78, R 18; T 98; and oxygen saturation 97%. (amount of oxygen in the blood system, O2 Sat). RN 2 noted that the patient was post un-witnessed fall and that the patient was claiming to be unable to move his legs. The patient was also noted with a history of psychiatric illness (paranoid schizophrenia). The triage category was indicated as non-urgent.

Review of ED provider's notes showed that Patient 1 was seen on 9/25/11 (entries not timed) and was noted with LBP (lower back pain). The provider documented that Patient 1 was observed moving his legs. Patient 1 had a CT (computerized tomography, a radiological study) of the brain and blood laboratory tests were done. There was no CT scan of the patient's back, the pain site of the chief complaint. The change in Patient 1's blood pressure readings between the pre-hospital measurement and the ED measurement in triage were not addressed by the ED provider. The provider (PA 1) noted that patient was treated with intravenous fluids, Benadryl (antihistamine medication) and Ativan (antianxiety medication) and the patient was discharged at 5:23 a.m. with diagnoses of ground level fall, schizophrenia and substance abuse.

The nursing notes showed that on 9/25/11 at 5:23 a.m. Patient 1 was discharged via gurney with "medics." Vital signs upon discharge were documented as: BP 184/80; P 62; and R 18. The discharge instructions directed Patient 1 to return if worse, stop smoking "pot" and follow up with a physician on Monday (the following day).

On 11/13/12 at 3:45 p.m. the Director of Standards and Compliance stated that Patient 1's first visit to the ED was peer-reviewed (by the Peer Review Committee) on 11/23/11. The peer review identified no problems with care and identified no opportunities for improvement.

Review of the ED record for the 2nd ED visit showed that Patient 1 returned to the ED on 9/25/11 at 10:15 a.m. (5 hours after being discharge) by ambulance with the same complaint of "back pain."

The 2nd ambulance record on 9/25/11 starting at 9:51 a.m. documented that the ambulance was called by a bystander who observed Patient 1 walking holding his back and his legs very wobbly then the patient sat down. The patient told the ambulance crew this time that his back pain was chronic pain and when he started hurting he sat down. Patient 1's vital signs at 9:57 a.m. were noted in the ambulance record as follows: BP 220/114 (very high, normal average is 120/80); P 50 and R 18.

Review of the Medical Screening Exam/Triage form by RN 1 on 9/25/11 at 10:15 a.m. indicated Patient 1's vital signs measurements were as follow: BP 228/97 (very high); P 53, R 16; T 98.2; and oxygen saturation not recorded (blank). The triage nurse noted that according to medics the patient was out for a walk and couldn't walk because of back pain. Pain level was documented as 6 (0-10 pain scale). The patient was again noted with a history of schizophrenia and drug (cocaine) use. The triage category was indicated again as non-urgent and the patient was placed in ED room 12.

Review of ED provider's (Physician 1) notes showed Patient 1 was seen on 9/25/11 at 12 p.m. and that Patient 1 was complaining of weakness, nausea and vomiting and pain (written in musculoskeletal section). Physician 1 noted that Patient 1 was anxious. The high BP was not addressed. The Physician 1 referenced that labs were done on the first visit on 9/25/11 at 2 a.m. and ordered no additional studies (laboratory or radiological). Physician 1 noted that Patient 1 was discharged "home" with Clinical Impression now documenting: weakness and nausea/vomiting. Patient 1 was noted in "stable" condition (entry not timed).

Review of Nursing Progress notes for the 2nd visit to the ED on 9/25/11 showed that at 1:20 p.m. Patient 1 was administered Zofran and Morphine "as ordered" (antiemetic and narcotic pain medications; ordered 4 milligrams and 2 milligrams respectively) and that Normal Saline intravenous (IV) fluids were started. The physician orders indicated to give 500 milliters IV bolus times one, then IV infusion at 100 ml per hour. At 1:35 p.m. nursing notes indicated the patient was in no distress, IV catheter was removed (amount of fluids given not documented) and discharge instructions given to the patient. Discharge instructions on 9/25/11 at 1:38 p.m. contained instruction to "return if worse." Patient 1 was noted as discharged to "self" walking. The following vital signs were documented on 9/25/11 at 1:35 p.m. (prior to discharge): BP 200/101 (high); P 58, R 16 and T 98.2. The pain level was not documented. The patient was discharged 20 minutes after administration of powerful narcotic pain medications. The high blood pressure was not addressed.

In an interview with Physician 1 on 11/13/12 at 12:15 p.m., the physician stated that he was aware of Patient 1 being seen 3 times in the ED on 9/25/11 and was aware of the final diagnoses and outcome. Physician 1 stated that knowing what he knows now would not change how he treated Patient 1 during Patient 1's 2nd ED visit. The physician was not aware of any changes in ED provision of care resulting from any hospital reviews of Patient 1 care.

Review of the ED record for the 3rd ED visit showed that Patient 1 returned once more to the ED (3rd visit within 13 hours) on 9/25/11 at 2:25 p.m. per the Medical Screening Exam/Triage form (per the ED log arrival time was 2:28 p.m.). Staff checked boxes for patient arrived by "self" and "walk." Patient 1's chief complaint was noted "weakness." No time of triage and no vital signs were documented. RN 1's triage notes documented that the patient was brought in by an ambulance "for lying on ground at bus stop." The triage category was marked for both, "emergent" and "urgent". The physical exam portion of the form contained check marks in many boxes indicating a description of the patient's condition and there was a hand written note over the triage assessment section of "cancel please error."

Review of the 3rd ambulance pre-hospital record on 9/25/11 starting at 2:14 p.m. documented the chief complaint as general weakness, non-trauma, patient lying on side of roadway and ambulance called by the hospital guard. It was noted that Patient 1 was just discharged from the hospital 20 minutes earlier. Patient 1's vital signs at 2:45 p.m. were noted in the ambulance record as follows: BP 124/86; P 80 and R 18.

Review of nursing progress notes for the 3rd visit on 9/25/11 showed that at 2:30 p.m. Patient 1 was in a wheelchair awaiting registration with a male companion. At 2:40 p.m. RN 1 noted that nursing staff was obtaining contact information from the patient to arrange for a ride home (for his sister to come and pick him up). Patient 1 was in the waiting room near a water fountain having a drink. At 2:45 p.m. RN 1 documented that Patient 1 was lying on the ground under the water fountain complaining of his back hurting. RN 1 documented that she instructed the patient to get up and that Patient 1 was refusing help to get up to wheelchair. There was no documentation of a patient's assessment by RN 1 as he complained of pain. At 2:50 p.m. nursing notes documented that the patient continued to be "uncooperative" and that family was contacted and would pick up the patient in about 1.5 hours. The next nursing entry at 3 p.m. indicted that per housekeeping Patient 1 was lying on the floor in triage area unresponsive. The above nursing notes from 2:40 p.m. to 3 p.m. were signed by RN 1.

The ED provider (Physician 3) record for Patient 1's third visit to the ED on 9/25/11 (not timed) documented that Patient 1 was unresponsive, no BP, no pulse and no respirations. Resuscitation efforts were documented ineffective and Patient 1 was pronounced dead at 3:20 p.m. Physician 3 noted that Patient 1 came to the ED last night complaining of back pain and was discharged at 3:30 a.m. Physician 3 also noted that the patient returned with the same chief complaint, was discharged and came back with a friend in a.m., stating his back still hurt. Physician 3 further noted that while waiting, the friend left and Patient 1 "fell on to the floor dead." The record showed that prior to the patient collapsing unresponsive on the floor, no ED provider evaluated the patient after presenting for the 3rd time within 13 hours for his back pain and extremity weakness.

In an interview on 11/14/12 at 12:05 p.m. RN 1 stated that she was involved in care for Patient 1 during his 2nd and 3rd visits to the ED on 9/25/11. RN 1 stated that she was assigned to the ED (not triage) when Patient 1 arrived by an ambulance. After a brief look and recognizing the patient from the previous visit just 20 minutes ago, Patient 1 was redirected to triage. RN 1 stated that she completed part of the triage assessment while talking with the patient on the gurney escorting the ambulance crew to triage. RN 1 stated that as she asked the patient questions he told her that he used cocaine prior to coming in. During the short trip to the triage area, Patient 1 was complaining of back pain but otherwise looked stable. RN 1 confirmed that she took no vital signs and performed no physical assessment of the patient. RN 1 stated that she left the patient in triage and returned to ED. RN 1 left to make phone calls as requested by Patient 1 to his sister and also to answer calls from board and care returning her calls from the patient's earlier ED visit. The chief complaint "weakness" was documented by the clerk upon initiating ED record. RN 1 stated that report by medics was given to the triage nurse (RN 6). RN 1 stated that she wrote "cancel please" over the triage note after the patient collapsed and was transferred to ED room at 3 p.m. after Patient 1 was found unresponsive in the lobby.

RN 1 confirmed the nursing notes on 9/25/11 starting at 2:40 p.m. were accurate. RN 1 confirmed that she observed the patient standing up from the wheelchair leaning toward the water fountain and then lying down on the floor calling out for his friend and refusing to get up when instructed. RN 1 verified that she did not assess the patient at 2:45 p.m. when the patient was complaining of his back hurting and lying on the floor refusing to get up to wheelchair. The RN did not notify the ED provider that the patient was on the floor complaining of pain. RN 1 stated she did not believe that the patient's back pain was severe because he was moving his extremities even though he complained that he could not move his legs.

Review of the Emergency Medicine P&P #1201 titled "Standards of Care" (effective 6/21/11) indicated that "Standards of practice or care shall be observed." The P&P in part indicated, that "Registered Nurse performs a comprehensive nursing assessment and develops and implements patient treatments consistent with objectives of multidisciplinary treatment ..." All data collected will be obtained and documented through interview process, patient health history, observation, physical examination, record review, diagnostic reports and consultation reports. The patient assessment includes chief complaint and present physical and emotional status, method of arrival, special dietary needs, vital signs, pain assessment, focused review of affected systems and medical history, medications, allergies, etc. The P&P indicated, that "...Assessments and supportive data are thoroughly documented... assessments and patient needs are communicated to the healthcare provider(s) who are responsible for the care and treatment of the patient... the nursing process is used on ongoing basis to reflect the patient's current condition and treatment plan..."

The P&P further indicated, that "The goal for initiation of the Medical Screening Exam is as soon as possible and ideally no longer than 15 minutes from patient presenting to the Emergency Department" and will include sign-in date/time, complaint, vital signs, medications, allergies, pain assessment, past medical history/social history, physical exam of affected systems, physical exam of potentially affected systems and known chronic conditions, any testing necessary to rule out the presence of "legally defined emergency medical condition", triage category and adequate documentation of all above. It continued to say, "The patient will receive treatment based on the nursing and ED Provider assessment and all members of the multidisciplinary team will coordinate efforts to plan, identify, and meet patient outcome goals..."

In a collaborative interview on 11/15/12 starting at 9:30 a.m. with the ED Nursing Department Manager and the Director of Standards and Compliance both stated that no reviews of total care for Patient 1 was conducted by the quality process. A peer review was performed for the first visit only, with no problems and no improvement opportunities identified. Both stated that the hospital had no system in place to be able to monitor and did not monitor patients returning to the ED within 72 hours, to evaluate possible reasons for patients returning to the ED and/or to identify potential problems with the triage process, Medical Screening Exams and/or stabilizing treatments.

In a collaborative interview on 11/15/12 starting at 12:45 p.m. with the Emergency Department Chairman (Physician 2) and the Director of Standards and Compliance, Physician 2 stated that part of the ED Medical Staff's role was to ensure quality of patient care in the ED by various methods such as credentialing of providers in the ED, reviewing of ED cases for appropriate care, including all deaths in the ED, and developing and implementing ED policies. Physician 2 stated that when reviewing ED deaths the expectation was for all ED care for the patient to be reviewed, including appropriate triage prior to MSE by the ED provider. The physician acknowledged that this was not done for Patient 1. The physician confirmed that triage RNs were not qualified to perform MSEs in the hospital (not authorized per the Medical Staff Bylaws or Rules and Regulations).

Review of the ED policy titled "Plan for Patient Care and Performance Improvement" (effective 6/16/2011) in part indicated that "The Nursing Department Manager, in collaboration with the Emergency Department Chairman and Medical Director, coordinates plans and implements a multidisciplinary plan for a variety of patients. Professional and ancillary nursing staff members deliver nursing care according to established Emergency Department standards and participate in all aspects of healthcare delivery. The Nursing Department Manager or Assistant Department Manager directs and evaluates nursing staff in all patient care functions..." The purpose was in part identified as "...To identify important aspects of patient care in high-volume, high-risk and problem-prone populations; to develop pertinent measurable indicators; to monitor and evaluate quality and appropriateness of healthcare delivery..." The policy identified high-volume, high-risk and problem-prone populations. MSE was included in the list of High-Volume Procedures. High risk procedures included "unplanned return within 72 hours." The policy named important aspects of care that included "timeliness of access to care."

In summary, the hospital failed to monitor patient returns to the ED within 72 hours per their quality plan. Patient 1 presented to the ED three times within a 13 hour period on 9/25/11. Patient 1 had no additional diagnostic procedures performed when presenting to the ED the second time. Patient 1 collapsed in the ED lobby and expired in the ED during the third visit while awaiting a MSE. There was no documentation that the patient was appropriately assessed and triaged to facilitate timely access to care by an ED Qualified Medical Practitioner, to determine if an emergency medical condition existed. There was no evidence presented that the case was reviewed by the hospital quality process and that improvements were identified and implemented to prevent recurrence.

2. Review of ED triage nursing documentation showed that Patient 2 arrived to the ED on 9/14/12 at 6 p.m. by an ambulance with a chief complaint of "overdose." Vital signs were as follows: BP 109/72; P 84; T 36.6; RR 14; and O2 Sat 96%. The ambulance pre-hospital record showed that Patient 2 was found unconscious with respiratory arrest due to heroin (a powerful narcotic made from morphine) overdose and had to be resuscitated.

The ED triage nurse (RN 7) noted on 9/14/12 at 6:23 p.m. that the Fire Department staff administered 2 mg Narcan intramuscular (a narcotic antagonist used to counteract the effects of the heroin) to the patient for agonal respirations (very slow abnormal respirations). The patient was noted as alert and oriented and "active" on arrival to the ED. RN 7 noted, the patient "did heroin" at approximately 5:30 p.m. and "states it was accident." The note indicated the patient was placed in bed "F" (an unmonitored bed located in the end of the ED hallway near the ambulance entry door). The patient was assigned triage category "urgent."

The ED record showed no monitoring and no further evaluation of Patient 2 in the ED. A nurse (RN 3) documented at 8:30 p.m. (two and a half hours after arrival to ED) that Patient 2 was not found on gurney or in the lobby. The ED log documented that Patient 2 left without being seen.

In an interview with ED Nursing Department Manager on 11/14/12 at 11 a.m., the Manager stated that "urgent" triage category was appropriate for Patient 2, since on presentation the patient was alert and oriented and appeared in no distress, regardless of his earlier overdose on heroin requiring rescue with Narcan.

Review of ED policy titled "Medical Screening Examination-Triage protocol for overdose/ingestion" (2/14/07) indicated in the section "Triage to the Emergency Department" that "All drug overdose patients should be categorized as Emergent."

"Naloxone hydrochloride (Narcan) prevents or reverses the effects of opioids, including respiratory depression, sedation, and hypotension... The duration of action is dependent upon the dose and route of administration of Naloxone hydrochloride. Intramuscular administration produces a more prolonged effect than intravenous administration. The requirement for repeat doses of Naloxone, however, will also be dependent upon the amount, type and route of administration of the narcotic being antagonized... The patient who has satisfactorily responded to Naloxone should be kept under continued surveillance and repeated doses of Naloxone should be administered, as necessary, since the duration of action of some narcotics may exceed that of Naloxone." http://www.drugs.com/pro/naloxone.html.

In an interview with ED Physician 2 (Chairman of ED) on 11/15/12 at 1 p.m., the physician confirmed that the expectation was that patients presenting for overdose were to be evaluated upon arrival to the ED and ideally monitored for at least an hour to ensure no respiratory distress recurred for patients that had Narcan administered as a rescue drug.

Review of the P&P #1211, titled "Emergency Department Throughput Standards" (effective 6/22/11) addressed the completion of the "Initial Nursing Assessment/Triage Form" to be completed by the triage nurse. The policy indicated to perform triage interventions as appropriate per triage protocols.

3. Review of ED triage nursing documentation showed that Patient 3 arrived to the ED on 9/2/12 at 5:30 p.m. by "wheelchair" with a chief complaint of "choking." Vital signs were as follows: BP 130/96; P 122; T 36.8; RR 20; and O2 Sat 98%. The triage nurse (RN 9) noted (no time) that the patient was complaining of coughing, headache, difficulties breathing and weakness of lower extremities for 1 month and a half and that after 5 minutes was able to breathe "better." RN 9 documented positive findings under patient's respiratory assessment as "labored" and "cough." It was noted that Patient 3 was placed in a hallway bed "F" at 6 p.m. The triage category non-urgent was assigned for Patient 3. The record showed that the patient was seen by an ED provider at 10:55 p.m. for shortness of breath and was diagnosed and treated for asthma then discharged home on 9/3/12 at 1:25 a.m.

A nursing note on 9/2/12 at 10:25 p.m. by RN 3 documented that Patient 3 was found sitting in hallway and after signing out AMA (against medical advice), returned back to previously assigned hallway bed for treatment and was waiting to be seen. Patient 3's initial 5:30 p.m. vital signs readings were recopied at 10:25 p.m. The next reassessment was not completed until upon discharge on 9/3/12 at 1:25 a.m.

In an interview with RN 3 on 11/14/12 at 11:30 a.m., the RN 3 stated that on 9/2/12 at 10:25 p.m. she noticed Patient 3 sitting in a chair near bed "F" in the ED hallway. There was no chart for the patient and his English was poor. After looking around she found a chart for Patient 3 in the "discharged " pile. The chart contained an AMA form signed by Patient 3 and a staffing clerk indicating that the patient was leaving the hospital "against the advice of, and without the consent of the attending Doctor" and that "the patient was informed of the risk involved." RN 3 stated that the staffing clerk had no clinical background, was not a nurse or a physician, and it was not clear why the clerk was having the patient sign the AMA form. RN 3 confirmed that the vital signs at 10:25 p.m. were the original vitals recopied and that the patient was not reassessed and not seen by the ED provider until 10:55 p.m.

Review of ED policy titled "Medical Screening Examination-Triage protocol for respiratory" (dated 2/14/07) indicated in the section "Triage to the Emergency Department" that patients presenting with difficulties breathing should be assigned triage category urgent at minimum. Policy # 1203 titled "Assessments of the Emergency Department Patient" (7/30/05) directs that "The goal of ongoing vital signs shall be obtained based on patient's triage category:
> emergent or critical patients every 5-15 minutes until stable; then every 1 hour, or sooner if needed, and prior to admission or transfer;
> urgent patients every 2 hours, and prior to admission, transfer or discharge;
> non-urgent patients every 4 hours and prior to discharge."
Patient 3 was not reassessed per policy requirements.

4. Review of ED triage nursing documentation showed that Patient 4 arrived to the ED on 9/28/11 at 5:30 p.m. with a chief complaint of "left flank pain times 2 days, light headed, dysuria." Vital signs were within normal limits and O2 Sat 95%. The triage nurse (RN 11) assigned triage category "urgent" for the patient. Review of the ED record showed that the patient was called but did not answer at 0010 a.m., 0031 a.m. and 0108 a.m. The patient was not reassessed at least every 2 hours per policy to ensure timely access to care based on the patient's condition.

5. Review of the ED triage nursing documentation showed that Patient 5 arrived to the ED on 9/3/12 at 4:43 pm with a chief complaint of "5-weeks pregnant - bleeding like period. The patient's vital signs were within normal limits and oxygen saturation was 95%. Further documentation noted that "LMP 7/27/12 having pain prior to urination. Also spotting blood. called nurse line and instructed to go to ER states pain spotting times 1 week blood now increased." The triage nurse (RN 12) assigned a triage category of non-urgent. There was no documentation of any further reassessments. Nursing staff documented that they attempted to locate Patient 5 at 10:28 p.m., 11:03 p.m. and 11:35 p.m. but the patient had LWBS. The patient was not reassessed per policy of at least every 4 hours.

6. During observations of the ED on 11/14/12 at 2 p.m. it was noted that Patient 13's chart was located in the section for charts to be seen by a ED provider. Review of the chart showed that Patient 13 was assessed and triaged by a Licensed Vocational Nurse (LVN 1) who assigned triage category "emergent" to the patient on 11/14/12 at 1:20 p.m. The ED Charge Nurse on duty confirmed that the LVN was assigned to the patient and performed the triage and initial assessment of the patient. On 11/14/12 at 2:13 p.m. the ED provider (PA 2) was observed picking up the chart for Patient 13 and confirmed that she has not yet seen the patient.

In an interview on 11/14/12 at 2:05 p.m. LVN 1 stated that she triaged Patient 13 upon arrival to the ED and assigned category "emergent" because the patient was a rule out stroke diagnosis and she wanted the patient to be "seen soon." LVN 1 stated that she was called in from the Nursing Staffing Pool to work in the ED and was assigned four patients independently.

Review of the Emergency Departmental P&P #2319 titled "Staffing" (11/18/09) indicated that "Only Registered Nurse will be assigned to the role of Charge Nurse, Triage Nurse or to the care of critical care/trauma patients."