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UNIVERSITY OF ILLINOIS HOSPITAL 1740 WEST TAYLOR ST SUITE 1400 CHICAGO, IL 60612 June 6, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on review of Hospital policy, Emergency Department (ED) log, clinical records, and staff interview, it was determined, that for 8 of 15 patients (Pt's. #3, 4, 6, 7, 9, 12, 13, & 15), the Hospital failed to reassess patients, as required by policy.

Findings include:

1. Hospital policy titled, "Nursing Assessment and Documentation Standards for UIC Emergency Department", revised on 12/10, required, "Triage... 2. Patients sent to the waiting room due to bed unavailability must be reassessed as delegated by the charge nurse. Reassessment should include recheck of any abnormal vital signs, pain assessment, and observations, related to the chief complaint... Main Treatment Area... 2. Reassessment including vital signs should be done minimally every two hours while in the main treatment area or more frequently as appropriate." The policy did not require patient reassessment for patients in the waiting room.

2. On survey date 6/4/12, at 9:15 AM, the Emergency Department (ED) Log for 1/30/12 was reviewed. The log included 18 patients who Left Without Being Seen (LWBS) on 1/30/12. An ambulance bypass was in effect on 1/30/12 between 6:50 PM and 1/31/12 at 2:50 AM

3. Eight of those 18 LWBS patients' (Pt's. #1 - 8) clinical records were reviewed on 6/4/12 between 9:40 AM and 10:30 AM. Four patients (Pt's. #3, 4, 6 & 7), with serious complaints (seizures, chest pain, and overdose), were triaged, but LWBS 4 to 6 hours later and had not received subsequent assessment after triage.

- Pt #3 was a [AGE] year old male, arriving in the ED on 1/30/12 at 2:45 PM, with a complaint of Possible Seizures. Pt. #3's vital signs and pain level (high at 8/10) were assessed during triage at 3:24 PM, but were not reassessed. Pt. #3 LWBS at 6:05 PM.

- Pt #4 was a [AGE] year old female, arriving in the ED on 1/30/12 at 3:38 PM, with complaints of Chest Pain and Shortness of Breath. Pt. #4's vital signs and pain level (moderate 6/10) were assessed during triage at 3:41 PM, but were not reassessed. Pt. #4 LWBS at 7:44 PM.

- Pt #6 was a [AGE] year old female, arriving in the ED on 1/30/12 at 4:12 PM, with complaints of Chest Pain and Shortness of Breath. Pt. #6's vital signs (high blood pressure 164/106) and pain level (highest 10/10) were assessed during triage at 4:39 PM, but were not reassessed. Pt. #6 LWBS at 9:00 PM.

- Pt #7 was a [AGE] year old male, arriving in the ED on 1/30/12 at 4:41 PM, with a complaint of Drug Overdose. Pt. #7's vital signs (poor oxygen saturation 88%) were assessed during triage at 4:41 PM, but were not reassessed. Pt. #7 LWBS at 9:36 PM.

4. An additional 7 clinical records of patients who LWBS selected from 3 additional ambulance bypass days (3/4/12, 3/5/12, and 3/30/12) were reviewed. Four LWBS patient records (Pt's. #9, 12, 13, & 15) lacked reassessment after triage.

- Pt #9 was a [AGE] year old male, arriving in the ED on 3/4/12 at 1:14 PM, with a complaint of Right Chest Pain. Pt. #9's vital signs (elevated blood pressure 165/101) and pain level (moderate 5/10) were assessed during triage at 2:01 PM, but were not reassessed. Pt. #9 LWBS at 10:14 PM.

- Pt #12 was a [AGE] year old male, arriving in the ED on 3/4/12 at 1:18 PM, with a complaint of Fall with Swelling. Pt. #12's vital signs (elevated blood pressure 148/83) and pain level (moderate 4/10) were assessed during triage at 2:08 PM, but were not reassessed. Pt. #12 LWBS at 10:18 PM.

- Pt #13 was a [AGE] year old female, arriving in the ED on 3/5/12 at 9:16 PM, with a complaint of High Blood Pressure. Pt. #13's vital signs (elevated blood pressure 180/98) and glucose level (high 165 mg/dl) were assessed during triage at 9:19 PM, but were not reassessed. Pt. #13 LWBS on 4/5/12 at 12:14 AM.

- Pt #15 was a [AGE] year old female, arriving in the ED on 3/4/12 at 1:18 PM, with a complaint of Chest Pain. Pt. #15's vital signs (elevated blood pressure 173/99) and pain level (moderate 6/10) were assessed during triage at 2:03 PM, but were not reassessed. Pt. #15 LWBS at 5:36 PM.

5. The findings related to Pt's. #3, 4, 6 & 7 were discussed with a Clinical Nurse II (E #2) during the record review. E #2 stated that vital signs should have been taken every 2 hours. The findings related to Pt's. #9, 12, 13, & 15 were discussed with a Clinical Informatics/ Nurse (E #5) during the record review. E #5 stated that vital signs should have been taken every 2 hours.

6. These findings regarding lack of reassessment for patients in the ED waiting room were discussed during an interview on 6/5/12 between 2:00 PM and 2:45 PM, with the Chief of Emergency Medicine, ED Associate Director of Nursing, and ED Nurse Manager.

B. Based on review of clinical records and staff interview, it was determined, that for 3 of 15 patients treated in the Emergency Department (ED) (Pt's. #3, 7, &13), the Hospital failed to provide appropriate care and treatment.

Findings include:

1. On 6/4/12 at 10:00 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old male, arriving in the ED on 1/30/12 at 2:45 PM, with a complaint of Possible Seizures. Pt. #3's triage notes included, "Triage Subjective Complaint - Feeling that he will have a seizure for 3 days. Seen in other hospital for 2x for same problem and had test done. Dilantin level high..." Nursing notes did not indicate that Pt. #3 was placed on seizure precautions. Pt. #3 Left Without Being Seen (LWBS) at 6:05 PM.

2. On 6/4/12 at 10:20 AM, the clinical record of Pt. #7 was reviewed. Pt #7 was a [AGE] year old male, arriving in the ED on 1/30/12 at 4:41 PM, with a complaint of Drug Overdose. Pt. #7's triage note included, "Brought in by Paramedic per report heroin overdose. Given Narcan on route." Pt. #7's vital signs included, pulse 149, blood pressure 148/90, and oxygen saturation 88%. The Triage notes included, "Psych History." Pt. #7's admission history and physical, dated 12/8/11, from an admission less than 1 month earlier, (12/7/11 to 12/27/11) included, "Patient says he has thoughts of hurting himself for 2 - 3 months. Patient reports he came to the ED to be admitted because he is concerned about doing 'stupid things'. Patient denies a specific plan to harm himself but repeatedly stated that he did not feel safe to be discharged ..." Pt. #7 was not further assessed for danger to himself or placed on precautions. Pt. #7 LWBS at 9:36 PM.

3. The clinical record of Pt. #13 was reviewed on 6/4/12 at 2:15 PM. Pt #13 was a [AGE] year old female, arriving in the ED on 3/5/12 at 9:16 PM, with a complaint of High Blood Pressure (180/98). Pt. #13's random blood glucose level was 165 mg/dl. Pt. #13 stated "does not feel good". Pt. #3's blood pressure or blood glucose was not treated or reassessed. Pt. #13 LWBS on 6/5/12 at 12:14 AM.

4. The findings related to Pt's. #3 & 7 were discussed with a Clinical Nurse II (E #2) during the record review. E #2 stated that the seizure patient (Pt. #3) should have been placed on a cart for protection and that further triage assessment should have occurred for the psych patient (Pt. #7). The findings related to Pt. #13 were discussed with a Clinical Informatics/ Nurse (E #5) during the record review. E #5 stated that there was no documentation to indicate Pt. #13 received insulin or was treated for high blood pressure.