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.

WATAUGA MEDICAL CENTER 336 DEERFIELD ROAD BOONE, NC 28607 April 17, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on hospital policy reviews, open and closed medical record reviews, observations during tours and physician and staff interviews the hospital's Emergency Department staff failed to provide ongoing reassessment of the patient while in the triage waiting area 1 of 10 sampled patients (#3).

The findings include:

A review of the hospital's policy and procedure Assessment/Reassessment in the Emergency Department dated 03/12 revealed "....Patient Observation: Patients in the Waiting Room waiting for treatment will be monitored by the Triage Nurse and their acuity level will be reprioritized if their reassessment warrants. The Triage Nurse and Team Leader will work jointly to keep the Physicians informed as to the acuities and quantities of patients waiting to be seen and other significant changes as they occur..."

1. Closed medical record review of patient (#3) revealed an 84 y.o. (year old) female presenting to the ED (emergency department) on 01/16/2013 at 1759 and Triaged on 01/16/2013 at 1810, eleven minutes after arriving to the facility ED. Review of the Nursing Documentation Triage on 01/16/2013 at 1810 revealed "Triage Chief Complaint: Ear Discharge ...reports she has not felt well since Christmas. Had W/U (work up) for headache and numbness in left head about then. Left ear now draining ...Associated Signs and Symptoms: Denies: Earache, reports left face numbness past month. Not eating well c/o (complains of) nausea ...VS's (vital signs) T (temperature) - 98.4, P (pulse) - 98, BP (blood pressure) - 142/99 (elevated), R (respirations) - 18, weight - 95 pounds. ESI (Emergency Severity Index) Level III (score is level I - V with one being critical, life threatening emergency)"

Continued record review revealed on 01/16/2013 at 2159 "the patient was placed in Main ED Ex (exam room) 11." (4 hours after arrival to the ED; 3 hours and 49 minutes after initial triage).

Continued record review revealed the medical screen was completed by the ED physician 01/16/2013 at 2202. Review of the Physician Documentation on 01/16/2013 at 2202 revealed "The patient is an 84 y.o. female who presents to the facility with a complaint of Ear Discharge. Patient says she noticed blood drainage from her left ear this morning. She has been having intermittent, brief left-sided ear pain/headache for the past several weeks without improvement. She has also felt nauseated at times but has not vomited. She denies numbness or specific weakness but feels weak in general. She also reports that she has been having anterior chest pain tonight but says that is common for her. She denies shortness of breath ....the symptoms began 3 weeks ago...Past/Current Illness: Atrial fibrillation; Congestive heart failure (CHF);...Hypertension...Physical Exam: Head/Ears/Nose/Throat:...there is moderate amount of bloody discharge in left ear canal. No obvious perforation to TM (tympanic membrane)...Cardiovascular: Auscultation: Normal Rate; Irregularly irregular rhythm...Final Impressions: Acute chest pain, Left otitis media with probable TM perforation, [DIAGNOSES REDACTED], mild hypokalemia. Disposition: Admit; Condition at disposition: Stable; Admit to: As an inpatient to this hospital."

Continued record review revealed on 01/16/2013 at 2322 the pulse ox (pulse oximetry - measures oxygen) is 100% with 2L (liters) of oxygen being administered. Continued review revealed no documentation of the VS's. On 01/16/2013 at 2349 the VS's documented revealed P - 80; BP - 152/95 (elevated); R - 18; Pulse Oximetry is 100% with 2L of oxygen. Continued review revealed no other documented VS's.

Continued record review of the nursing assessment documentation on 04/16/2013 at 2343 revealed "Cardiovascular:..c/o pain to center of chest at bedtime only. Auscultation: Irregular rhythm; afib (atrial fibrillation)."

Observation during tour of the ED (Emergency Department) on 04/16/2013 at 1500 revealed the triage area is staffed with RN's (Registered Nurse) 24 hours a day 7 days a week who have completed a formal ESI (Emergency Severity Index) triage training program. Interview with the triage nurse (RN #1) revealed "...if the ED is full and a patient must return to the waiting room after triage to wait to be seen by the doctor then I would reassess that patient every 20-30 minutes, bring them back for BP (blood pressure) check and document my reassessment...I also inform the patient and/or family to notify me of any change or worsening in condition while they wait. I'm not sure what the policy says about reassessing in the waiting room after the patient has been triaged."

Continued tour of the ED was conducted on 04/17/2013 at 0900. An interview with RN #2 during the tour revealed "...If the patient must return to the waiting room to wait after being triaged then we always tell them or the family to notify us if their condition changes. I will reassess the patient in the waiting room as often as possible, probably every 15 - 30 minutes because their condition could change while waiting... the policy for reassessing the patient's who are waiting is every 4 hours."

An interview on 04/17/2013 at 0830 with ED physician treating patient (#3) revealed "I don't recall the patient but after looking at the chart she presented to triage at 1810 with c/o of ear drainage and then when I evaluated her at 2202 she was also complaining of chest pain that apparently she had not mentioned to the triage nurse...The physicians can see the computer screen that lists the patient's and their triage assessment who are waiting if we (the physician) feel, based upon the nurses triaged chief complaint (of the patient), VS's, and associated signs and symptoms, the patient needs to be brought back to a room we will call and have them brought back. I don't really know if the patient was reassessed while in the waiting room. Not sure of the policy for reassessing the patient's waiting to be seen but I would think they are being observed for changes in their condition."

An interview on 04/17/2013 at 1000 with RN #1 revealed "...this person (Patient #3) should have gone back pretty quick but I see she didn't get to a room until 4 hours after presenting... if we were busy with Level I & II's it's possible she would have had to wait but if a patient has to go back to the waiting room then we do reassessments every 30 minutes or so and document them in the computer...there is no documentation of a triage reassessment on this patient while she was waiting in the waiting room. According to my assessment and the physicians by the time she reached the ED treatment room her condition had changed and she was c/o of chest pain."

An interview on 04/17/2013 at 1140 with RN #3 revealed " ...I did the triage on patient #3 at 1810 then my shift would have ended at 1915. I screened her as a Level III. We must have been busy or I would have taken her straight to an ED room...She was taken to the treatment room at 2159...My shift ended at 1900 so I would not know why there was a delay in taking her to an ED room ...While in triage if waiting we should reassess and document the reassessment; I personally try to reassess hourly...I think the policy is every hour...I do not see a documented reassessment for the patient while she was waiting in the waiting room."

An interview with 04/17/2013 at 1215 with administrative staff revealed "the policy does not state a time the reassessment is to be done but I would expect it to be done within 1-2 hours based upon the acuity level of the patient. This patient (#3) was a Level III and was not reassessed and should have been while in the waiting room."