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MARY WASHINGTON HOSPITAL, INC 1001 SAM PERRY BOULEVARD FREDERICKSBURG, VA 22401 June 21, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and document review it was determined the emergency department staff failed to follow the facility's policy for monitoring/reassessment of triaged patients.

The findings included:

An interview was conducted on 06/20/2017 at 3:19 p.m., with Staff Member #2. Staff Member #2 provided and explained the facility's policy for reassessment of emergency department patients with a designated acuity of level three (Level 3). Staff Member #2 reported patients designated as level three (Level 3) acuity needed to be re-assessed every two (2) hours or more often if their condition changed. Staff Member #2 reported being aware of Patient #13's emergency department experience. Staff Member #2 reported nursing staff failed to maintain the facility's standard for every two hour reassessment of Patient #13.

Review of the facility's policy titled "Emergency Care and Treatment" read in part: "Assessment ... 2. Reassessment: a. Patients are re-evaluated by nurses based upon the assigned triage level and the patient's clinical status. Changes in the patient's status are communicated to the physician. Reassessment occurs as the patient condition warrants and upon discharge. b. The time standard for reassessment and documentation is: Acuity 1 : Every 15 minutes; Acuity 2: Every hour; Acuity 3: every 2 hours; Acuity 4: Every 4 hours; [and] Acuity 5: Every 4 hours ..."

[See citation 2406 for details]
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and document review it was determined the facility staff failed to monitor patients after triage and prior to the start of the medical screening examination for two (2) of thirty-three patients included in the survey sample. (Patients #13 and #14)

The findings included:

Review of Patient #13's electronic medical record (EMR) began on 06/20/2017 at 1:27 p.m., with Staff Member #12. Patient #13's EMR documented the patient arrived by emergency medical transport at "2337 (11:37 p.m.)" on 03/25/2017. Patient #13's EMR indicated he/she was triaged at 11:51 p.m. by Staff Member #17. Staff Member #17 documented Patient #13's vital signs, symptoms of generalized abdominal pain and the patient's stated pain level of eight (8) on a ten (10) point scale. Staff Member #17's documentation ended at "2356 (11:56 p.m.)." Staff Member #20, a technician, documented the completion of Patient #13's electrocardiogram (EKG) at 1:40 a.m. on 03/26/2017. Staff Member # 20 documented Patient # 13's EKG was shown to the emergency department (ED) physician, who determined Patient #13's acuity level as Level 3 (Non-Urgent). Patient #13's EMR did not contain additional nursing re-assessment documentation during the patient's wait of approximately three (3) hours and forty-five (45) minutes before being seen by the physician at approximately 5:25 a.m. 03/26/2017. Nursing staff failed to perform the required every two (2) hour monitoring/re-assessment while Patient #13 was waiting for his/her medical screening examination and determination of his/her emergency medical condition.

An interview was conducted on 06/20/2017 during the review of Patient #13's EMR with Staff Member #12. Staff Member #12 verified the above findings. Staff Member #12 provided the emergency department policy related to acuity levels and the required reassessment times.

Review of Patient #14's EMR was conducted on 06/20/2017 at approximately 2:02 p.m., with Staff Member #12. Review of Patient #14's EMR revealed the patient came to the facility's emergency department on 04/03/2017 at "9:43 p.m." via private vehicle. Patient #14's chief complaint was documented as "6 weeks pregnant and bleeding." The documentation indicated Patient #14 was triaged and assessed by nursing staff at "2228 (10:28 p.m.)." Nursing staff determined Patient #14's acuity level as "Level 3." Patient #14's EMR indicated at approximately 1:30 a.m. on 04/04/2017 the patient had an abdominal ultrasound. Patient #14's EMR documented an approximate three (3) hours wait between triage and the ultrasound without receiving the required every two hour monitoring/re-assessment.

An interview was conducted on 06/20/2017 during the review of Patient #14's EMR with Staff Member #12. Staff Member #12 verified the last triage nursing entry was documented as completed at "2229 (10:29 p.m.)" on 04/03/2017. Staff Member #12 verified Patient #14's EMR did not have documentation the patient moved from triage back to the lobby or went from triage to the treatment area. Staff Member #12 verified the next nursing entry was for the administration of medications timed at "0252 (2:52 a.m.)" on 04/04/2017.

An interview was conducted on 06/20/2017 at 3:19 p.m., with Staff Member #2. Staff Member #2 presented the facility's policy for emergency department patients with a designated acuity of level three (Level 3) and the required monitoring times. Staff Member #2 reported patients designated as level three (Level 3) were required to be re-assessed every two (2) hours or more often if their condition changed. Staff Member #2 reported being aware of Patient #13's emergency department experience. Staff Member #2 reported nursing staff failed to maintain the facility's standard of every two hour reassessment for Patient #13.

Review of the facility's policy titled "Emergency Care and Treatment" read in part: "Assessment ... 2. Reassessment: a. Patients are re-evaluated by nurses based upon the assigned triage level and the patient's clinical status. Changes in the patient's status are communicated to the physician. Reassessment occurs as the patient condition warrants and upon discharge. b. The time standard for reassessment and documentation is ... Acuity 3: every 2 hours ..."