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ST CATHERINE OF SIENA HOSPITAL 50 ROUTE 25A SMITHTOWN, NY 11787 Sept. 13, 2018
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review and interview, the facility failed to assign an appropriate Emergency Severity Index (ESI) Triage Level and conduct appropriate medical assessments and reassessments in one (1) of eleven (11) patients presenting to the Emergency Department (ED) (Patient #1).

Findings include:

Review of Patient #1's Medical Record identified the following: This [AGE]-year-old was brought to the ED on 05/02/18 at 5:14PM for complaints of head and hand injuries after falling in her home the day before. At 5:21PM the patient was triaged with vital signs as follows: BP 88/55 (Normal range - below 120/80); Pulse 103 (Normal range - 60-100 beats per minute).

The patient was assigned Emergency Severity Index (ESI) Level 4, (Stable patient with only one {1} type of resource anticipated). The patient was sent to the Fast Track Area (less urgent patients are evaluated in Fast Track).

The patient was assessed by a Physician's Assistant at 5:46PM, the plan: CT scan of head, facial bones and x-ray of left hand. The CT scan of the head was ordered at 6:01PM. Findings identified superficial brushing of the left forehead. CT scan of the facial bones was unremarkable. The x-ray of the left hand performed at 6:29PM identified a fracture of distal left finger.

The Physician's Assistant documentation states that he went to reassess the patient at 7:18PM. Patient was found unresponsive. A Code was called, and resuscitation was initiated. The patient was pronounced dead at 7:33PM.

Review of the Emergency Department Triage Protocol last reviewed 10/2017 notes that an ESI Level 4 is assigned to patients who require one (1) resource only. Outcomes will not be adversely affected if evaluation and treatment were delayed many hours. The Policy emphasizes that when making a triage decision the patient's chief complaint is considered along with vital signs...in the event that the patient does not clearly fall in one of the ESI Levels the RN will up-triage, that is, classify the patient into the next highest severity level.

There was no indication that the patient was assigned the appropriate triage level in view of the patient's low blood pressure (88/55) and an elevated heart rate of 103. Based on the facility's Triage Policy, the patient required more than one (1) resource.

At interview on 09/12/18 at 11:20AM, Staff C (RN Triage Nurse) stated that the ED Charge Nurse advised her to change the patient's (Patient #1) ESI Level from a 4 to a 2 as a patient with a low BP and hand pain should have been assigned a Level 2. Staff C acknowledged that "I don't know what happened. It didn't get changed."

Review of the facility's Policy titled, "Assessment/Reassessment of Patients" revised 04/2016, stated, "The patient is reassessed throughout hospitalization to ensure that pertinent changes in the patient's care or needs are recognized promptly and reported to appropriate members of the health team ... The team will develop or revise the plan of care, provide appropriate management of the patient's ... changing health care needs ..." "Reassessment will be ongoing."

There is no documented evidence of a reassessment of the patient or monitoring activities. There were no documented vital signs until approximately two (2) hours after, when a Rapid Response was called at 7:18PM. The documented blood pressure during the initiation of the Code was 90/22 at 7:20PM.

During interview on 09/13/18 at 11:55AM with Staff H (ED Attending) he stated that if he was informed that the patient's blood pressure was low, he would have had the patient moved to the Main ED where she would have received continuous monitoring and reassessment.