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.

OSF SAINT ANTHONY MEDICAL CENTER 5666 EAST STATE STREET ROCKFORD, IL 61108 Dec. 22, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 3 of 5 (Pt. #1, Pt. #2 and Pt. 6) Emergency Department (ED) patients reviewed for extended waiting room times, the Hospital failed to ensure patients were monitored every 2 hours, as per policy.

Findings included:

1. The Hospital's policy titled, "Triage and Admission to the Emergency Department (9/4/2020)" was reviewed on 12/21/2020 and required, "Patients in the waiting room will be reassessed as condition warrants or a minimum of at least once every 120 minutes. Reassessments will be documented on the patient's medical record."

2. The clinical record of Pt. #1 was reviewed on 12/21/2020. Pt. #1 (MDS) dated [DATE] at 10:44 AM with complaints of shortness of breath. Per the ED notes, Pt. #1 completed triage on 11/9/2020 at 11:40 AM and was placed in the waiting room, until a bed became available in the ED. After being triaged, while in the waiting room, Pt. #1 had vital signs (blood pressure, temperature, pulse and respirations) performed at 1:25 PM and 2:19 PM, no other vital signs were documented. Pt. #1 left AMA (against medical advice) at 7:25 PM (5 hours).

3. The clinical record of Pt. #2 was reviewed on 12/21/2020. Pt. #2 (MDS) dated [DATE] at 1:39 PM with complaints of fever and back pain. Per the ED notes, Pt. #2 completed triage on 10/8/2020 at 2:27 PM and was placed in the waiting room. The clinical record lacked vital signs after the original, performed during triage at 2:27 PM. Pt. #2 left AMA on 10/8/2020 at 8:15 PM (6 hours).

4. The clinical record of Pt. #6 was reviewed on 12/22/2020. Pt. #6 (MDS) dated [DATE] at 9:51 AM with complaints of throwing up blood. Per the ED notes, Pt. #6 completed triage on 11/9/2020 at 10:05 AM and was placed in the waiting room. Pt. #6 had vital signs performed at 12:00 PM and 1:35 PM, no other vital signs were documented. Pt. #6 left AMA at 6:20 PM (5 hours).

5. The Triage Nurse (E#6) on duty was interviewed on 12/22/2020 at 10:15 AM. E#6 stated that patients are triaged based on their chief complaint as they arrive. E#6 stated, "Depending on our patient census, a patient may be required to remain in the waiting room until a bed opens up in the department. They could be there for several hours." E#6 stated that if a patient is in the waiting room, they need to be checked on at least every 2 hours or more often if needed.