HospitalInspections.org

Based on document review and interview, the hospital failed to ensure triage prioritization of patients for a medical screening examination (MSE) was provided at the time of arrival to the hospital/Emergency Department (ED) or in a timely manner, as indicated in the medical records (MR) for 3 of 20 patients (P9, P12, and P17).

Findings include:

1. Review of the policy titled Triage, Last Revised 1/2021, indicated the following:
Policy: Upon presenting to the Emergency Department, each patient will be triaged as quickly as possible and assigned a level of acuity.
Priorities of Care/Triage Categories: The Emergency Severity Index (ESI) triage algorithm yields rapid, reproducible and clinically relevant stratification of patients into five groups, from level 1 (critical) to level 5 (fast track). 1-Critical: Conditions requiring immediate life-saving medical interventions. Any delay in treatment is potentially life or limb threatening. Includes conditions such as airway compromise; Cardiac arrest; Severe shock; Cervical spine injury; Multisystem trauma; Altered level of consciousness; Eclampsia. 2-Emergent: Patients who arrived in high-risk situations. Includes conditions such as: Confused; Lethargic/Disoriented; Severe pain/distress; Pediatric fever... Danger Zone Vitals. 3-Urgent: Patients who present as stable but whose condition requires medical intervention within a few hours. Includes conditions such as: Fever; Minor burns; Minor musculoskeletal injuries; Dizziness; Lacerations. 4-Non-Urgent: Patients who present with chronic or minor injuries. There is no danger to life or limb by having these patients wait to be seen. Includes conditions such as: Chronic low back pain; Dental problems. 5-Fast Track: Patients who present with chronic or minor injuries. There is no danger to life or limb by having these patients wait to be seen.

2. Medical record (MR) review indicated the following:
Patient MR #9 lacked documentation of a MSE. The patient presented to the ED on 3/14/22 at 19:35 hours and was documented as left prior to triage without being seen (LWBS) at 20:33 hours. The patient registry indicated the patient had COVID symptoms.
Patient MR #12 lacked evidence of a prompt MSE. The patient presented to the ED on 3/13/22 at 22:35 hours with a complaint of chest pain and triage was not conducted until 23:04 hours; The MSE was not conducted until 23:05.
Patient MR #17 lacked evidence of a prompt MSE. The patient presented to the ED on 3/15/22 at 02:12 hours with a complaint of shortness of air/difficulty breathing. and triage was not conducted until 03:35 hours; The MSE was not conducted until 03:35 hours.

3. The following was indicated in interview on 3/31/22:
Beginning at approximately 11:15 AM:
A5, RN, indicated recent changes to ED triage included a return to a previous plan, from which they had moved away. A5 described the process as one that included assignment of the 2 staffed ED nurses; one to each hall/side and 1 of those two to triage. A5 indicated this gave specific responsibility for triage to 1 RN, but did not necessarily improve triage times. A5 indicated that without the registration person and/or first person to see the patient having medical experience, there may be a delay in triage if all rooms are full and/or patients in the back/ED are in need of immediate and continued nursing/medical attention when another person arrives to the ED due to trained staff being unavailable. A5 indicated ED staff could call for a "code help", but indicated staff who could respond often included housekeeping and/or maintenance.

A6, RN, indicated that at this hospital, they typically staff 2 nurses from 7am to 7pm and 2 from 7pm to 7am and a 3rd nurse may come in mid shift (11am to 11pm). A6 reiterated that while someone is assigned to triage they are also assigned patient care and are responsible for patient's in the bays on their side. He/she indicated that if a patient in the ED were in need of a lot of care, then triage of a newly arrived patient might have to be delayed. When asked what options were available for additional help during an influx, A6 indicated that if the ED Director was available he/she would/could provide additional assistance. A6 further indicated that if there was an emergency in the ED then it would be "all hands on deck" still leaving no one available for triage of a patient upon arrival. A6 indicated that staff could call a "code help". A6 indicated additional help was always appreciated, but the additional help was often maintenance who could not provided nursing services/patient care.

Beginning at approximately 1:30 PM, A2, Director of Quality Management, verified MR findings.