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The failure of medical staff to assure that patients receive adequate assessment. There is further lack of medical staff supervision of Emergency Room staff resulting in patients not being adequately assessed for the extent of their condition and to determine appropriate level of care. Medical staff oversight has not been provided to detect this systemic failure/problem. (See Tag 1104).

Based on document review and staff interview it was determined the hospital's Quality Assessment/Performance Improvement (QA/PI) program failed to detect and correct the systemic failure of the Emergency Department (ED) to assure that patients receive adequate assessment. This failure creates the potential for an adverse impact on the quality of care for all ED patients.

Findings include:

1. During the course of the survey it was determined the ED was not adequately assessing patients who presented to the ED and were required to wait for a medical screening examination. In addition, it was determined the triage classifications were not being assigned correctly.

2. An interview with the ED Nurse Manager during the course of the survey, and review of QA/PI documentation for the past year, revealed the hospital was aware of issues with the triage classification process. The hospital failed to address and correct the identified problems.

3. The above findings were reviewed and discussed with the Director of Quality at 1:15 p.m. on 4/29/15 and she agreed with the findings.

Based on record review, document review and staff interview it was determined the medical staff failed to establish and maintain a procedure/policy for ensuring completion of a triage assessment, which includes vital sign assessment prior to establishment of triage class for all Emergency Department (ED) patients who wait for a medical screening examination. This deficient practice was identified in ten (10) of ten (10) records reviewed (patients # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure has a high potential to negatively impact the care and condition of all ED patients.

Findings include:

1. Review of the 3/23/15 ED record for patient #1 revealed he arrived at the ED at 2:22 p.m. Review of the Triage, documented by Registered Nurse (RN) #1 at 2:22 p.m., revealed the Date of Occurrence/Symptom Onset section of the triage assessment was not completed. The chief complaint was recorded as: "eval." The nurse noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's Emergency Severity Index (ESI) was recorded as four (4). The patient's vital signs were not assessed.

Further review of the record revealed the patient waited one (1) hour and twenty-two (22) minutes before vital signs were assessed at 3:44 p.m. The patient's blood pressure was 202/82 (normal is 130/80). The nurse also recorded, "reports feeling depressed and worthless, reports feeling suicidal at times, denies homicidal thoughts", at 3:42 p.m. The patient was in the ED for five (5) hours and thirty-three (33) minutes before he eloped. The patient's vital signs were never reassessed.

2. The above record was reviewed and discussed with the ED Nurse Manager at 1:45 p.m. on 4/27/15. The Nurse Manager agreed with the above findings, stating the patient's triage assessment was incomplete, the ESI score should have been three (3), not four (4), due to the suicidal ideations, and his elevated blood pressure was not reassessed as required by policy.

When asked why the patient's vital signs were not assessed at triage, she stated the expectation for triage is that patients who need immediate treatment are taken directly into the ED. Patients who wait are asked what their complaint is, what their signs and symptoms are, and are then assigned an ESI number (triage class), which indicates severity of symptoms. The Nurse Manager stated vital signs are not assessed at triage and are not part of the ESI assignment process. She explained the ESI process includes a rating scale of one (1) to five (5), with one (1) being the most serious.

The Nurse Manager acknowledged the hospital is aware there are problems with the accuracy of the ESI numbers being assigned to ED patients. She stated she felt staff needed education related to the ESI process and noted she recently e-mailed the ESI handbook to all ED nurses. When asked what the ESI handbook stated about vital sign monitoring she indicated she was not sure. The Nurse Manager stated she just received a hard copy of the handbook and had not yet had time to review the information.

3. The policy, "Triage Classification", last reviewed 9/14, was provided for review. The policy states, in part: "All individuals presenting to EMSTAR for treatment are triaged by a registered nurse within 5 minutes and assigned a triage classification Emergency Severity Index 1-5 based on severity of illness or injury and anticipated resources needs..." The policy does not reference vital signs.

4. The policy, "Assessment and Reassessment of Patients", last reviewed 9/14, was provided for review. The policy states, in part: "The initial assessment determines the patient's care needs...Any abnormal vital signs must be reported immediately to the EMSTAR physician and repeated within 30 - 60 minutes...Reassessment of patients is determined by the triage classification, response to interventions, and when significant change occurs in the patient's condition or diagnosis. Reassessment should include vital signs as appropriate including reassessment of pain...Reassessment shall be done at a minimum: ESI-1: every thirty minutes, ESI-2: every thirty minutes until stable or improvement in patient's condition, ESI-3: hourly, ESI-4: every two hours, ESI-5 every two hours...Prior to discharge, patients shall have documentation of patient's condition including response to interventions and vital signs as appropriate."

5. A request was made for the ESI handbook. The "ESI handbook, A Triage Tool for Emergency Department Care, version 4, 2012 edition" was provided for review. The handbook states, in part: "Before assigning a patient to ESI level 3, the nurse needs to look at the patient's vital signs and decide whether they are outside the accepted parameter...based on the patient's history and physical assessment, the nurse must ask if the vital signs are enough of a concern to say that the patient is high risk and cannot wait to be seen,...examples of high risk situations (ESI 2) ...suicidal or homicidal patient...the ESI Research Team recommends a full set of vitals at triage, including temperature, heart and respiratory rates, and blood pressure..."

6. The above findings were shared with the Nurse Manager and she agreed with the findings. At 10:20 a.m. on 4/28/15, the Nurse Manager stated she spoke with both the Charge Nurse and the Triage Nurse the prior evening and made it clear vitals signs were now required for all patients at the time of triage. She stated she also spoke with the Education Nurse regarding providing ESI education to all nurses and sent an e-mail to all ED nurses regarding the change. She also confirmed she spoke with both the ED Medical Director and Chief Nursing Officer (CNO) regarding the implemented change. She provided a copy of the e-mail titled, "New Changes for Triage Starting Now", dated 6:00 p.m. 4/27/15, which was provided to staff.

The e-mail stated, in part: "We have some problems with the current triage process and ESI scoring that needs changed today...The changes we have to start now are, If a patient is a ESI level 1 or ESI level 2 they go straight back to the rooms with no delays, the nurse or tech is informed and vitals happen right away. All other patients that present to the window for triage must have a set of vital signs including a temperature to decide the ESI score they should be assigned. This needs to be done as soon as you make contact with the patient.

The four decision points depicted in the ESI algorithm are critical to accurate and reliable application of ESI. The figure shows the four decision points reduced to four key questions: A. Does this patient require immediate life-saving interventions? B. Is this a patient who shouldn't wait? C. How many resources will this patient need? D. What are the patient's vital signs?

This is a process that has to start today and we must follow..."

7. An interview was conducted with the ED Medical Director at 10:45 a.m. on 4/28/15. The record for patient #1 was discussed, along with the complaint investigation conducted by the hospital regarding the 3/24/15 complaint that was filed with the hospital regarding the patient's care in the ED. The Medical Director stated he was not familiar with the patient/record and was unaware of the complaint. The Medical Director agreed that vital signs should be evaluated initially in triage and abnormals re-evaluated as indicated. He stated he was not very familiar with the ESI scoring process but that suicidal patients' scoring should reflect the higher risk. The Medical Director stated he received the e-mail regarding the change in triage process with addition of vital signs up front and he had also discussed it with the Nurse Manager. He confirmed he was not previously aware of when vitals signs were being assessed but supported the change and stated it was his expectation that vital signs be obtained.

8. An interview was conducted with the CNO at 12:05 p.m. on 4/28/15. She stated she was made aware of the findings regarding triage and the lack of vital sign monitoring and incorrect ESI assignments by the Nurse Manager the previous evening. The CNO stated she was not aware vital signs were not being assessed at triage prior to this. She stated it would be corrected immediately.

9. Review of the 3/23/15 ED record for patient #2 revealed she arrived at the ED at 3:40 p.m. Review of the Triage, documented by RN #2 at 3:41 p.m., revealed the Date of Occurrence/Symptom Onset section of the triage assessment was not completed. The chief complaint was recorded as: "eval." The nurse noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's Emergency Severity Index (ESI) was recorded as four (4).

At 4:02 p.m., the nurse documented the patient was "feeling depressed with anxiety, denies suicidal or homicidal thoughts, states she has a lot of family issues and chronic pain." At 4:04 p.m., twenty-four (24) minutes after triage, the patient's vital signs were assessed and the patient's blood pressure was elevated at 151/93 (normal 130/80). The patient was in the ED for four (4) hours and thirty-five (35) minutes. The patient received multiple intramuscular (IM) medications, which included pain medication. The patient's vital signs, including pain and response to medications, were not assessed.

The above record was reviewed and discussed with the Nurse Manager at 9:15 a.m. on 4/29/15. She agreed with the findings, stating the triage documentation was incomplete, the patient should have been classified as ESI-3, not ESI-4, and should have had vital sign monitoring.

10. Review of the 3/23/15 ED record for patient #3 revealed he arrived at the ED at 4:19 p.m., per ambulance, and was triaged at 4:25 p.m. The Date of Occurrence/Symptom Onset section was recorded as 3/23/13. The triage chief complaint was recorded as: "MH" (mental health). RN #3 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as three (3).

At 4:27 p.m., the nurse recorded: "pt arrived via EMS (emergency medical system) for overdose." At 4:31 p.m., sixteen (16) minutes after arrival and six (6) minutes after triage, the patient's vitals signs were assessed and the patient's blood pressure was elevated at 166/106 (normal 130/80). At 4:34 p.m., the nurse noted the patient had a plan to kill himself and thoughts of killing children. The blood pressure was re-evaluated at 4:58 p.m. and the blood pressure was 150/77. The patient was admitted to the hospital.

The above record was reviewed with the Nurse Manager at 9:17 a.m. on 4/29/15. She agreed with the findings, noting the initial triage information needs to be expanded and that the actual correct ESI level would be two (2), not three (3).

11. Review of the ED record for patient #4 revealed she arrived at the ED at 7:05 p.m. and was triaged by RN #2 at 7:08 p.m. The Date of Occurrence/Symptom Onset section was not completed. The triage chief complaint was recorded as: "anxiety and suicidal thoughts." RN #2 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as four (4). The patient's vital signs were not assessed.

At 9:33 p.m., two (2) hours and twenty-eight (28) minutes after triage, the nurse recorded the patient "states she took 5 ativan before arrival to calm her nerves, states if she doesn't get admitted then she is going to harm herself, denies homicidal thoughts."

The patient waited two (2) hours and thirty-two (32) minutes before vital signs were assessed at 9:37 p.m. The patient's blood pressure was elevated at 160/107 (normal 130/80) and heart rate was elevated at 105 (normal 60-80). The patient was in the ED for five (5) hours and thirty-three (33) minutes and never had her vital signs reassessed.

At 9:20 a.m. on 4/29/15, the above record was reviewed and discussed with the Nurse Manager. She agreed with the findings, noting the triage information was not complete, the ESI score was incorrect and vital sign assessment and reassessment did not occur, as expected.

12. Review of the ED record for patient #5 revealed she arrived at the ED at 7:21 p.m. on 3/23/15, accompanied by a sheriff's deputy. The patient was triaged by RN #2 at 7:21 p.m. The Date of Occurrence/Symptom Onset section was not completed. The triage chief complaint was documented as: "involuntary." RN #2 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as four (4). The patient's vital signs were not assessed.

One (1) hour and forty-two (42) minutes later, the patient's vital signs were assessed and the blood pressure was elevated at 158/99 (normal 130/80). The vital signs were rechecked one (1) time while the patient was in the ED, at 7:58 a.m. on 3/24/15, which was ten (10) hours and fifty-five (55) minutes later.

The above record was reviewed with the Nurse Manager at 9:30 on 4/29/15. She agreed with the findings, noting the triage documentation was incomplete, the ESI score was incorrect and vital signs were not reassessed per policy, as required.

13. Review of the 3/23/15 ED record for patient #6 revealed she arrived to the ED at 11:04 p.m. Her mode of arrival was noted as stretcher. The Date of Occurrence/Symptom Onset section was not completed. The triage chief complaint was recorded as: "eval." RN #2 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as four (4). The patient's vital signs were not assessed prior to assignment of ESI.

At 11:10 p.m., the nurse recorded: "patient states she rear-ended her ex-boyfriend approx one hour ago, states she was not restrained, stated 'the pedal was to the floor' but has no idea how fast she was going, reports pain to her chest, states she wanted to kill herself but does not now, denies homicidal thoughts." At 11:12 p.m., eight (8) minutes after triage, the patient's vital signs were assessed. The patient was in the ED for eight (8) hours and thirty-two (32) minutes. The patient's vital signs and pain were never reassessed.

The above record was reviewed and discussed with the Nurse Manager at 9:40 a.m. on 4/29/15. She agreed with the findings, noting the triage assessment was incomplete, the ESI score was incorrect and vital sign reassessment was not performed per policy, as required.

14. Review of the 4/23/15 ED record for patient #7 revealed she arrived at 9:07 a.m. and RN #4 triaged her at 9:07 a.m. The Date of Occurrence/Symptom Onset section was not completed. The triage chief complaint was recorded as: "MH" (mental health). RN #4 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as three (3). At 9:19 a.m., the nurse noted "pt reports anxiety has been extremely high lately, reports last night was having thoughts of suicide..." The patient's vital signs were assessed at 9:20 a.m., thirteen (13) minutes after assignment of ESI. The patient was discharged home in the company of her mother, ninety-one (91) minutes later, without any recheck of vital signs.

The above record was reviewed and discussed with the Nurse Manager at 9:45 a.m. on 4/29/15. She agreed with the findings, stating the triage documentation was incomplete, the ESI was incorrect and there was no recheck of vitals at discharge, as expected.

15. Review of the 4/23/15 ED record for patient #8 revealed she arrived at 11:53 a.m. and was triaged by RN #5 at 11:54 a.m. The Date of Occurrence/Symptom Onset section was not completed. The triage chief complaint was recorded as: "eval." RN #5 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as three (3). The patient's vital signs were not assessed prior to assigning the ESI class.

At 11:54 a.m., the nurse recorded: "pt reports is addicted to heroin, reports needs help getting off, does not want to go to Northwood (community behavioral provider) again because she can leave and will use again, reports wants to go to Hillcrest (hospital unit), reports is having suicidal thoughts." The vital signs were assessed at 11:56 a.m. The record reflects the patient reported using "a lot of heroin last night and has been sick this morning." The patient's vital signs were not reassessed until 3:00 p.m., three (3) hours and four (4) minutes later, not hourly, as required.

The above record was reviewed and discussed with the Nurse Manager at 9:50 a.m. on 4/29/15. She agreed with the findings, stating the triage documentation was incomplete, the ESI was incorrect based on current ESI handbook guidelines and vital sign monitoring did not occur as expected, per policy.

16. Review of the 4/23/25 ED record for patient #9 revealed he arrived at 8:26 p.m. and was triaged by RN #6 at 8:34 p.m. The triage chief complaint was recorded as: "eval." The Date of Occurrence/Symptom Onset section was not completed. RN #6 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as four (4). The patient's vital signs were not assessed prior to assigning the ESI class.

At 8:35 p.m., the patient's vital signs were assessed. At 8:37 p.m., the nurse documented: "states has high anxiety, gets meds filled at Northwood and they did not fill one yesterday."

The above record was reviewed and discussed with the Nurse Manager at 9:52 a.m. on 4/29/15. She agreed with the finding, stating the triage documentation was incomplete.

17. Review of the 4/23/15 ED record for patient #10 revealed he arrived at 8:45 p.m. and was triaged by RN #6 at that time. The Date of Occurrence/Symptom Onset was not completed. The triage chief complaint was recorded as: "eval." RN #6 noted "yes" to 'Alert?', 'Acute distress absent?' and 'respirations nonlabored?'. The patient's ESI was recorded as four (4). The patient's vitals signs were not assessed prior to assigning the ESI class.

At 9:03 p.m., eighteen (18) minutes after triage, the nurse assessed the vital signs. At 9:04 p.m., the nurse documented the patient had thoughts of suicide and "states would probably use a gun or slit wrist." The patient was in the ED for four (4) hours and did not have vitals reassessed.

The above record was reviewed and discussed with the Nurse Manager at 9:55 a.m. on 4/29/15. She agreed with the findings, stating the triage documentation was incomplete, the ESI was incorrect and the vital signs were not monitored per policy, as expected.

18. The Nurse Manager reiterated that corrections were implemented the evening of 4/27/15, education would be provided and the issues with triage and patient monitoring would be corrected.