HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 9 patients' (Pt #1) emergency department clinical records reviewed for assessment/reassessment, the hospital failed to ensure that a reassessment was conducted within the timeframe required per hospital's policy.

Findings include:

1. The hospital's policy titled, "Triage Policy" (reviewed 05/27/2025) was reviewed and required, "Emergency Severity Index (ESI): Five-level triage algorithm that provides clinically relevant stratification of patients into five groups ... Level 1-resuscitative ... 3-Urgent ... 5-nonurgent." 3. ... For level 3, 4, & 5, care will be expedited as treatment space becomes available. 4. Patients waiting longer than 2 hours in the waiting room will be reassessed by medical staff."

2. The clinical record of Pt. #1 was reviewed on 08/01/2025. Pt. #1 presented to the Hospital via ambulance on 06/23/2025 at 12:05 PM. The clinical record included the following:

- 12:05 PM, (Pt. #1) arrived in ED, arrival complaint - MG (Myasthenia Gravis - a chronic, autoimmune disorder that causes weakness in the voluntary muscles and fatigue).

-12:10 PM, ED Note - Medical Screening Exam (E #1/Physician Assistant) Chief Complaint; weakness, generalized. Alert and oriented (person, place, time, situation), arrived via FD (fire department) reporting several episodes of general weakness x2 days. History of MG since 2016, and states this seems like a typical flare-up. Denies cp (chest pain) sob (shortness of breath) dizziness, fever, chills, pain. Compliant with medications Vss (vital signs stable) BP 141/68 (blood pressure, ref range 90/60 - 140/90) Pulse 78 (ref range 60-90) O2 99% on room air (oxygen - ref range 95% or greater). Stable awaiting further evaluation and treatment. A full evaluation will be performed when a treatment room becomes available.

-12:12 PM, ED ESI Calculator Urgency, (E #2/RN) 3; Requires Immediate life-saving attention? No. ED Pain Assessment: No pain.

-3:21 PM, ED Vitals Re-Assessment; BP 134/71, Pulse 71, Respirations 16, O2 100 % room air. (3 hours and 11 minutes after arriving in triage). The clinical record lacked documentation of a vital signs re-assessment while waiting longer than 2 hours in the waiting room.

3. An interview was conducted with the Assistant Unit Director (E #5) on 08/01/2025 at 2:15 PM. E #5 stated that for patients that are required to wait in the waiting room because there are no beds available, staff (PCT or RN) are required to re-assess vital signs every two hours and report any change in their condition to a provider or the charge nurse.