HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff followed facility policy related to rounding/assessing patients' vitals and failed to ensure nursing staff followed facility policy related to acuity level of patients and time seen for 1 of 12 medical records (MR) reviewed (Patient #1).

Findings include:

1. Facility policy titled "Triage of ED [Emergency Department] Patients" approved 8/2021 indicated the following: "III, PURPOSE: A. To quickly identify the priorities of care and need for treatment and assign the appropriate Emergency Severity Index (ESI) score. B. Decide who requires immediate care and who is safe to wait for care and assign an accurate acuity level by assigning an Emergency Severity Index score (ESI). C. Determine appropriate area of treatment. D. Facilitate patient flow through the ED. E. Provide continued reassessment of patients in the waiting room. IV. GUIDELINES: A. Make a decision as to need for immediate care based on chief complaint and across-the-room assessment (levels 1 and 2). Examples of patients that need to be immediately placed in a treatment room include, but not limited to: 1) Uncontrolled hemorrhage. 2) Airway compromise 3) Neurological deficits 4) Acute Coronary Syndrome. B. All patients will receive an ESI level. C. Patients that do not require immediate care will have focused assessment and vital signs done to decide priority of care (Levels 3, 4, and 5). D. Patients that have been designated "ok" to wait in lobby will be rounded on at least every 30 minutes and have vital signs repeated per the timelines in the ED Assessment/Reassessment policy. Table 6.2 ESI Vital Signs Criteria: ESI Level 2 Returning to waiting room. Complete set of vital signs at Triage (YES/NO): YES. Evaluation Plan: Vital sign assessment is prudent to ensure patient safety."

2. Facility policy titled "Assessment and Reassessment in the Emergency Room (ED)" approved 9/2021 indicated the following: "II. PURPOSE: The goal of assessment and reassessment is to determine patient acuity and develop and update the patient's needs and plan of care as the patient's condition changes. III. ACTIONS: C. Emergency Department patients are monitored and reassessed at regular intervals based on triage level, condition, plan of care, treatment provided, and condition changes. Nursing reassessment will occur per patient condition but a minimum of: ESI level 1 and 2 - every hour. D. Vital signs (b/p [blood pressure], HR [heart rate], respirations, pain status) should be reassessed per patient condition, but a minimum of ESI 2 - every hour for the first four hours - then every two hours if clinically stable. G. Both physicians and nurses should document assessment, reassessment, and vital signs in the medical record real-time whenever possible. This promotes timely medical decision making and interventions. J. Any deviation from these standards must have the reason for deviation documented (i.e., patient refusal, etc.)."

3. Facility protocol titled "ED Triage Arrival to Initial 12-Lead ECG [Electrocardiogram]" approved 9/22/21 indicated the following: "Triage RN [Registered Nurse] obtains chief complaint for visit. Does the patient have: -chest pain/pressure? Yes. Patient taken directly to room via wheelchair. ED tech/Second RN obtains: -STAT 12 lead ECG, -Place order in Cerner. Completed 12-lead ECG taken directly to ED provider for interpretation. STEMI? No. ED MD to initiate Chest Pain Order Set...ED bed available? No. Patient placed in monitored lobby. Yes. Patient placed in monitored bed."

4. Review of Patient #1's medical record indicated the following:
The patient arrived via private vehicle to the emergency department on 11/21/22 at 2012 hours with complaints of left sided chest pain that radiates into his/her left shoulder, and down his/her left arm. Patient #1 was triaged on 11/21/22 at 2016 hours and had a triage/acuity level of 2. Patient #1 was placed in ED room 23 on 11/22/22 at 0223 hours. Patient #1 was seen by MD1 on 11/22/22 at 0235 hours, approximately 6 hours after being triaged and admitted inpatient on 11/22/22 at 1422 hours with an admitting diagnosis of acute coronary syndrome. Patient #1 was discharged to home on 11/23/22 at 2015 hours.

a) On 11/21/22 at 2016 hours, Patient #1 had an oral temperature of 98.4 degrees F (Fahrenheit), blood pressure of 151/78 mmHg (millimeters of mercury), heart rate of 82 bpm (beats per minute), respiratory rate of 18 (breaths per minute) and SpO2 (peripheral capillary oxygen saturation) of 99% on room air. Chest pain level of 6/10 at rest.

b) On 11/22/22 at 0153 hours, Patient #1 had a blood pressure of 140/69 mmHg, heart rate of 72 bpm and SpO2 of 100% on room air.

c) The medical record for Patient #1 lacked documentation of rounding on the patient every 30 minutes while in the waiting room. The medical record for Patient #1 lacked documentation of a nursing assessment/vitals and/or refusals every hour on 11/21/22 at 2116 hours, 2216 hours, 2316 hours and on 11/22/22 at 0036 hours.

5. Review of Patient #4's medical record indicated the following:
The patient arrived to the emergency department via private vehicle on 11/21/22 at 2041 hours with complaints numbness/tingling on his/her right side times three hours and also complained of locked jaw. Patient #4 was triaged on 11/21/22 at 2047 hours and had a triage/acuity level of 2. Patient #4 was seen by an ED provider on 11/21/22 at 2047 hours.

a) On 11/21/22 at 2047 hours, Patient #4 had an oral temperature of 97.8 degrees F, blood pressure of 166/82 mmHg, heart rate of 85 bpm, respiratory rate of 18 breaths per minute and SpO2 of 97% on room air. Jaw pain level of 6/10 at rest.

6. Patient #4 with arrival date/time of 11/21/22 at 2041 hours to the ED and triage/acuity level of 2 was seen by an ED provider prior to Patient #1, who arrived on 11/21/22 at 2012 hours and had a triage/acuity level of 2.

7. Review of Patient #12's medical record indicated the following:
The patient arrived to the emergency department via private vehicle on 11/21/22 at 2159 hours with complaints of increasing pain and swelling at his/her surgery site from neck surgery on 11/15/22, developed a lump in his/her throat on 11/20/22, that has since increased in size and the patient also reports difficulty breathing. Patient #12 was triaged on 11/21/22 at 2209 hours and had a triage/acuity level of 3. Patient #12 was seen by MD1 on 11/21/22 at 2221 hours.

a) On 11/21/22 at 22:09 hours, Patient #12 had an oral temperature of 98.7 degrees F, blood pressure of 149/96 mmHg, heart rate of 106 bpm, respiratory rate of 20 breaths per minute and SpO2 of 99% on room air. Pain level of 3/10 at rest.

b) On 11/21/22 at 2230 hours, Patient #12 had a heart rate of 104 bpm, respiratory rate of 20 breaths per minute and SpO2 of 96% on room air.

c) The ED provider note dated 11/21/22 at 2253 hours by MD1 indicated a physical examination was completed on Patient #12 and indicated the patient was alert, oriented to person, place, time, situation, no acute distress, respirations were non-labored, lungs were clear to auscultation, breath sounds were equal and symmetrical chest wall expansion. Trachea was midline, mild erythema of the anterior neck with some firmness/fluctuance at the incision area and medial to it. No crepitus, the neck was not taunt, patient maintaining own airway well and mild oropharyngeal erythema.

8. Patient #12 with arrival date/time of 11/21/22 at 2159 hours to the ED and triage/acuity level of 3 was seen by MD1 prior to Patient 1, who arrived on 11/21/22 at 2012 hours and had a triage/acuity level of 2.

9. During an interview with A11 (Accreditation Manager) on 1/24/23 at approximately 12:30 p.m., he/she verified a patient with chest pain should be seen by an ED provider right away and could be seen in a triage room if there were no ED rooms/beds available.

10. During an interview with A7 (Network Health Information Management Director) on 1/24/23 at 3:53 p.m., he/she verified the medical record information for Patients #1, 4 and 12.

11. During an interview with A6 (Director of Emergency Room) on 1/24/23 at 3:56 p.m., he/she verified the medical record information for Patient #1 lacked documentation of rounding every 30 minutes while in the lobby/waiting area and every hour for the first four hours, then every two hours if clinically stable of vitals for ESI level of 2.