HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 4 (Pt #2, Pt.#3, Pt.#5 and Pt #7) out of 9 patients in the Emergency Department (ED), the Hospital failed to ensure the policies and procedures governing the care provided in the ED were followed by failing to ensure ongoing reassessment were conducted and that patients were seen by a provider in a timely manner, as required.

Findings include:

1. The Hospital's policy titled, "Emergency Department Triage Procedure" (revised 7/2022), included, "B. Prioritize and sort patients for the medical screening exam .... E ...clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). This method provides a method for categorizing ED patients by both acuity and resource needs ... 3. Level III Urgent ...acuity and predicted resource needs are considered, and intervention may begin in the triage area. These patients should be seen by a physician or advanced practice provider with physician oversight when appropriate within 30 minutes. 4. Level IV Less Urgent... should be seen by the physician or advanced practice provider when appropriate within 60 minutes... H. Delays: 2. ED patients who are in the waiting room will be assessed periodically by the triage RN/ED Tech, First Point RN to ensure no change in condition. This assessment will be documented in the Electronic Medical Record."

2. The Hospital's policy titled, "Triage Policy" (revised 5/2022), included, "1. Patients entering the ED are initially assessed by point of first contact nurse at arrival ... vital signs are obtained ... D. Responsible to reassess patients in the waiting room every two hours for patients with abnormal vital signs. All other patients waiting a four or more hours, with previous normal vital signs, will have a reassessment performed every four hours while waiting to be placed in a room from the waiting room.

3. The Hospital's "Job Description: Registered Nurse" dated 4/10/2019, included, "The Registered Nurse (RN) is responsible for providing total comprehensive nursing to patients ... through ... implementing, reassessing, evaluating and revising the plan of care ... The RN integrates knowledge, skills, and experiences to meet the needs of patients ... communicates timely changes in patients' assessment/ongoing reassessment to providers that warrant consideration and/or a change ..."

4. On 10/11/2022, Pt. #2's clinical record was reviewed. Pt.#2 came to the Hospital's Emergency Department (ED) on 8/29/22. The clinical record included the following:

-The Patient Care Timeline dated 8/29/2022 at 12:10 PM to 8/30/2022 4:25 AM, indicated that:

At 12:10 PM, (Pt.#2) arrived to ED with chief complaint of emesis (vomiting).

At 12:12 PM patient assessed by Triage Nurse (E#1), vital signs: Temp: (patient vomiting), Pulse: 76, Respirations: 16, Blood Pressure (BP): 229/100 (normal range 100/60-140/90), Acuity: 3, Pain Score: 10-Abdomen. At 1:47 PM, BP: 223/89.

At 1:48 PM, Medication administered: ondansetron (used to treat nausea/vomiting) tablet 4 mg (milligrams) oral.

At 1:49 PM, patient taken to lab area in ED for blood work-up, returned to waiting room at 3:05 PM.

At 7:22 PM, patient transferred from waiting room into ED patient room.

At 7:57 PM, vital signs: Pulse 112, BP 225/98. The clinical record lacked documentation of vital signs reevaluated from 1:47 PM to 7:57 PM (6 hours, 10 minutes) there was no pain reassessment after 12:12 PM. There is no documentation that the provider was informed of BP of 229/100 at 1:47 PM.

At 7:22 PM, Time first seen by Provider to conduct a Medical Screening Examination ... "MDM (Medical Decision Making) Patient seen and evaluated ... history of hypertension, diabetes, and CAD (coronary artery disease) who presents to emergency room with altered mental status. Vital signs upon evaluation hypertensive at 225/98, tachycardic at 112. Physical exam shows the patient in acute distress, who is writhing in bed and loudly retching ..." The clinical record indicated that the patient was seen by a provider approximately 6 hours after arriving to the ED and not within 30 minutes after being triaged.

5. On 10/13/2022, Pt.#3's clinical record was reviewed. Pt.#3 came to the Hospital's ED via ambulance on 8/29/2022. The clinical record included the following:
-Patient Care Timeline dated 8/29/2022 at 12:48 PM to 8/30/2022 at 3:00 AM, indicated that:
At 12:51 PM, (Pt#3) was triaged, vital signs were assessed at this time, and categorized as Acuity level 3, with Pain Score at 10 out of 10. The next vital sign reassessment was completed on 8/30/2022 at 1:46 AM (approximately 12 hours and 4 minutes.) There were no further pain reassessments conducted during this time.
At 1:30 PM through 7:20 PM, (Pt#3) ambulatory to bathroom, laying on floor, refused wheelchair.

6. On 10/11/2022, the clinical records of Pt.#5, Pt.#6, and Pt.#7 were reviewed and indicated:

-Pt.#5 was admitted to the ED on 10/11/2022 with a diagnosis of urinary frequency. Pt.#5's vital signs assessment was dated 10/11/2022 at 3:07 AM, and the next vital sign assessment was 10/11/2022 at 9:58 AM (approximately 6 hours and 52 minutes later). The Acuity level was 4, the patient was seen by the provider on 10/11/22 at 10:07 AM (8 hours after arriving to ER).

-Pt.#6 was admitted to the ED on 10/10/2022 with a diagnosis of gangrene of left foot. Pt.#6's vital signs assessment was dated 10/10/2022 at 12:36 PM, the next vital sign assessment was on 10/10/2022 at 7:03 PM (approximately 6 hours and 33 minutes). Vital signs on 10/11/2022 at 2:42 AM, the next vital sign assessment was on 10/11/22 at 12:40 PM (approximately 10 hours and 2 minutes).

-Pt#7 was admitted to the ED on 8/29/2022 with a diagnosis of abdominal pain. Pt.#7's vital signs assessment was dated 8/30/2022 at 12:29 AM. The clinical record lacked documentation of any other vital signs while Pt.#7 was in the ED.

7. On 10/12/2022, at approximately 10:00 AM, video footage from the ED main entrance dated 8/29/2022 at 1:55 PM to 7:06 PM was reviewed with the Director of Risk Management (E#2). The video showed that during this time Pt.#2 was laying on the ground near the ED main entrance. At 3:42 PM, 3:45 PM staff (unable to identify) were observed pass by patient and without stopping to check on (Pt.#2). At 3:45 PM one staff (unable to identify) stopped and bent down to check on the patient for approximately 3 seconds, then left and returned at 3:47 PM with what appears to be a towel, then left the patient on the floor. From 4:02 PM to 6:00 PM, there were 4 occasions where staff was observed passing by the patient without checking on the patient. At Approximately 7:07 PM, staff is observed going to (Pt.#2) with a wheelchair and taking the patient inside the ED. At this time (Pt.#3) came into view of the camera was bent over and appeared to be in discomfort. Video footage from the Triage area was viewed from 8/29/22 at 12:49 PM to 7:30 PM, (Pt.#3) was observed being brought in by EMS (emergency medical services) in a wheelchair and being assessed by (E#1). (Pt.#3) was then wheeled to the front of the reception desk, where he sat rocking back and forth in wheelchair. The video footage shows (Pt.#3) at approximately 1:30 PM lying on the floor in front of the reception desk for approximately 2 hours. Staff is observed checking on (Pt.#3) periodically.

8. On 10/11/2022 at approximately 1:44 PM, an interview was conducted with the ED Manager (E#4). E#4 stated that all patients in the waiting room should be reassessed by the 1st look nurse or the ED Technician based on their acuity and symptoms. If there is a change in the patient's condition or in the vital signs, that patient should be re-evaluated to make ensure they are getting the proper treatment.

9. On 10/12/2022 at approximately 1:00 PM, an interview was conducted with the ED Triage Nurse (E#1). E#1 stated that she recalls (Pt.#2) because this patient presents to the ER frequently. E#1 states that she was working on this day and recalls that (Pt.#2) was laying on the floor and E#1 made several attempts to get patient onto a chair and offered a basin in case of vomiting, but the patient refused each time. E#1 stated that she does not recall if she reassessed (Pt.#2's) vital signs or condition after the patient was triaged. E#1 stated that if it is not documented in the clinical record then it means it was not done. E#1 stated that she does not recall any other patients laying on the floor vomiting.