HospitalInspections.org

Based on review of patient records, facility policy and procedures, and emergency personnel interviews, it was determined the hospital medical and nursing personnel qualified in emergency care failed to meet the needs of the patients in accordance with acceptable standards of practice, and implement their written emergency procedures and needs anticipated by the facility in accordance with the policies and procedures for 6 of 20 patient's reviewed (Patient's #1, #5, #6, #8, 10 and #11) that left the Emergency Department (ED) Against Medical Advice (AMA).

Specifically, on 4/30/23:

-Patient #1 a 6-month-old febrile patient was in the ED for almost 5 hours without a reassessment or review of rapid test diagnostics. The parents and the patient left AMA and without an evaluation of a provider. The AMA form was incomplete in its entirety, and no occurrence report documented,

-Patient #5 was in the ED for over 5 hours without reassessments and no documentation of medication administration as ordered. The AMA form was incomplete, and no occurrence report documented,

-Patient 6# was in the ED for 4 hours without a reassessment, ordered medications not documented as administered and no documentation that his IV was discontinued before leaving AMA. AMA form was incomplete, and no occurrence report documented,

-Patient #8 was an emergent patient who arrived via ambulance and was in the ED for almost 6 hours. No reassessment documented by the nursing staff. No documentation of the administration of the ordered medications. No occurrence report provided. Patient documented as eloped,

-Patient #10 was in the ED for 6 hours without any nurse or provider reassessment and left the ED AMA. The AMA form was incomplete in its entirety, and no occurrence report documented, and

On 5/25/23, Patient #11 was in the ED for 2.5 hours without documentation of medication administration as ordered. No documentation that the IV was discontinued before leaving AMA. AMA for was incomplete, and no occurrence report documented.

Refer to deficiency A1112, CFR §482.55(b)(2) for specific evidence.

Based on review of patient records, facility policy and procedures, and emergency personnel interviews, it was determined the medical and nursing personnel qualified in emergency care failed to meet the needs of the patients and implement their written emergency procedures and needs anticipated by the facility in accordance with the policies and procedures for 6 of 20 patient's reviewed (Patient's #1, #5, #6, #8, 10 and #11) that left the Emergency Department (ED) Against Medical Advice (AMA).

Specifically, on 4/30/23:

-Patient #1 a 6-month-old febrile patient was in the ED for almost 5 hours without a reassessment or review of rapid test diagnostics. The parents and the patient left AMA and without an evaluation of a provider. The AMA form was incomplete in its entirety, and no occurrence report documented,

-Patient #5 was in the ED for over 5 hours without reassessments and no documentation of medication administration as ordered. The AMA form was incomplete, and no occurrence report documented,

-Patient 6# was in the ED for 4 hours without a reassessment, ordered medications not documented as administered and no documentation that his IV was discontinued before leaving AMA. AMA form was incomplete, and no occurrence report documented,

-Patient #8 was an emergent patient who arrived via ambulance and was in the ED for almost 6 hours. No reassessment documented by the nursing staff. No documentation of the administration of the ordered medications. No occurrence report provided. Patient documented as eloped,

-Patient #10 was in the ED for 6 hours without any nurse or provider reassessment and left the ED AMA. The AMA form was incomplete in its entirety, and no occurrence report documented, and

on 5/25/23, Patient #11 was in the ED for 2.5 hours without documentation of medication administration as ordered. No documentation that the IV was discontinued before leaving AMA. AMA for was incomplete, and no occurrence report documented.

Findings included:

Review of complaint intake #TX00455801 revealed a complaint was reported on behalf of Patient #1. The complainant stated Patient #1 was a 6-month-old that was taken to the facility's ED on 4/31/23 at 6:30 PM with the complaint of lethargy and fever of 102 degrees. Patient #1 was taken back to the screen room immediately and had two nostril swabs completed and one throat swab. It was stated that there were not any consent forms signed for any procedures or treatment. Patient #1 was then sent back to the waiting room to wait. The complainant stated an outgoing nurse provided Tylenol for the fever. After three hours of waiting in the waiting room, the complainant asked the intake person at the desk for an update on the test results and how much longer it would be. The complainant was told there was not a doctor there to read the results. The complainant stated again, after 6 hours, they asked for an update, how much longer it would be and asked for more Tylenol. The complainant was told by a Male nurse, "did not we give you Tylenol as soon as you got here." The complainant then replied; that that was six hours ago. Patient #1 was not given any further medication. After 10 hours, the complainant asked a male nurse if they could at least get the test results to go somewhere else. The nurse reported to the complainant that the test results were negative for strep, covid-19, RSV, and the Flu. The nurse stated to the complainant, to "go to another hospital because she still needs to be seen." The complainant stated it was 5:30 AM and she left to go home to get kids to school and then got into her pediatrician right away. Patient #1 was diagnosed with a severe ear infection and provided with prescriptions for treatment from the pediatrician. The pediatrician stated all of those tests were not necessary if the hospital ED Doctor would have just completed a physical examination of Patient #1 and they would have seen the infected ear.

Patient #1

Review of Patient #1's ED record and Emergency Provider report dated 4/30/23 to 5/1/23 revealed the following:

Patient #1, a 6-month-old female arrived at the ED on 4/30/2023 at 6:38 PM with parents. The chief complaint was fever, crying and loss of consciousness.

Patient #1 was triaged by a Registered Nurse (RN) on 4/30/23 at 6:56 PM with an Emergency Severity Index (ESI) of 3-urgent. Vital signs were taken on 4/30/23 at 6:56 PM. Vital signs were as follow: 101.8 rectal, pulse of 187, respirations of 30 per minute, oxygen saturation of 99% on room air.

The Medical Screening Examination (MSE) was started on 4/30/23 at 6:38 PM by the triage/MSE Physician Assistant (PA).

Review of the ED note dated 4/30/23 at 6:38 PM by PA was as follows:
Free text [Provider in Triage] PIT notes:
"Patient is febrile and mother states that patient has been having passing out episode."
Provider in triage, initial greet note;
"Greet note, I have greeted and performed a focused rapid initial assessment of this patient. A comprehensive ED assessment and evaluation of the patient, analysis of all test results, and completion of the medical decision-making process will be conducted by additional ED providers."
History of Present Illness (HPI), Chief Complaint; fever. "MSE not complete, the medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department."

The triage PA ordered rapid test diagnostics, Acetaminophen (Tylenol) 130mg to be given by mouth at 7:02 PM. The record also shows that the provider ordered a Covid 19 test, Influenza A+B (rapid), Strep A (rapid) and a corona virus PUI Rapid to be done nasopharyngeal (per nose) at 6:39 PM on 4/30/2023.

A review of the nurses note documented by triage RN on 4/30/23 at 7:13 PM revealed that the Acetaminophen (Tylenol) 130mg was administered.

There was no reassessment of the patients fever or symptoms after the Tylenol administration.

The triage PA orders documentation showed that on 4/30/24 at 10:06 PM Ibuprofen 90 mg to be given by mouth was ordered.

Review of the nurse's notes revealed that the Ibuprofen dose was not documented as completed. No reassessment found in the nurse's notes.

The results of the rapid nasopharyngeal swabs testing for Covid 19 test, Influenza A+B (rapid), Strep A (rapid) and a corona virus PUI Rapid were marked as completed by the lab at 7:23 PM and 7:51 PM. No provider notes to reflect that these results were convey to the parents of patient #1.

There were no further interventions, assessments, or re-assessments documented by a nurse or provider until 05/1/2023 at 12:02 AM when the triage nurse documented the patient's disposition.

Review of the disposition assessment, in the nurses notes, is as follows; " ...Refused treatment ...Pt left ER signing AMA form".

Review of the Against Medical Advice (AMA) document for Patient #1 dated 4/30/23 at 23:10 (11:10 PM) revealed the form was blank and incomplete in its entirety. There were no patient or legally authorized representative signatures, or the patient attestation completed. There were two medical staff signatures in the area of "Patient refused to sign", (two employee signatures are required below). There was no documentation that any discussion of risks and benefits, or patient counseling was performed. There was no documentation about the disposition of the patient available for review.

No occurrence report found or provided for Patient #1.

Patient #5

Review of Patient #5's ED record and Emergency Provider report dated 4/30/23 to 5/1/23 revealed the following:

Patient #5 was a 45-year-old female who arrived at the ED on 4/30/23 at 5:20 PM. Patient #5 had a stated complaint of nausea and vomiting and a chief complaint of Gastrointestinal / abdominal pain.

Patient #5 was triaged by the RN on 4/30/23 at 5:31 PM with an ESI of 3-Urgent. Vital signs were taken on 4/30/23 at 5:35 PM. The vital signs were as follows; Temperature 99.0, pulse 76, Blood pressure 138/82, respirations 94%, pain 6 out of 10.

MSE was started on 4/30/23 at 5:31 PM by the MSE PA.

A review of the ED note dated 4/30/23 at 5:31 PM by the PA provider in triage was as follows:
"Greet note, I have greeted and performed a focused rapid initial assessment of this patient. A comprehensive ED assessment and evaluation of the patient, analysis of all test results, and completion of the medical decision-making process will be conducted by additional ED providers."
HPI, Chief Complaint; Nausea/vomiting/diarrhea. "MSE not complete, the medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department."
Free text PIT Notes. "Patient complains of nausea, vomiting and diarrhea x3 days. Patient is being seen today with her husband who has similar symptoms that started today. Patient with history of diabetes."

The triage PA ordered lab work, Intravenous (IV) normal saline 1000 ml IV bolus, Pepcid 2 ml IV and Zofran 4 mg IV.

A review of the nurse's note documented on 4/30/23 at 6:10 PM revealed the IV was started in the left wrist after 1 attempt. No documentation noted regarding the administration of Pepcid or Zofran in the nurses notes.

A review of medication discharge summary for the visit dated 5/2/2023 reveals that the Normal saline 1000 ml IV bolus was discontinued at 6:30 PM. No documentation showing that Pepcid 20 mg IV and Zofran 4 mg IV were administered, both medications show this remark in the medication discharge summary, "Pt needs meds".

There was no reassessment of the patient's conditions after interventions in the nurse's notes.

On 4/30/23 at 10:27 PM the disposition was documented as AMA with a stable condition. No other comments noted.

There were no further interventions, assessments, or re-assessments documented by a nurse or provider until 5/1/2023 at 12:11 AM when the patient disposition was documented on the nurses notes by the RN.

A review of the disposition nurses note was as follows, "refused treatment, chief complaint: GI/abdominal pain"

Review of Patient #5's AMA form dated 4/30/23 at 22:27 (10:27 PM) revealed Patient #5 signed the AMA form and two employees. The form was not completed in its entirety and areas were left blank.

No occurrence report found or provided for Patient #5.

Patient #6

Review of Patient #6's ED record and Emergency Provider report dated 4/30/23 revealed the following:

Patient #6 was a 52-year-old male who arrived at the ED on 4/30/23 at 6:10 PM. Patient #6 had a stated complaint of Nausea, Vomiting and Diarrhea.

He was triaged by an RN on 4/30/23 at 6:03 PM with an ESI 3 Urgent. Vital signs were taken on 4/30/23 at 6:03 PM. Vital signs were as follow: Temperature 37.6 Celsius, Pulse 100, respirations 18, blood pressure 141/79, Pulse oximetry 97%. Pain scale 2 out of 10.

The MSE was started on 4/30/23 at 6:10 PM by a Nurse Practitioner (NP).

A review of the ED provider note dated 4/30/23 at 6:10 by NP was as follows:
"Greet note, I have greeted and performed a focused rapid initial assessment of this patient. A comprehensive ED assessment and evaluation of the patient, analysis of all test results, and completion of the medical decision-making process will be conducted by additional ED providers."
"MSE not complete, the medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department."

Free text PIT Notes. "52-year-old male with history of hypertension, diabetes, hyperlipidemia, quadruple bypass presents to the emergency room with complaints of subjective fever, nausea and vomiting patient reports spouse with similar symptoms."

On 4/30/23 at 6:12 PM, the NP ordered blood work diagnostics, an electrocardiogram (EKG), Blood cultures, Urine analysis, a Normal Saline 1000 ml IV bolus over one hour, Zofran 4mg intravenous (IV) and Ceftriaxone 1000mg IV.

A review of the nurse's notes documented by RN on 4/30/23 at 6:19 PM show that the EKG was completed.

A review of the nurse's notes documented by RN on 4/30/23 at 6:51 PM show a 20-gauge intravenous device was inserted to the right forearm after one attempt.

No documentation was found that the medications were administered as ordered.

There were no further interventions, assessments or reassessments documented by the nurse or provider until 4/30/23 at 10:27 PM when the disposition was documented as against medical advice by the RN.


Review of Patient #6's AMA form dated 4/30/23 at 22:27 (10:27 PM) revealed Patient #6 signed the AMA form and two employees. The form was not completed in its entirety and areas were left blank.

No occurrence report found or provided for Patient #6.

Patient #8

Review of Patient #8's ED record and Emergency Provider report dated 4/30/23 to 5/1/23 revealed the following:

Patient #8 was an 18-year-old male who arrived at the ED via Emergency Medical Services (EMS) on 4/30/2023 at 6:33 PM. Patient #8 stated complaint was asthma attack.

He was triaged by the RN on 4/30/2023 at 6:38 PM with an ESI of 2-emergent. Vital signs were taken on 4/30/23 at 6:38 PM. Vital signs were as follow: temperature 98.3, pulse 75, respirations 18, blood pressure 141/86. Pain scale 5 out of 10.

The MSE was started on 4/30/23 at 6:49 PM by NP.

The review of the ED provider notes dated 4/30/23 at 6:49 was as follow:
"Free text HPI notes, 18-year-old male with history of asthma presents to the emergency room with shortness of breath. Patient states he woke up feeling short of breath however symptoms have worsened and called 911 and was 92% on room air. Patient did received treatments in route as well as 10mg dexamethasone IV."

The NP ordered blood work, albuterol sulfate 5mg nebulizer, magnesium sulfate 100ml IV x1 and a chest Xray.
A review of the nurse's documented by the RN at 4/30/23 at 7:15 PM revealed that the EKG was completed and presented to the provider. On 4/30/23 at 7:28 PM the nurse documented that an IV placed by EMS prior to arrival was intact.

A review of the nurses notes revealed that the medications ordered were not documented. A review of the provider notes revealed that the albuterol was provided and that the magnesium sulfate 100 ml IV was completed on 4/30/23 at 7:48 PM.

Further review of the nurses notes revealed that the patient was not reassessed for his condition or treatment.

On 4/30/23 at 11:50 PM a nurse documented "eloped from the emergency department". "Disposition, Against medical Advice"

On 5/1/23 at 12:12 AM the nurse documented "pt names called in lobby. No response, will re-attempt in 10 min."

On 5/1/23 at 03:25 the nurse documented the disposition as Against Medical advice. No further documentation by Nurse or provider.

Further review of Patient #8's ED records revealed there was not an AMA form provided from the facility. The patient was categorized as an elopement at 12:24 AM on 5/1/23.

No occurrence report found or provided for Patient #8.

Patient #10

Review of Patient #10's ED record and Emergency Provider report dated 4/30/23 to 5/1/23 revealed the following:

Patient #10 was a 35-year-old female who arrived via EMS at the ED on 4/30/23 at 8:46 PM. Patient #10 stated complaint was vomiting and diarrhea and a chief complaint of Gastrointestinal abdominal pain.

Patient #10 was triage by the RN on 4/30/23 at 8:55 PM with an ESI 3-urgent. Vital signs were taken on 4/30/23 at 9:00 PM. The vital signs were as follow; Temperature 98.4, pulse 88, respirations 18, blood pressure 113/57, pain 10 out of 10.

MSE was started on 4/30/23 at 8:55 PM by the MSE NP.

A review of the ED notes dated 4/30/23 at 8:55 PM by the MSE NP was as follows:
"Greet note, I have greeted and performed a focused rapid initial assessment of this patient. A comprehensive ED assessment and evaluation of the patient, analysis of all test results, and completion of the medical decision-making process will be conducted by additional ED providers."
"MSE not complete, the medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department."
Free text PIT Notes, "35-year-old female presents to the emergency room by EMS with complaints of nausea, vomiting. Onset of symptoms 2 days ago."

The MSE NP ordered blood work, urine analysis and normal saline 1000 ml over 1 hour IV.

A review of the nurse's notes documented by the RN on 4/30/23 at 8:46 PM revealed that the IV was started prior to arrival by the EMS transport. The site was assessed by the RN. On 4/30/23 at 8:56 PM the RN documented that the normal saline was started.

On 5/1/23 at 01:30 AM the nurse documented the patient was stable with a disposition of Against medical Advice.

There were no further interventions, assessments, or re-assessments documented by a nurse or provider until 5/1/23 at 03:24 AM when the disposition was documented as AMA, refused treatment. The note states that the IV was not discontinued.

Review of the AMA document for Patient 10# dated 5/1/23 at 01:30 AM revealed the form was blank and incomplete in its entirety. There were no patient or legally authorized representative signatures, or the patient attestation completed. There were two medical staff signatures in the area of "Patient refused to sign", (two employee signatures are required below).

No occurrence report found or provided for Patient #10.

Patient #11

Review of Patient #11's ED record and Emergency Provider report dated 5/25/23 revealed the following:

Patient #11, a 23-year-old female, with a possible ibuprofen overdose.

5/25/2023 at 04:02 AM. The patient was greeted by a provider and orders were placed for an
Intravenous device to be placed and medications to be administered. The ED record shows the
documentation for the intravenous device placement, but the medications were not documented as given. The patient was documented as leaving AMA. No documentation that the patient had the intravenous device removed or discontinued.

Review of Patient #11's AMA form dated 5/25/23 at 06:32 AM revealed Patient #11 signed the AMA form and two employees. The form was not completed in its entirety and areas were left blank.

No occurrence report found or provided for Patient #11.

Interview on 6/14/23 at 10:15 AM with RN #6 in the nursing triage area stated the following:
RN #6 was asked about their role in the ED. She stated that the nursing staff triage the patients in tandem with the provider who initiates an MSE. They perform treatments and administer medications for patients. She added that they also communicate with the charge nurse to obtain treatment spaces for patients waiting in triage or MSE area. The staff member stated that reassessment takes place depending on the condition of the patient. RN #6 was asked if the patients in the waiting room were assigned to a specific nurse for the reassessments, she stated that "everyone is responsible." RN #6 stated that the patients in triaged were not assigned to a specific provider or a specific nurse until the patient was placed in to an ED room.

Interview on 6/14/23 at 10:53 AM with Nurse Practitioner (NP) Provider #8 in the ED triage
area stated the following:
He performs a greet and initiation of the MSE in tandem with the triage nurse. Provider #8 stated that the daily census is high but that they have additional staff to cover times of influx. Provider #8 stated that all the providers can see pediatric patients in the ED. Provider #8 stated that most diagnostics, medications, and treatment plans are initiated in the MSE area. He denied any use of nursing protocols in the triage area. He stated that "we always have a provider available". He stated that he is notified of any critical values by the lab services or nursing staff, yet he stated that there is no official notification for negatives results on diagnostics. Provider #8 was asked about reassessing patients seen in the MSE area. He stated that discharging patients from the MSE area "is not uncommon" if the case is not complicated or the diagnostics results are negative results on patients without complicated complaints, "we can discharge those patients" but he stated that "we don't reassess the patient unless the nurses have a concern or a positive result."

Interview on 6/14/23 with the ED Medical Director (MD) stated the following:
When asked about the greet process and MSE procedure, the ED/MD stated that ED staff have worked very hard to "meet the greet metric." The ED/MD stated that as soon as a patient reported to the ED they would be greeted by a provider and the MSE would start. He stated that their goal is less than 10 minutes but that they were between 11 and 12 minutes so far but continue working on it. He was asked about patient records found with "MSE not complete". He stated that if the MSE provider cannot complete the MSE the patients go back to complete their care and assessments. He was asked on the sentence regarding MSE not complete. He stated that the that all the patients were greeted upon their arrival and that the MSE was started at that point, he continued; if the provider in the MSE area cannot complete the MSE for whatever reasons the patient was seen in the back. He was asked about patients leaving AMA or eloping without an MSE completed. He stated all the patients are greeted. He stated again, that all the patients were greeted by a provider upon arrival.

Review of the facility's policy titled, "Leaving Against Medical Advice (AMA).
Status Active, Policy Stat ID 10277525. Methodist Healthcare revealed the following:

"Purpose:
To provide nursing personnel with consistent guidelines for management of hospital patients who opt to leave the hospital Against Medical Advice (AMA).

The procedure:
1. Fully explain to the capacitated adult patient or to the responsible parent or legally authorized representative the ramifications of such a decision, including the risks associated with refusal of treatment and the need for follow-up care.
2. Attempt to remove patient identification band, equipment and discontinue invasive lines. Attempt to return patient belongings prior to leaving.
3. If the patient refuses to sign the release, a notation to this effect should be made on the form (witnessed by one employee) and in the medical record with a detailed time, date, last seen information, and condition of the patient. The patient cannot be forced to sign the release or be prevented from leaving. Tell the patient that they can return at any time.
4. The nurse will document pertinent information, including but not limited to risks of discharge as explained to the patient, instructions regarding alternative follow-up care, relatives or friends in attendance and teaching they received, and stated destination. Every effort should be made to contact the attending and, if available, consulting physicians so they can discuss the issue with the patient prior to leaving.
5. For inpatient Psych units, the psychiatrist has 4 hours to decide if the patient may leave AMA or should be held as an Emergency Detention.
6. An occurrence report should be completed."

Review of reassessment Policy (Policy Stat ID 12290156) last revised 10/2022 revealed the
following; in part:

PURPOSE:
1. To provide all patients with an appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organizational setting.
2. The assessment process will be a continuous, collaborative effort with all departments functioning as a team. Patient assessment is an inter-disciplinary function. The importance of input by various members of the health care team is valued and supported by the organization.

POLICY:
1. All patients at this Facility receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow-up assessments based upon their individual physical, psychological, social and cultural needs.
2. This assessment process will determine the need for care and/or treatment, the type of care to be provided and the patient's needs through the continuum of care.
3. The goal of the assessment/reassessment process is to provide the patient with the appropriate care to meet individual and potentially changing needs.
4. Care and/or treatment provided by all health-care professionals will be based on each patient's specific needs with respect to his/her right to privacy.
5. Relevant biophysical, psychosocial, spiritual, nutritional, functional, educational, environmental, and discharge planning needs will be the determining factors considered in the assessment process.
6. Assessments provided by health-care professionals will be based upon and include:
a. Data collected to assess the needs of the patient.
b. Analysis of data to develop a plan to meet the patient's care or treatment needs.
c. Prioritization of decisions based upon analysis of data regarding patient care needs. Decisions made regarding patient care or treatments are prioritized based on analysis of the information collected.
II. Reassessment
A. Each patient is to be reassessed according to the guidelines established by the clinical discipline. Further assessment and reassessment will be based on a collaborative effort as warranted by the patient's condition.
B. Reassessment is to be ongoing and may be triggered by key decision points and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care.
C. Reassessment is based on the patient's diagnosis, the care setting, the patient's desire for care, and the patient's response to any previous care. Reassessment may be at specified/regular intervals related to:
1. The patient's treatment
2. The patient's response to treatment
3. Significant change in the patient's condition
4. Significant change in the patient's diagnosis
5. Discharge/transfer
6. Discharge planning where appropriate in the scope of care of the department involved.

4. EMERGENCY DEPARTMENT
A. Emergency department side holding for room assignment or pending discharge:
1. Upon patient's arrival, vital signs will be taken.
2. Immediate assessment will be performed by the registered nurse and will coordinate with the admitting physician to obtain admission orders if applicable.
3. Once the physician's order is available, it will be prioritized and transcribed based on the patient's needs. A plan of care will be addressed by the registered nurse within 2 hours.
4. If the patient will be held within 12 hours in this area, an admission history and assessment will be completed by the registered nurse and will be documented in Meditech.
5. While the patient is in this area, a focused assessment will be appraised by the registered nurse and vital signs will be monitored as well every 4 hours. These will be documented in Meditech.
6. An on-going appraisal will be conducted and an immediate reassessment will be performed by the registered nurse for the following:
a. Change in patient's status and / or condition
b. Change in patient's vital signs
c. Evaluation of treatment or intervention
d. As per specific LIP order
7. The above immediate reassessment will be reported to the admitting physician as soon as possible.