HospitalInspections.org

Based on hospital policy and procedure review, open and closed medical record review, and staff interviews, the hospital failed to have sufficient emergency department staff to ensure appropriate and timely triage of patients for 1 of 12 patients presenting to the emergency department for treatment (#2).

The findings include:

Review of the hospital's Emergency Department "Policy and Procedure" document (last revised 11/07 and under current revision beginning in October 2010) revealed, "...V. HOURS OF OPERATION...Staffing will be adjusted for census changes and increases or decreases in acuity level among the patients on the unit ...VII. STAFFING ...C. Levels ...2. All patients presenting to the Emergency Department will be assessed and triaged by a registered nurse."

Review of hospital's computer documentation (printed computer screen shot) titled, "Patient Whiteboard (Electronic board which tracks ED patient from time of arrival) for Nursing Administration Patient Movement for (patient #2)," revealed patient #2 was "WAITING PRETRIAGE" on 06/08/2010 at 2007 to 2057 (50 minutes), "TRIAGED" on 06/08/2010 at 2057 to 2058 (1 minute), "WAITING PRETRIAGE" on 06/08/2010 at 2058 to 2113 (15 minutes), and "Out of Department" on 06/08/2010 at 2113. Review of documentation confirmed patient #2 presented to the admissions clerk and waited 66 minutes prior to leaving. Record review revealed no available evidence the patient was seen by a nurse; there was no available nursing documentation of the patient's vital signs or triage level.

Review of hospital's computer documentation (printed computer screen shot) titled, Accounts Receivable - Registration and ADT," revealed, "Admission Date/Time: 06/08/2010 2102" and "Discharge Date/Times: 06/08/2010 2102. Document review revealed "Discharge ...Code Q (Not Seen)" and admission clerk's initials.

Review of staffing information provided by ED Nurse Manager revealed the unit was staffed with 1 physician, 3 registered nurses (including triage nurse), 1 Certified Nurse Assistant (CNA), and 1 admissions clerk on 06/08/2010 at 2007 (time patient #2 presented to ED). Staffing information revealed the CNA left at 2030. Review of staffing information revealed 58 patients presented to the ED on 06/08/2010 with 20 of those patients presenting between 2000-2230 on 06/08/2010. Staffing information revealed there were 2 admission clerks working prior to 2000 and one of the two clerks clocked out at 2009 on 06/08/2010.

Medical record review of patient #2 revealed a single sheet with demographic information (referred to as a "face sheet"). Review of face sheet revealed patient #2's date & time of admission and discharge was 06/08/2010 at 2102. Face sheet review revealed hand-written across the sheet were the words, "Left w/o (without) being seen."

Observations and interviews with Emergency Department (ED) staff during unit tour on 12/03/2010 at 1045 revealed upon arrival to the ED patients present to the admissions clerk and provide them their name and date of birth; the admissions clerk then pages the nurse that a patient is waiting. Observations revealed the triage nurse calls the patient into triage from the lobby after receiving page on beeper.

Interview with Emergency Department's Nurse Manager and administrative staff on 12/03/2010 at 1315-1530 confirmed there was no medical record for patient #2's ED visit on 06/08/2010. Interview revealed the only record of patient #2's visit was the white face sheet. Interview revealed, "The nurse never writes on the face sheet. I don't think the nurse ever saw the patient." Interview revealed, "The admissions clerk puts the patient's name on the 'Whiteboard' and then pages the triage nurse." Interview confirmed the ED had 58 admissions on 06/08/2010. Interview further revealed, "35-40 admissions is a typical day in the ED, 58 admissions was a busy day." Interview revealed on 06/08/2010 "one patient left (ED) without completion."

Telephone interview on 12/03/2010 at 1420 with the ED triage nurse working on 06/08/2010 revealed, "If a child was projectile vomiting, that would be a priority. If extremely busy and backed up, that would be a priority." Interview revealed, "If I go out and call and patient has left, I don't know when they left. The receptionist (admissions clerk) doesn't tell the nurse the patient has left or is leaving." Interview revealed the nurse does not document on the computerized face sheet. Interview revealed the nurse documents patients vital signs on a pink sheet when she triages a patient. Interview revealed the "pink sheet is not thrown away, even if the patient leaves." Interview revealed a patient that leaves after being taken back to the treatment room is considered AMA (leaving Against Medical Advice). Interview revealed absence of a pink sheet indicates a patient was not triaged.

Telephone interview on 12/03/2010 at 1500 with the admissions clerk working on 06/08/2010 from 1500-2300 revealed, "The patient comes to the window and I get the basic (name and date of birth) information, I put the patient's name on the Whiteboard and ring the beeper. The nurse comes out and gets the patient." Interview revealed the nurse returns the patient to the lobby after triage, if not in need of immediate attention; where they would wait to be called back "in order of severity" of condition. Interview revealed the face sheet is generated after the patient is triaged or "when I realize they left."

Interview with Medical Records clerk on 12/03/2010 at 1530 revealed the hand written message across the face sheet was placed there for information purposes prior to providing sheet to surveyor. Interview confirmed a medical record for the visit did not exist because the patient was not seen.

Interview on 12/03/2010 at 1530 with Administrative Staff and the ED Nurse Manager confirmed 20 patients presented to the ED on 06/08/2010 between 0800-2230. Interview revealed 20 patients would "overload" the ED. Interview revealed "patient #2 never got to triage." Interview revealed the ED needed more clerical staff to better monitor the patients awaiting triage.