HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the development and implementation of policies/procedures relating to the evaluation and supervision of care to patients who are transported to the hospital's ED (Emergency Department) by ambulance service providers. This was evidenced by the registered nurses failure to ensure that a triage assessment was performed on a patient (Patient #2) prior to the transfer of care from the ambulance service provider to a staff member in the hospital's ED. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to the ED (Emergency Department) at North Oaks Medical Center on 1/21/10 via an ambulance service provider. There were two medical records created for Patient #2 on 1/21/10 relating to this visit. The first medical record (Patient Account #1002100344) was relating to Patient #2's presenting to the ED on 1/21/10 at 12:43 p.m. The second medical record (Patient Account #1002100410) was relating to Patient #2's being re-registered in the ED on 1/21/10 at 1:43 p.m.

The medical record (Patient Account #1002100344) relating to Patient #2's presenting to the ED on 1/21/10 at 12:43 p.m. was reviewed. Review of the "Disposition Summary" revealed that Patient #2 arrived at the hospital's ED on 1/21/10 at 12:43 p.m. with a chief complaint of "Syncope". Documentation on this "Disposition Summary" revealed that Patient #2 left without being seen. Review of the "Nursing Chart" revealed a nursing note that documented "LWOT - Patient called for the 3rd time per PCT. No answer. Patient not found in waiting room, emergency department or immediate vicinity". There was no documentation in this medical record to indicate the name of the staff member who called for Patient #2 or the time that Patient #2 was called for triage.

The medical record (Patient Account #1002100410) relating to Patient #2's being re-registered in the ED on 1/21/10 at 1:43 p.m. was reviewed. Review of the "Disposition Summary" revealed that Patient #2 arrived at the hospital's ED on 1/21/10 at 1:43 p.m. with a chief complaint of "Syncope". Documentation on this "Disposition Summary" revealed that Patient #2 left without being seen. Review of the "Nursing Chart" revealed a nursing note, entered by S5 (RN) on 1/21/10 at 2:02 p.m., which documented "Pt family member to desk asking if pt's name has been called. Informed family member that pt had been previously called several times and pt did not answer. Family member states that pt has been in ED waiting area entire time. Pt was previously aware that she had been removed from triage system and has checked in again. Family member states 'You are lucky she is not dead.' Pt and family member seen ambulating out of ED without difficulty and getting into car". Further review of the nursing chart revealed an entry, entered by S4 (Patient Care Technician) on 1/21/10 at 2:07 p.m., which documented "pt called several times and I walked around lobby, no answer. Paging system not working today- no pagers given".

S6 (Registered Nurse) was interviewed on 2/09/10 at 2:45 p.m. S6 reported that she was working as the ER charge nurse on 1/21/10 at the time of Patient #2's arrival to the ER. S6 reported that Patient #2 was transported to the hospital's ER by (ambulance service provider) on 1/21/10. S6 reported that she (S6) received a telephone report from (ambulance service provider) on 1/21/10 at 12:24 p.m. while they were in route to the hospital with Patient #2. S6 reported that she was informed that Patient #2 was a 20 year old with Syncope who was alert and oriented with stable vital signs. S6 reported that she "eyeballed" Patient #2 as the ambulance provider was bringing Patient #2 in to the ER. S6 reported that Patient #2 appeared to be in no apparent distress at the time of entering the ER so she informed Acadian Ambulance to bring Patient #2 to the triage area so that a triage assessment could be conducted. S6 reported that (ambulance service provider) then started toward the triage area with Patient #2 and indicated that Patient #2 should have been handed off from (ambulance service provider) to the triage nurse so that a triage assessment could be conducted on Patient #2. S6 reported that she had no knowledge that a triage assessment was not conducted on Patient #2. S6 reported that she did not see or hear anything about Patient #2 after she (Patient #2) was taken to the triage area. S6 reported that she could provide no documentation of an assessment being conducted on Patient #2 after her arrival to the hospital's ER

S4 (Patient Care Technician) was interviewed on 2/08/10 at 12:40 p.m. S4 reported that she worked the 7:00 a.m. through 7:00 p.m. shift on 1/21/10 and stated that she was assigned to assist the registered nurses in the triage area from 1:00 p.m. through 4:00 p.m. on 1/21/10. S4 reported that her assignments when assisting in the triage area include calling for patients who are in the ER waiting room, obtaining vital signs on patients, and alerting nurses if she feels that a patient is in need of a nursing assessment. S4 reviewed the medical record of Patient #2 and reported that she did remember working in the triage area at the time Patient #2 was in the ER. S4 reported that she was not the ER staff member who called for Patient #2 after arriving in the ER on 1/21/10 at 12:43 p.m. S4 indicated that she did not know which ER staff member called or attempted to locate Patient #2 during the patient's first registration as this information was not documented in the medical record. S4 indicated that she became involved after Patient #2 had been re-registered in the ER on 1/21/10 at 1:43 p.m. S4 reported that the triage nurse (S5) handed her the paperwork on Patient #2 on 1/21/10 at approximately 2:07 p.m. and told her that admitting had reported that Patient #2 had left the ER. S4 reported that she immediately made a round through the ER waiting area calling the patient by name and reported that the patient did not answer. S4 reported that she informed the triage nurse (S5) that Patient #2 did not answer when called.

S5 (Registered Nurse) was interviewed on 2/09/10 at 1:00 p.m. S5 reported that he worked the 12:00 noon through 12:00 midnight shift on 1/21/10 and stated that he was assigned to the triage area at the time of Patient #2's arrival to the ER. S5 reviewed the medical record of Patient #2 and reported that he did remember the patient. S5 reported that Patient #2's initial registration into the ER was on 1/21/10 at 12:43 p.m. and that her chief complaint was Syncope. S5 reported that his first interaction with Patient #2 was on 1/21/10 when Patient #2 presented to the triage area and asked why she had not been called. S5 reported that he did not know exact time that Patient #2 presented to the triage area but thought it was around 1:35 p.m. S5 reported that he explained to Patient #2 that her name had been called several times for triage but she did not answer and her name had been taken out of the system. S5 reported that he instructed Patient #2 to return to the ER registration desk to be re-registered into the system. When asked by the surveyor, what time Patient #2 was called for triage and by whom after being registered at 12:43 p.m., S5 stated that the record indicated that a PCT had called for the patient 3 times before her being listed as left without being seen and removed from the system. S5 reported that he could not identify the time that Patient #2 was called for triage. When asked the name of the PCT who had called for Patient #2, S5 reported that he could not recall which PCT had called for Patient #2 and that it was not documented in the medical record. When asked if any of the triage nurses had attempted to locate Patient #2 prior to listing Patient #2 as left without being seen and removing Patient #2 from the system, S5 reported that he could not recall if he had attempted to locate Patient #2 prior to removing the patient from the system and could not recall if any other nurse had attempted to locate Patient #2. S5 reported that Patient #2 was re-registered into the system on 1/21/10 at 1:43 p.m. When asked what happened after Patient #2 was re-registered into the system, S5 reported that the patient's father approached the desk at about 2:02 p.m. asking about Patient #2 being called for triage. S5 reported that the PCT (S8) told Patient #2's father that Patient #2 was called and that she (Patient #2) did not respond. S5 reported that Patient #2's father reported that Patient #2 had not left the ER waiting area. S5 reported that S8 again told Patient #2's father that Patient #2's name was called and that she did not answer. S5 reported that S8 was waiving her hands while talking to Patient #2's father. S5 reported that Patient #2's father turned to walk away and said "you are lucky she is not dead" as he was walking away. S5 reported that he then saw Patient #2 and her father leave the ER.