HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to maintain adequate triage staffing to provide a prompt and appropriate triage examination in one 11 emergency department medical records reviewed (MR1).
Findings include:
A review on November 21, 2017 at 2:45 PM of facility policy "Triage," last reviewed by the facility on December 30, 2016 revealed "Policy: To provide an assessment by a Registered Nurse for all patients presenting to the Emergency Department seeking care. Procedure: 1. All patients will be assessed by a Registered Nurse upon arrival. 2. All patients will be assigned an Emergency Severity Index score. This score is determined by preset guidelines developed by the Agency for Healthcare Research and Quality ... 4. Ambulatory patients will be evaluated by a Registered Nurse to determine whether placement in a treatment area is needed immediately or if the patient treatment can be placed into the waiting room to await an available treatment area ..."
A review on November 21, 2017 at 3:00 PM of facility policy "Nursing Process in the Emergency Department," last reviewed by the facility on December 30. 2016 revealed "Policy: The Emergency Department incorporates the nursing process in caring for each patient that presents to the Emergency Department. The nursing process then serves as a template for clinical practice reasoning, data collection and analysis, the nursing conclusion about the data's meaning, the approach to planning and implementation of treatment and evaluation. Procedure: 1. Nursing Process A. Assessment: ... 2. A health history consisting of the patient's chief complaint(s), pertinent medical history, history of the presenting problem, and a review of systems pertinent to presenting complaint. 3. Emergency Department Documentation: 1. Every Emergency Department patient will have a nursing assessment completed on the Emergency Department Assessment e-form. 2. When additional entries need to be documented they will be completed on the Emergency Department Nursing Notes e-form ... 4. Guidelines for Completion of the Emergency Department Triage Assessment & Assessment e-forms: ... 2. The nursing triage assessment will include, time of assessment, subjective and objective assessment illness or injury, vital signs, allergies ... home medications, past medical and surgical history ... 6. Patient condition will be documented upon patient admission, discharge, or transfer ..."
Review on November 21, 2017 of the Emergency Medicine meeting minutes January to October 2017 revealed the facility was working on decreasing the rate at which patients left the emergency department without being seen. The minutes noted the national average was 2.0%. The facility's average was greater than 3%.
A review on November 21, 2017 at 10:55 AM of emergency department staffing for evenings on October 16, 2017 revealed there were six registered nurses on staff which included one assigned registered nurse to the triage area.
A review on November 21, 2017 at 11:05 AM of the emergency department (ED) log for date October 16, 2017 revealed MR1 arrived at 16:50 and was discharged at 18:45, left without being seen. Further review of the ED log revealed that 38 patients arrived at the ED on the 3-11 shift on October 16, 2017.
A review on November 21, 2017 at 11:15 AM of MR1 revealed documentation by the triage nurse (EMP3) at "1655 Pt [patient] ambulatory to waiting area Pt alert and oriented" and at "1845 Called pt and reported by registration pt left ..." Further review of MR1 revealed there was no documentation of vital signs or neurologic assessment.
Interview with EMP2 on November 21, 2017 at 11:30 AM confirmed there was no documentation of an assessment of vital signs or neurologic assessment on MR1.
EMP2 stated the triage nurse needed to prioritize patients or call in back up staff when it was too busy for one triage nurse to handle. EMP2 was unaware if back up was called in on October 21, 2017.