The Condition of Emergency Services has not been met. Based on clinical record reviews and interviews for three (3) of eleven (11) patients who presented to the Emergency Department (ED) for care and treatment, (Patient #1, #3, and #8) the hospital failed to ensure that the patients were assessed in a timely manner to include an Emergency Severity Index (ESI) level, vital signs and/or pain assessment during the triage process and failed to ensure that ED policies and protocols for the triage of patients was adequate to ensure timely assessment and treatment. Please see A1104

Based on clinical record reviews and interviews for three (3) of eleven (11) patients who presented to the Emergency Department (ED) for care and treatment, (Patient #1, #3, and #8) the hospital failed to ensure that the patients were assessed in a timely manner to include an Emergency Severity Index (ESI) level, vital signs and/or pain assessment during the triage process and failed to ensure that ED policies and protocols for the triage of patients was adequate to ensure timely assessment and treatment. The findings include: a. Patient (P) #1 had undergone a Transurethral Resection of the Prostate (TURP) on 9/10/18, performed by Medical Doctor (MD) #1. On 10/1/18 at 8:46 PM P#1 arrived in the Emergency Department (ED) with a chief complaint of bleeding/hematuria starting around 4:15 PM after lifting a heavy object. A triage nurse's note by Registered Nurse (RN) #1 dated 10/1/18 at 8:47 PM indicated P#1 reported he had a TURP procedure 3 weeks earlier. Since 4:00 PM P#1 had been passing blood and clots (from the urethra) and had difficulty urinating. Review of the medical record failed to identify that the patient was traiged in accordance with the Emergency Severity Index (ESI) level (1 most urgent/5 least urgent). The record failed to indicate that the patient's vital signs and/or level of pain were obtained or assessed. According to a nurse's note dated 10/1/18 at 9:23 PM, a urology practitioner called the ED requesting P#1 to be seen. The practitioner was made aware of high volume and extremely high acuity in the department at that time. The practitioner verbalized understanding. On 10/1/18 at 9:38 PM (52 minutes after arrival) P#1 left the hospital without being seen prior to triage and that procedure and treatment not carried out due to patient leaving prior to being seen by health care provider. P#1 indicated he/she was going to another hospital for care. During an interview with RN#1 on 2/13/19 at 11:10 AM, he/she indicated when P#1 arrived to the ED, P#1 appeared slightly uncomfortable, was alert and oriented, stable ambulating, had good color and had driven him/herself to the ED. RN#1 indicated he/she reviewed P#1's symptoms and explained that the ED had a high acuity and critical patients and that P#1 would be seen as soon as possible, but to let RN#1 know if anything changed. RN#1 indicated at the time of P#1's ED encounter, the policy was not to do initial vital signs "up front" but rather as a nursing judgment call (when to do the vital signs) which could be once the patient gets placed in an ED room. RN#1 indicated that P#1 came to the triage desk several times (no more than 3) after using the restroom and RN #1's quick visual assessment indicated that P#1's condition had not changed. RN#1 indicated he/she had received a call from MD#2 inquiring as to when P#1 would be seen. RN#1 explained the acuity/volume of patients in the ED and his/her initial assessment of P#1. RN#1 indicated MD#1 did not indicate P#1 needed to be seen sooner. RN#1 indicated he/she had called back to the treatment area of the ED and briefly spoke with the charge nurse who was managing 2 cardiac arrests, a stroke alert and full rooms. The charge nurse indicated as soon as things settled and they could rearrange things, patients would be moved from the waiting area to a room. During an interview with Medical Doctor (MD) #1 on 2/7/19 at 10:50 AM he/she indicated bleeding 3 weeks post operatively is not unusual however most cases resolve after continuous bladder irrigation and there is a small percentage that require going to the Operating Room (OR) for cautery. MD#1 indicated it was very rare that a patient would lose a life threatening amount of blood through the urinary tract. During an interview with MD#2 on 2/7/19 he/she indicated P#1 had called the urology service twice post operatively. The first time MD#2 spoke with P#1 based on the symptoms P#1 had reported he/she instructed P#1 on some interventions to attempt to stop the bleeding and then be evaluated by MD#1 the next day. MD#2 indicated he/she told P#1 if he/she continued to have concerns P#1 should seek further evaluation. MD#2 indicated when P#1 called the second time that evening based on what P#1 reported and his/her level of alertness and sound on the phone, MD#2 did not feel P#1's situation was critical. However P#1 seemed more upset about having to wait in the ED to be evaluated. MD#2 then called and spoke to the triage nurse in the ED to see if he/she could expedite P#1 being seen. However the triage RN explained the acuity and volume of patients in the ED and indicated P#1 would be seen as soon as possible. During an interview with the ED Manager on 2/6/19 at 9:40 AM he/she indicated that in discussing the events of 10/1/18 with the Charge Nurse, it was felt that staffing was adequate. The issue was that there were no available rooms due to multiple emergent cases in the ED at that time. Once the emergent cases were attended to and were less critical, staff would reassess the situation. The ED manager identified that he/she was aware of the process should he/she need additional staff. During review of the medical records for P#1 with the ED Manager on 2/13/19 at 12:45 PM he/she indicated although the ED treatment area was full, vital signs and an ESI level should have been obtained in the triage area and documented as indicated in the triage policy and nursing protocol for ED nursing assessment and documentation. The ED Manager indicated that the triage policy is in the process of revision to include that vital signs need to be done immediately in triage. Review of the "Triage of Patients Presenting in the Emergency Department" policy directed that all patients presenting to the ED would be triaged and have an intake note documented by the RN. The ESI triage system would be used to categorize the patients based on severity and resource needs. ESI triage algorithm indicated in order to establish an ESI triage level, a patients cognitive orientation, pain/distress, heart rate, respiratory rate and oxygen level needs to be assesed. The policy indicated all ED patients would receive prompt emergency care according to their urgency level. After the initial intake, Patients with an ESI of 1, 2 or 3 (resuscitation, emergent and urgent) would be placed into appropriate ED treatment rooms so that emergency measures can be initiated immediately. Patients with an ESI of 4 or 5 (less urgent/non-urgent) would be placed in an up-front provider room where care can be provided, which includes vital signs. A nursing protocol for ED nursing assessment and documentation identified to assess the patient and assign an acuity level and complete the triage process by obtaining in part, vital signs and a pain assessment. However, the protocol failed to identify when staff should be expected to complete the triage process. The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment. b. P#3 arrived in the ED on 10/1/18 at 7:51 PM with a chief complaint of back pain after a fall at home. At 7:51 PM, RN #1 designated that the patient was an ESI level 3, was placed in a room at 8:09 PM, and evaluated by the Physician Assistant (PA) at 11:51PM. An assessment by the PA indicated as of 11:51 PM (4 hours after arrival) no vital signs were documented. A nurse's note dated 10/2/18 at 12:33 AM indicated P#3 signed the required documentation and left Hospital #1 against medical advice (AMA). c. P#8 arrived in the ED on 10/1/18 at 8:06 PM with a chief complaint of hypertension. Review of RN #1's nurse's note dated 10/1/18 at 8:07 PM indicated P#1 reported a high blood pressure at home and that he/she had not felt well since his/her medication had been changed. P#8 reported his/her systolic BP had been >100. Review of the medical record failed to identify vital signs or an ESI level had been obtained/documented until 9:25 PM. P#8 was placed in a room at 9:27 PM (1 hour 18 minutes after arrival) and left without further evaluation at 9:30 PM. During an interview with the ED Manager on 2/6/19 at 9:40 AM he/she indicated ideally vital signs should be obtained right away however if there was a line, the vital signs might not be taken right away and the patient would subsequently be called back to triage as soon as possible to have vital signs obtained. During review of the medical records for P#3 and P#8 with the ED Manager on 2/13/19 at 12:45 PM he/she indicated if P#3 was triaged at 7:51 PM, it was unacceptable that as of 11:51 PM no vital signs had been obtained and documented. In addition if P#8, with a reported history of hypertension arrived to the ED at 8:06 PM complaining of a headache, vital signs and an ESI level should have been obtained and documented.