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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to conduct a complete triage assessment, follow emergency department (ED) protocols, and report changes in condition while the patient was in the waiting room to ensure an appropriate medical screening examination was completed to determine if an emergency medical condition existed. See deficiency at A-2406 (a).

The Immediate Jeopardy (IJ) began 1/3/2023 due to the Hospital's failure to conduct a medical screening examination in an appropriate and timely manner to determine if any emergency medical condition existed. Subsequently, the patient was transferred to a higher level of care. The IJ was identified on 1/30/2023, at 42 CFR 489.24 (a) (c). The IJ was announced on 1/30/2023 at 4:45 PM during a meeting with the Director of Quality & Safety, Regulatory Coordinator, Manager Quality &Safety, Chief Nursing Officer, Chief Executive Officer, Chief Medical Officer, and Director of Regulatory, and was not by the survey exit date of 1/31/2023.

A. Based on document review and interview, it was determined that for 1 of 20 clinical records (Pt.#9) reviewed for patients seeking emergency medical services, the Hospital failed to conduct a complete triage assessment, follow emergency department (ED) protocols, and report changes in condition while the patient was in the waiting room to ensure an appropriate medical screening examination was completed to determine if an emergency medical condition existed.

Findings include:

1. The Hospital's policy titled, "Copy of Standards in Care in the Emergency Department and Emergency Nurses Association Guidelines" (dated 6/20/2022), was reviewed on 1/26/2023, and required, " ...c. The patient is evaluated according to the Emergency Severity Index Guidelines [ESI] ... Assessment and patient need are communicated to the health care provider(s) who are responsible for the care and treatment of the patient ...The patient should receive treatment based on the nursing assessment and members of the interdisciplinary team should coordinate efforts to plan, identify and meet the patient outcome goals ...The patient should receive appropriate nursing care and emergency interventions to meet his/her assessed needs ... Urgent notification is needed for ESI 2 patients. ESI 3, 4 and 5 patients are brought to the physician's attention via the [computer] trackboard, or sooner per the discretion of the Registered Nurse ...Vital signs monitoring recommendations include: ...2. ESI 2 every hour X 4 hours based on clinical presentation, then every two hours ...ESI 3 every 2 hours based on clinical presentation ..."

2. The Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA), dated 6/1/2021, was reviewed on 1/26/2023, and required, " ...6. Emergency Medical Condition (EMC): a, A medical condition that manifests itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual, pregnant woman or unborn child in serious jeopardy ...9. Medical Screening Examination (MSE): Appropriate process (examination and evaluation of the individual) within the capability of the hospital's ED or OB Department, including ancillary services routinely available to these departments: a. To determine whether or not an EMC exists; or b. Whether or not a woman is in labor ..."

3. The Hospital's policy titled, "Obstetrics in Emergency Department" (dated 6/2022), was reviewed on 1/26/2023, and required, " ...Patients less than 16 weeks gestation will be triaged by RN and evaluated by the Emergency Physician regardless of presenting complaint ..."

4. The Hospital's "ED Adult Chest Pain Standing Order" (dated 11/1/2022), was reviewed and required, "For Use in all Emergency Department patients 18 years of age or greater presenting with ...acute chest pain ...Initiate ED non-traumatic acute chest pain standing order. 1. Apply cardiac monitor. 2. Obtain bilateral blood pressures. 3. EKG [electrocardiogram] 12 lead ..."

5. The Hospital's policy titled, "ED Adult Back Pain/Injury Standing Order" (dated 10/28/2022), was reviewed on 1/26/2023, and required, " ...Ibuprofen 600 mg [milligrams] PO [oral], once (if none given 6 hours prior to ED arrival) ..."

6. The clinical record for Pt #9 was reviewed on 1/25/2023. Pt #9 presented to the ED (emergency department on 1/3/2023 at 3:21 PM, status post motor vehicle accident at 13 weeks gestation. The patient arrived via ambulance and was placed in general waiting room after triage at 4:04 PM.

- The triage note (dated 1/3/2023 at 4:04 PM), documented by the ED Triage RN (E #12) included, "Pt states restrained passenger in MVC [motor vehicle crash], vehicle rear ended and pushed in wall +airbag deployment, c/o [complaints of] chest pain and back pain. Pt reports being 3 months pregnant, denies abdominal pain or bleeding.". Pt #9's vital signs in triage were recorded as stable at 4:02 PM as: temperature 98.8 Fahrenheit, blood pressure 108/51, pulse 80, respirations 18.

-The clinical record did not include any further vital signs, from time of triage at 4:03 PM, until 1/3/23 at 7:40 PM (3 hours and 38 minutes after the initial vital signs).

- Pt #9's pain score at triage (1/3/23 at 4:03 PM), was documented as 10/10 (10 being the worst pain), location: chest, description: constant.

-The ED Medication Administration log, from 1/3/2023, was reviewed and indicated that the 1st dose of pain medication (acetaminophen 650 mg/milligrams) was given at 19:41 (7:41 PM/3 hours and 39 minutes after patient's initial report of chest pain and back pain).

-An EKG (electrocardiogram) was done on 1/3/23 at 16:00 (4:00 PM). However, the clinical record did not include any documentation of cardiac monitoring, documentation of bilateral blood pressures, or any further cardiac workup, per protocol, during triage.

- Pt #9's ESI level (emergency severity index/triage algorithm) at triage (1/3/23 at 4:03 PM) was level 3 (urgent - physician notification through trackboard). The clinical record lacked any assessment of the fetal well being during triage. The clinical record lacked documentation of a physician being notified of Pt #9's presenting condition/chief complaint and less than 16 weeks gestation, at the time of triage.

-Pt #9's ESI level subsequently changed to a higher level of 2 (emergent - requiring urgent physician notification) at 6:03 PM due to patient report of vaginal bleeding. The clinical record lacked documentation of a physician being notified of Pt #9's ESI change.

- The ultrasound order for (pregnant uterus), was not entered until 1/3/23 at 6:30 PM. The ultrasound was performed at 7:01 PM (approximately 3 hours after triage). The indication: "patient presents with lower abdominal pain and vaginal bleeding status post motor vehicle accident." The ultrasound results included, "Intrauterine gestation of estimated gestational age 13 weeks and 6 days +/- 10 days. There are no fetal cardiac pulsations seen compatible with fetal demise. The fetus appears to be decapitated." The Preliminary Radiology Report indicated that this case was discussed by the radiologist, with MD #3 on 1/3/23 at 8:08 PM.

-Pt #9's laboratory orders and results were reviewed. The clinical record included the following documented lab collection times (approximately 3 hours and 36 minutes after triage)
- CBC (complete blood count with differential) at 7:50 PM
- CMP (comprehensive metabolic panel) at 7:49 PM
- Troponin (rules out damage to heart) at 7:49 PM
- HCG (human chorionic gonadotropin) level at 7:49 PM
There were no labs collected prior to 7:49 PM for Pt #9.

- The HPI (history of present illness), dated 1/3/2023 at 9:09 PM (5 hours and 48 minutes after arrival), documented by the Emergency Department Physician (MD #3), included, "Patient is a 23-year-old female ...that is dated at 14 weeks gestational age that presents [to the] emergency department for further evaluation following motor vehicle accident. States that she was on the highway as a restrained passenger when they rear-ended and pushed into the median/wall. Airbags were deployed. Patient was hit in the abdomen by the airbags. She is here for further evaluation and she is having lower abdominal pain, some chest discomfort, and lower back pain ...Patient does have blood oozing from cervical os [opening]. No active hemorrhaging ..."

- A subsequent physician note documented by MD #3 on 1/3/2023 at 11:56 PM, included, " ...Presentation at this time concerning for fetal demise, intra-abdominal injury, chest wall contusion, possible although less likely lumbar spine fracture ...Patient's workup reviewed, unfortunately per Radiology read, there is a fetal demise with severe fetal trauma ...During the patient's stay in the ER she did begin to develop vaginal bleeding, following my speculum exam, she did have continuous oozing from the cervical os (opening). I did discuss care with Ob gyn (obstetrics gynecology [MD #4]. Patient's CT [cat scan] imaging was returned showing L1-L2 compression fractures, additionally patient with free fluid in the pelvis concerning for hemorrhagic component [potential blood loss] ...Given that patient is having ongoing bleeding from the cervical os [opening] that is slow with deterioration of her vital signs with more tachycardia [increased heart rate] and a 1 g (gram) drop in her hemoglobin I feel she requires trauma evaluation. Patient will be transferred to [trauma center] for further evaluation ..."

- The Emergency Transfer Form (dated 1/4/23 at 12:59 AM), indicated that Pt #9 was transferred via ambulance, to a higher level of care due to trauma.

7. On 1/25/2023 at 10:25 AM, an interview was conducted with E #12 (ED Triage RN). E #12 stated that Pt #9 came via ambulance and was brought to triage. E #12 stated that he didn't receive the EMS run sheet report. E #12 stated that Pt #9 was complaining of chest pain at 10/10 and mid back pain. E #12 stated that when a patient presents with chest pain, the protocol would be to get an EKG and labs at the time of triage. E #12 stated that if a pregnant patient presents to the ED, they follow the OB protocol. E #12 stated that if the patient is less than 16 weeks, then the triage RN will have labs ordered and get an ultrasound. E #12 stated that regarding Pt #9, she did not have vaginal bleeding during triage, but later went to the front desk while she was in the waiting room, to let them know of bleeding around 6 PM (2 hours after triage). E #12 stated that this is when he put in the orders for the ultrasound and labs. E #12 stated that when Pt #9 started bleeding, this is when he changed her ESI level to 2 (emergent). E #12 stated that when her ESI level changed, the expectation is to communicate this with the Charge RN to facilitate the patient going to the back treatment area. E #12 stated that there was no communication with the Charge Nurse or the ED Physician. E #12 stated that potential risks of a pregnant women with trauma, could be bleeding/hemorrhage, ectopic pregnancy that can be life-threatening, or miscarriage. E #12 stated that he has not received any coaching from management regarding this situation.

8. On 1/25/2023 at 12:10 PM, an interview was conducted with the OB/GYN Physician (MD #4). MD #4 stated that she received a call from the ED wanting to discuss the case of Pt #9. MD #4 stated that the care of a pregnant patient presenting following a motor vehicle accident, would be dependent on the impact. MD #4 stated that at a minimum, vital signs monitoring should be at least every 30 minutes to one hour and obtain labs. MD #4 stated that the ED staff can either do a bedside ultrasound, a formal ultrasound, or a handheld doppler to check for fetal well-being. MD #4 stated that the concern with an OB patient presenting after a motor vehicle, is the potential for placenta abruption, maternal death, organ displacement, hemorrhage, or pre-term delivery.

9. On 1/26/2023 at 11:35 AM, an interview was conducted with the ED Physician (MD #3/cared for Pt #9 in the ED). MD #3 stated that when a pregnant patient presents to the ED and has had trauma, the patient should have an ultrasound right away to determine if the fetus is viable or not. There are protocols that the nurses can implement when the patient comes in. MD #3 stated that he relies on the triage nurse's assessment and would like to know how and when the patient presents to the ED. MD #3 stated that the doctors do the full evaluation to determine the patient's condition. MD #3 stated that if a patient presents with chest pain, there are other factors to assess, but at the bare minimum, he would personally, want the nurse to get an EKG and labs at triage. MD #3 stated that chest pain should be evaluated as ESI level 2 (emergent). MD #3 stated that regarding Pt #9, there was a time lapse (around 4 hours, as he is reviewing the chart), with him being aware that Pt #9's change of condition in the waiting room. MD #3 stated that the only way he knew that the patient was in the ED was when the Radiologist called him to let him know about Pt #9's fetal trauma seen on ultrasound. MD #3 stated that he then told the Charge RN to bring Pt #9 to the back ED from the waiting room. MD #3 stated that Pt #9's fetus was not viable at 13-14 weeks gestation, but there are potential concerns with the pregnant patient including the hemorrhagic component. MD #3 stated that Pt #9 was transferred to [trauma center] due to the slow bleeding from the cervix, increasing heart rate and lumbar fracture.

10. On 1/26/2023 at 1:15 PM, an interview was conducted with the Charge RN (E #14). E #14 stated that she was in charge and took the radio report from [ems/fire department] on Pt #9. E #14 stated that when Pt #9 came in, she took a quick glance from across the room and the patient was then taken to triage. E #14 stated that she had no other contact or communication about the patient after the initial contact. E #14 stated that she gave the 3 PM-7 PM Charge Nurse, report. E #14 stated that since Pt #9 came in with trauma due to car accident and was complaining of back pain, the "low back pain" protocol should have been initiated. E #14 stated that chest pain, could be depending on other factors, but the "chest pain" protocol should be initiated if someone is complaining of chest pain. E #14 stated that if a patient's ESI level changes to a higher level, the Charge Nurse should be notified.

11. On 1/30/2023 at 9:02 AM, an interview was conducted with the ED Charge RN (E #15). E #15 stated that she was the charge nurse on 1/3/2023, from around 3 PM-7 PM (when Pt #9 was in the waiting room). E #15 stated that she was never made aware of Pt #9, by the triage nurse (E #12) and did not have any interaction with the patient. E #15 stated that if a patient presents to triage with chest pain and/or as an OB patient, she will get vital signs and initiate any nurse-driven protocol. E #15 stated that if the nurse thinks there should be any orders outside of the protocols, then the nurse should notify the physician. E #15 stated that with an OB patient, the triage nurse would at a minimum get labs and speak with the provider to see if they want an ultrasound. E #15 stated that the chest pain protocol includes getting a chest x-ray, EKG, asking if they are on coumadin (blood thinner), an aspirin order, a troponin level, and anything else that the MD orders. E #15 stated that a patient at the ESI level 2, would need to be seen right away and taken to the back treatment area.

12. On 1/30/2023 at 10:40 AM, an interview was conducted with the ED Medical Director (MD #5). MD #5 stated that when a patient presents to the ED with a complaint, the triage nurse will ask pertinent questions and make a determination based on clinical presentation. MD #5 stated that it is "pretty" important for the nurses to communicate with the provider, when changes with the patient occurs. MD #5 stated that when a patient presents with chest pain, they would at least get the basic blood work, and an EKG. MD #5 stated that vital signs should be obtained when the ESI category changes. MD #5 stated that if a nurse is unsure if an intervention or order is needed that is not in protocol, then the nurse should immediately ask the provider.



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B. Based on document review and interview, it was determined that for 2 of 20 clinical records (Pt. #10 and Pt. #11) reviewed for patients identified as leaving the ED (emergency department) without being seen, the Hospital failed to provide a medical screening examination, including assessment and/or reassessment, to determine if an emergency medical condition existed.

Findings include:

1. On 1/26/2023, the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" (effective 6/2021) was reviewed and included, "Definitions... 6. Emergency Medical Condition (EMC): a. A medical condition that manifests itself by acute symptoms of sufficient severity... 10. Qualified Medical Person (QMP): A physician is a QMP qualified to provide an appropriate MSE... Policy: 1. Individuals who come to the ED receives a MSE by a QMP to determine if an EMC exists..."

2. On 1/26/2023, the Hospital's policy titled, "Copy of Standards of Care in the Emergency Department and Emergency Nurses Association Guidelines (effective 6/2022) was reviewed and included, "... Process...1. The Registered Professional Nurse (RN) performs a nursing assessment... b. The patient assessment should be completed within a reasonable amount of time... and may include: i. Chief complaint and present physical status... 3... e. The patient should be continuously assessed for changes... Standard III... f. Fundamental Emergency department nursing interventions should include, but are not limited to... iii...Vital Sign monitoring recommendations include... 2. ESI (emergency severity index of) 2 every hour x 4 hours based on clinical presentation, then every two hours... "

3. On 1/26/2023, the clinical record for Pt. #10 was reviewed. Pt. #10 came to the ED on 10/3/2022 due to shortness of breath. The clinical record included:

- At 11:58 AM, Pt. #10 was triaged with an ESI of 2 (emergent)
- At 12:21 PM, the nurse's note indicated, " ... (History of Sarcoidosis/condition of the immune system) (complaining of shortness of breath). Pt. #10's vital signs were as follows: Blood Pressure 92/55 (normal reading at
least 120/80); Pulse 82 (normal); Respiration 24 (normal); and Temperature of 98.2-degree Fahrenheit (normal).
- There were no vital signs monitoring from 12:21 PM through 7:38 PM (approximately seven hours) for Pt. #10.
- At 9:52 PM, after being called three times, Pt. #10 was identified as leaving the ED without being seen by a QMP.

4. On 1/26/2023, the clinical record for Pt. #11 was reviewed. Pt. #11 came to the ED on 9/3/2022 due to MVA (motor vehicular accident). The clinical record included:

- At 1:09 AM, Pt. #11's vital signs were as follows: Blood Pressure: 106/64; Pulse 73; Respiration 18; Temperature 98.3 degree Fahrenheit.
- At 1:15 AM, the clinical record indicated, "... (Pt. #11) was involved in a car accident today and has pain to the front of his neck where he had surgery.
- There were no pain assessments or reassessments conducted for Pt. #11's pain.
- At 5:20 AM (four hours since Pt. #11's arrival), Pt. #11 was called and could not be found.
- At 6:24 AM, after being called three times, Pt. #11 was identified as leaving the ED without being seen by a QMP.

5. On 1/30/2023 at approximately 10:40 AM, an interview was conducted with MD #5 (Medical Director) and E #4 (ED Director). MD #5 stated that all patients coming to the ED should receive a MSE. MD #5 stated that nurse's assessments and monitoring are part of the MSE. Findings were also discussed with E #4. E #4 stated that Pt. #10's vital signs should have been monitored more frequently. E #4 added that pain assessment should be conducted for Pt. #11 to identify if an intervention requiring physician's notification are necessary and pertinent to the physician's medical screening examination.