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A. Based on staff interview, medical record review, and review of the Inspira Medical Center of Woodbury Satellite Emergency Department (SED) log, it was determined that the facility failed to ensure that the log is complete.

Findings include:

1. On 8/2/2021, the ED (Emergency Department) log was reviewed for the date of 6/21/2021 and was noted to be missing the triage date and time for Patient #24, Patient #25, and Patient #26.

2. Upon request to Staff #4, the medical records of Patient #24, Patient #25, and Patient #26 were reviewed and their triage times were noted in the medical record.

3. An interview with Staff #4 on 8/2/2021 at 2:00 PM confirmed that the triage times were missing from the ED log, and that the triage date and time should have been recorded on the log.


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B. Based on a review of the Inspira Medical Center of Woodbury Satellite Emergency Department (SED) log entries on 8/2/2021, it was determined that the SED failed to maintain an accurate central log on each individual who came to the emergency department seeking assistance and whether the individual refused treatment, was refused treatment; or whether the individual was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

1. Upon interview on 8/2/2021 at 2:00 PM, Staff #7 stated that Patient #23 presented to the SED on 6/16/2021 seeking medical treatment and was informed by the greeter that no beds were available.

a. Upon review of the Central Log, there was no evidence that Patient #23 presented to the SED on 6/16/2021. Staff #7 stated that Patient #23 should have been documented on the central log and that a medical record should have been generated.

b. Staff #4, #7 and #8 confirmed the above findings.

2. Review of the central log dated 2/2/2021, revealed the following:

a. In the column marked "ED [Emergency Department] Discharge Disposition," Patients #27, Patient #28 and Patient #29 were listed as "Still a Patient." Patient #30 was listed as "Admitted as Inpatient."

b. Upon interview on 8/2/2021 at 1:00 PM, Staff #4 stated that the ED logs are not being maintained correctly.

A. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that Inspira Medical Center of Woodbury Satellite Emergency Department (SED) failed to ensure that an appropriate triage level was determined in one (1) of fifteen (15) medical records reviewed (Patient #9).

Findings include:

Reference: Facility policy titled, "Triage, Patient (ER.66) *IHN" states: "...PROCEDURE... C. The Pivot/Triage Nurse/RN [registered nurse] shall assign a Triage Level to each patient according to the Nationally recognized Emergency Severity Index (ESI) Guidelines and will be monitored consistent with the level assigned..... TRIAGE LEVELS: ...LEVEL 2... c. if the patient should not wait, the patient is triaged as an ESI Level 2. d. Three broad questions are used to determine whether patients meet Level 2 criteria... - Is this a high risk situation? Examples of high risk situations include: *Active chest pain, suspicious for coronary syndrome, but does not require an immediate life-saving intervention, stable... -Is the patient exhibiting new onset of confusion, lethargy or disorientation? ...-Is the patient in severe pain or distress? *The nurse needs to assess the level of pain or distress..... *The triage nurse observes physical responses to pain that support the patient's rating..... LEVEL 3... -Before assigning this, however, the nurse needs to look at the patient's vital signs and decide if they are outside the parameters for age and if it is felt by the nurse to be meaningful. If they are, the nurse should consider upgrading to ESI Level 2...."

1. On 8/3/2021, the medical record of Patient #9 was reviewed, and the following was identified:

a. Patient #9 arrived at the Emergency Department (ED) on 6/16/2021 at 2:17 PM and was triaged at 2:33 PM as a "Level 3H."

b. Patient #9 had the presenting complaint of being stabbed twice in the abdomen the night before with the associated following issues:

(i) Elevated blood pressure upon triage of 155/85 mmHg (millimeters of Mercury)

(ii) Pain level of 10 out of 10 indicating worst possible pain/Severe pain

c. An ED physician note, service date/time of 6/16/21 at 2:31 PM, stating:"...Patient... presents complaining of abdominal pain after [he/she] was stabbed twice in the abdomen last p.m.... complains of nausea without vomiting..... pain got worse since last p.m.... arrives diaphoretic..... arrives in extreme abdominal pain.... Patients' Condition: Critical...".

2. The above findings were shared with Staff #4. An interview with Staff #4 on 8/3/2021 at 11:20 AM confirmed the above findings and stated that Patient #9 should have been triaged at acuity Level 2 where he/she would not have waited, and not at a Level 3 where the patient could have waited for treatment.


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B. Based on review of hospital policies and procedures, and interviews with administrative staff, it was determined that Inspira Medical Center of Woodbury Satellite Emergency Department (SED) failed to provide an appropriate medical screening exam (MSE) to determine whether or not an emergency condition exists.

Findings include:

Reference: Facility policy titled, "Emergency Medical Treatment and Transfer" states, "...II Procedure A. MEDICAL SCREENING EXAMINATION: Any person who "comes to the Emergency Department" for treatment must be given a medical screening examination to determine if the person suffers from an "emergency medical condition." The medical screening examination goes beyond the hospital's initial triaging and includes all of the ancillary services normally available to the Emergency Department, ..."

1. Upon staff interview on 8/2/21 at 2:00 PM, the following was revealed:

a. Staff #7 stated that Patient #23 presented to the SED (Satellite Emergency Department) on 6/16/21 seeking emergency medical treatment and was informed by the greeter that no beds were available. Patient #23 left the SED without treatment and presented to another ED.

2. The facility failed to perform a Medical Screening Exam to determine if a medical emergency condition existed.

3. The above finding was confirmed with Staff #7.

The facility identified the above issue and self -reported an EMTALA incident to the Regional Office (RO) on 6/18/2021. Upon survey on 8/2/2021, the facility provided evidence of corrective actions taken upon identification of the EMTALA violation that included: Verbal re-education in addition to computer-based learning modules for the reinforcement of EMTALA regulations with all emergency room staff. Verbal re-education was initated immediately upon identification of the incident. Computer-based modules followed for re-enforcement of verbal re-education. All education was completed by the time of the survey on 8/2/2021. The facility has had no violations or similar problems for at least the past 6 (six) months.

Based on staff interview, medical record review, and review of facility policies and procedures, it was determined that the facility failed to ensure that the patient is treated once an emergency medical condition has been identified in one (1) of fifteen (15) charts reviewed (Medical Record #2).

Findings include:

Reference #1: Facility policy titled, "Leaving without Treatment/Against Medical Advice/Elopement ADM.283 *IHN" states: "...ELOPEMENT - patient who following [sic] a Medical Screening Exam being completed leaves the hospital prior to receiving medical advice about the risks of leaving by a physician..... b. All Elopements (competent and incompetent): ... *The physician should review the chart and any tests ordered by the nursing staff under protocol in real time. *When indicated, the department should contact the patient regarding the results of the tests and always document the review of the tests, any attempts to reach the patient and any instructions given to the patient....."

Reference #2: Facility policy titled, "Vital Signs (ER.70) *IHN*" states: "...PROCEDURE A. All patients presenting to the Emergency Department/S.E.D. [satellite emergency department] will have vital signs taken upon triage / first assessment. Additional vital signs will be taken for re-assessment at a minimum of four (4) hours and at time of discharge....."

1. On 8/3/2021, the medical record of Patient #2 was reviewed and the following was identified:

a. Patient #2 arrived to the facility ED on 7/26/2021 at 12:37 PM with complaints of abdominal pain of 7 out of 10 in intensity, and was triaged at 12:59 PM as an acuity Level 3V. Initial vital signs were taken at this time.

b. An ED disposition note written by Staff #21 on 7/26/2021 at 5:49 PM stated, "Patient eloped." The medical record lacked evidence that a re-assessment with vital signs and pain assessment was completed prior to 5:49 PM. This was five (5) hours and 12 minutes after the initial assessment.

c. An ED physician note written by Staff #22 on 7/26/2021 at 8:49 PM stated, "Impression: Acute liver failure; hyperbilirubinemia; incarcerated umbilical hernia without bowel involvement; cholelithiasis; hypomagnesemia; hypokalemia Plan: Plan was to admit the patient, unfortunately [the patient] eloped before I could explain this to [the patient]."

2. Upon request to Staff #4 and Staff #12, the facility was unable to provide evidence that Patient #2 was contacted regarding the results of his/her tests and the plan for admission.

3. Staff #4 and Staff #12 confirmed on 8/3/2021 at 11:33 AM that the patient should have been been reassessed by the nurse sooner, and should have also been contacted by the ED regarding his/her test results and plan for admission after the patient had eloped.