HospitalInspections.org

Based on interview, patient record review and a review of the Emergency Department log, hospital Security Officers' reports, "Important Registration Procedure" email, "Florida EMTALA Medical Screening Examination and Stabilization" and "Triage Process" hospital policies, and video, the hospital failed to triage on arrival and provide a medical screening exam for one (1) of 27 sampled patients, Patient #1.

Based on interview, review of the Emergency Department (ED) log, Security Officers' reports, "Important Registration Procedure" email, "Florida EMTALA Medical Screening Examination and Stabilization" and "Triage Process" hospital policies, and video, the hospital failed to maintain an Emergency Department (ED) Central Log on each individual who comes to the ED seeking assistance, whether he or she refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged, for one (1) of 27 sampled patients, Patient #1.

Findings:

1. Emergency Department (ED) Registration Document

The hospital ED staff was not able to produce any form of written or electronic documentation which reflected an actual or attempted registration for patient #1.

2. ED Log

The ED log for 2/19/2021 and 2/20/2021 did not reveal the name of patient #1, or any mention of any unnamed patient presentation from at least 10 PM on 2/19/2021 into 1 PM on 2/20/2021.

3. Video Review

A request was made for video covering the vestibule area which would have covered the time of late 2/19/2021 into early 2/20/2021. The video was reviewed on 2/28/2021 and 3/01/2021. There was only one outside camera angle which showed the patient's arrivals and departures. It showed an angle from above the one-way drive, towards the ED vestibule entrance. The vestibule was an area enclosed on two opposing sides by sliding glass doors. One door opened to the outdoors and the other opened into the ED lobby. Two additional videos showed a much more limited view, from inside the ED lobby. One was looking towards the vestibule entrance and the security officer seating area at the western portion of the vestibule. The other was angled more towards the lobby. The video showed a person resembling the description of patient #1 as follows. The patient arrived and checked in at the vestibule at 12:27:57 AM on 2/20/2021. It showed the patient sitting on the bench outside of the vestibule entrance at 12:28:10 AM. It showed the patient returning to the vestibule entrance at 12:31:05 AM. It showed her walking to her car at 12:31:10 AM. It showed her back at the vestibule entrance at 12:36:55 AM. Finally, it showed her leaving to her car, and not being seen again, at 12:37:41 AM. During this approximately one-minute time (12:36:55 AM & 12:37:41 AM) the patient interacted with staff. Video evidence revealed that patient #1 presented to the ED on 2/20/2021. Staff interviews acknowledged the presentation of patient #1. Since there was no mention of patient #1's presentation in the ED log, the log was not accurate and complete.

4. Interviews

On 2/26/2021 at approximately 8:25 PM, 8:55 PM and 9:50 PM, Security Officer A stated that he served as a "roaming officer", meaning that he periodically rounded the facility grounds every two hours. He stated that when not rounding the facility grounds, he would be stationed in the ED walk-in entrance with another officer. He stated that if a person answers "yes" to any of the COVID-19 questions they asked, the person is asked to wait just outside of the door on a bench which is positioned there. He stated that the Security Officer would then notify the nurse via radio of such a patient's presence. He stated that once a nurse is notified of a presentation, the Security Officer would either await instructions to take them into the ED for triage or that someone would come out from the ED to the lobby, or the designated area for potential COVID-19 patients, and bring the patient into the ED for triage and registration. He stated that during the preceding process, Security Officers do not document anything regarding the patient's presentation. He stated that the nurse has that responsibility.

On 2/26/2021 at approximately 8:35 PM, 9:05 PM and 9:53 PM, Security Officer B stated that he was involved with the presentation of patient #1 on late 2/19/2021 or early 2/20/2021. He stated that he was assigned to work solely in the ED. He confirmed the process for receiving walk-in patients as described by Security Officer A in the preceding interview. He also confirmed that during the process of receiving walk-in patients, they do not document anything, and that the nurse has that responsibility. Regarding the presentation of patient #1 to the facility, he recounted the following. He confirmed that she had presented to the ED. He stated that at some point, she had been directed to wait in an outside area designated for potential COVID-19 patients due to her having voiced respiratory symptoms. At some point, he realized that it was cold outside, where the bench was located, and that he was about to get a blanket for the patient when she came to the door and expressed displeasure about the wait. He stated that he tried to explain to her that someone would see her. She then stated that she would wait in her car and told him to get her in her car. He stated that he then went to notify the ED secretary and a nurse to explain that patient #1 went to wait in her car after having initially waited outside in the designated area for potential COVID-19 cases. At this point, the nurse was aware of the patient's presence. He stated that the patient came back around ten minutes later, screaming (per video review; time interval was actually six minutes). He stated that the patient said she could not understand why it was taking so long. After yelling, the patient stated she was leaving. He stated that he then went back and told the nurses about the situation.

On 2/26/2021 at approximately 9:57 PM, the ED Charge Nurse stated that she recalled patient #1 but had not seen her. She stated that she had interacted with the Security Officer on the radio. She stated that the Security Officer had told her that they had a possible COVID-19 patient. She told him that they were getting a room ready. She stated that a few minutes later, a Security Officer came to the desk and said that the patient had gone to her car. Less than five minutes later, the Security Officer stated that the patient came back, screaming. After that, per the Security Officer, the patient went to her car and left.

On 2/27/2021 at 1:55 PM, the ED Director stated that walk-in ED patients are received at the door by Security Officers, and that no other employee classifications await patient arrivals in the lobby area. She stated that it is their expectation that once a patient has been asked by a receiving Security Officer their reason for visiting, the Security Officer will notify nursing by radio of their presence, their presenting complaint, and its severity. Then, after the patient has either entered the lobby or entered the outside designated area for potential/confirmed COVID-19 patients, a nurse, medic, or ED secretary will come out as soon as possible. She stated that if a COVID-19 isolation room or standard room is not available for corresponding patients and the patient needs to remain in their waiting area, the staff member who comes out, gathers information from the patient for eventual but quick input into the computer system. She stated that if a COVID-19 isolation room or standard room is readily available, staff members will come out and take the patient directly to a room and enter demographic information at that time. She stated that the needed information is the patient's name, date of birth and chief complaint. She stated that the Security Officers do not have access to the medical record or registration system. She acknowledged that in the case of patient #1, who was a potential COVID-19 case, this had not been done when she arrived at the ED just after midnight on 2/20/21.

On 3/01/2021 at 10:18 AM, the ED Director was asked what should be done with ED walk-in cases where a patient leaves the lobby or COVID-19 waiting area before ED staff can obtain their demographic information. She stated that in such cases, it is the expectation that the departure be reported to the charge nurse, who would enter any available descriptive information in the ED log as obtained from the Security Officer. She stated that she was not aware of the ED log being incomplete in the case of patient #1.

On 3/01/2021 at 10:46 AM, the ED Charge Nurse stated that she did not enter anything on the ED log because she did not have a patient name and that without a name, she could not make an entry into the ED log. She stated that she had never been told to document in the ED log any walk-in patients who departed before registration was possible.

5. Statements

A review of Security Officer B's report revealed that the patient had been directed to the outside designated area for potential COVID-19 patients. The document read, "Approximately 10 minutes pass by, the woman enters the front doors and begins to verbally abusive to officer (Security Officer B). Officer (Security Officer B) explain to her that he was going to get her a blanket, she immediately storm's out of the vestaview (SIC) and tells officer (Security Officer B) that she is going to her car without giving any information of the car or description." Regarding the use of the term "vestaview", when considering what was seen in the video review, this can only be concluded to mean the vestibule or entrance area in which the Security Officer was stationed." The statement continued: "Approximately 10 minutes later the woman returns and begins to verbally abuse officer (Security Officer B). The woman stated she is leaving and started to verbally abuse officer (Security Officer B). Officer (Security Officer B) explained the situation to the head nurse from the ED...."

Regarding the statement by the Charge Nurse of not having been educated on documenting in the ED log any patient who leaves without being registered, the Risk Manager produced a copy of an email with the subject heading of "Important Registration Procedure" which had been sent to the ED staff, including Emergency Medical Technicians, Nurses and Unit Secretaries, on 7/22/2020. Among the recipients was the above-mentioned Charge Nurse. The email read, "If a person arrives at reception and indicates in any way that they want to be seen, they must be entered into the system. This includes those that change their minds and have not given their name.... We will still enter their name and a note about the encounter, then LPT (Left Prior to Treatment) in the record and OFF (taken off the tracker system) in the chart." The Charge Nurse did not follow these hospital ED instructions.

5. Hospital Policies

A review of facility policy "Triage Process" revealed the following: "All patients will be recepted into the Meditech System by the Triage Nurse, Paramedic, ED Tech or Unit Clerk....If a patient presents to the ED and decides to leave prior to triage.... the hospital should obtain or attempt to obtain in writing a waiver of right to a medical examination, an informed refusal of examination, or leaving AMA (Against Medical Advice)." This requirement is also stated in facility policy "EMTALA - Definitions and General Requirements."

A review of facility policy "Florida EMTALA Central Log Policy" revealed the following: "The hospital will maintain a Central Log containing information on each individual who requests emergency services or care....whether he or she left before a medical screening examination (MSE) could be performed, whether he or she refused treatment ....The logs must contain at a minimum, the name of the individual and whether the individual: refused....treatment ...." The hospital policy requires that ED presentations be documented in the ED log.


In Summary, on 2/20/2020 patient #1 presented to the ED voicing complaints of difficulty breathing and a history of asthma. The hospital failed to ensure an affective system was in place for documenting in the ED log when patients with difficulty breathing present to the ED. Per hospital policy, the patient must be registered, and their name entered in the hospital's ED computer system, which would create a log entry. In the case of patient #1, whose presentation was confirmed in video review, such an entry was not created. During an interview of the Risk Manager at 3:40 PM on 3/01/2021, she confirmed the findings.

Based on interview, review of the Emergency Department (ED) log, Security Officers' reports, "Important Registration Procedure" email, "Florida EMTALA Medical Screening Examination and Stabilization" and "Triage Process" hospital policies, and video, the hospital the hospital failed to triage on arrival and provide a medical screening exam for one (1) of 27 sampled patients, Patient #1.

Findings:

1. Emergency Department (ED) Registration Document

The hospital ED staff was not able to produce any form of written or electronic documentation which reflected an actual or attempted registration for patient #1.

2. ED Log

The ED log for 2/19/2021 and 2/20/2021 did not reveal the name of patient #1, or any mention of any unnamed patient presentation from at least 10 PM on 2/19/2021 into 1 PM on 2/20/2021.

3. Video Review

A request was made for video covering the vestibule area which would have covered the time of late 2/19/2020 into early 2/20/2021. The video was reviewed on 2/28/2021 and 3/01/2021. There was only one outside camera angle which showed the patient's arrivals and departures. It showed an angle from above the one-way drive, towards the ED vestibule entrance. The vestibule was an area enclosed on two opposing sides by sliding glass doors. One door opened to the outdoors and the other opened into the ED lobby. Two additional videos showed a much more limited view, from inside the ED lobby. One was looking towards the vestibule entrance and the security officer seating area at the western portion of the vestibule. The other was angled more towards the lobby. The video showed a person resembling the description of patient #1 as follows. The patient arrived and checked in at the vestibule at 12:27:57 AM on 2/20/2021. It showed the patient sitting on the bench outside of the vestibule entrance at 12:28:10 AM. It showed the patient returning to the vestibule entrance at 12:31:05 AM. It showed her walking to her car at 12:31:10 AM. It showed her back at the vestibule entrance at 12:36:55 AM. Finally, it showed her leaving to her car, and not being seen again, at 12:37:41 AM. During this approximately one-minute time (12:36:55 AM & 12:37:41 AM) the patient interacted with staff. Video evidence revealed that patient #1 presented to the ED on 2/20/2021. Staff interviews acknowledged the presentation of patient #1.

4. Interviews

On 2/26/2021 at approximately 8:25 PM, 8:55 PM and 9:50 PM, Security Officer A stated that he served as a "roaming officer", meaning that he periodically rounded the facility grounds every two hours. He stated that when not rounding the facility grounds, he would be stationed in the ED walk-in entrance with another officer. He stated that if a person answers "yes" to any of the COVID-19 questions they asked, the person is asked to wait just outside of the door on a bench which is positioned there. He stated that the Security Officer would then notify the nurse via radio of such a patient's presence. He stated that once a nurse is notified of a presentation, the Security Officer would either await instructions to take them into the ED for triage or that someone would come out from the ED to the lobby, or the designated area for potential COVID-19 patients, and bring the patient into the ED for triage and registration. He stated that during the preceding process, Security Officers do not document anything regarding the patient's presentation. He stated that the nurse has that responsibility.

On 2/26/2021 at approximately 8:35 PM, 9:05 PM and 9:53 PM, Security Officer B stated that he was involved with the presentation of patient #1 on late 2/19/2021 or early 2/20/2021. He stated that he was assigned to work solely in the ED. He confirmed the process for receiving walk-in patients as described by Security Officer A in the preceding interview. He also confirmed that during the process of receiving walk-in patients, they do not document anything, and that the nurse has that responsibility. Regarding the presentation of patient #1 to the facility, he recounted the following. He confirmed that she had presented to the ED. He stated that at some point, she had been directed to wait in an outside area designated for potential COVID-19 patients due to her having voiced respiratory symptoms. At some point, he realized that it was cold outside, where the bench was located, and that he was about to get a blanket for the patient when she came to the door and expressed displeasure about the wait. He stated that he tried to explain to her that someone would see her. She then stated that she would wait in her car and told him to get her in her car. He stated that he then went to notify the ED secretary and a nurse to explain that patient #1 went to wait in her car after having initially waited outside in the designated area for potential COVID-19 cases. At this point, the nurse was aware of the patient's presence. He stated that the patient came back around ten minutes later, screaming (per video review; time interval was actually six minutes). He stated that the patient said she could not understand why it was taking so long. After yelling, the patient stated she was leaving. He stated that he then went back and told the nurses about the situation.

On 2/26/2021 at approximately 9:57 PM, the ED Charge Nurse stated that she recalled patient #1 but had not seen her. She stated that she had interacted with the Security Officer on the radio. She stated that the Security Officer had told her that they had a possible COVID-19 patient. She told him that they were getting a room ready. She stated that a few minutes later, a Security Officer came to the desk and said that the patient had gone to her car. Less than five minutes later, the Security Officer stated that the patient came back, screaming. After that, per the Security Officer, the patient went to her car and left.

On 2/27/2021 at 1:55 PM, the ED Director stated that walk-in ED patients are received at the door by Security Officers, and that no other employee classifications await patient arrivals in the lobby area. She stated that it is their expectation that once a patient has been asked by a receiving Security Officer their reason for visiting, the Security Officer will notify nursing by radio of their presence, their presenting complaint, and its severity. Then, after the patient has either entered the lobby or entered the outside designated area for potential/confirmed COVID-19 patients, a nurse, medic, or ED secretary will come out as soon as possible. She stated that if a COVID-19 isolation room or standard room is not available for corresponding patients and the patient needs to remain in their waiting area, the staff member who comes out, gathers information from the patient for eventual but quick input into the computer system. She stated that if a COVID-19 isolation room or standard room is readily available, staff members will come out and take the patient directly to a room and enter demographic information at that time. She stated that the needed information is the patient's name, date of birth and chief complaint. She stated that the Security Officers do not have access to the medical record or registration system. She acknowledged that in the case of patient #1, who was a potential COVID-19 case, this had not been done when she arrived at the ED just after midnight on 2/20/21.

On 3/01/2021 at 10:18 AM, the ED Director was asked what should be done with ED walk-in cases where a patient leaves the lobby or COVID-19 waiting area before ED staff can obtain their demographic information. She stated that in such cases, it is the expectation that the departure be reported to the charge nurse, who would enter any available descriptive information in the ED log as obtained from the Security Officer.

On 3/01/2021 at 10:46 AM, the ED Charge Nurse stated that she did not enter anything on the ED log because she did not have a patient name and that without a name, she could not make an entry into the ED log. She stated that she had never been told to document in the ED log any walk-in patients who departed before registration was possible.

5. Statements

A review of Security Officer B's report revealed that the patient had been directed to the outside designated area for potential COVID-19 patients. The document read, "Approximately 10 minutes pass by, the woman enters the front doors and begins to verbally abusive to officer (Security Officer B). Officer (Security Officer B) explain to her that he was going to get her a blanket, she immediately storm's out of the vestaview (SIC) and tells officer (Security Officer B) that she is going to her car without giving any information of the car or description." Regarding the use of the term "vestaview", when considering what was seen in the video review, this can only be concluded to mean the vestibule or entrance area in which the Security Officer was stationed." The statement continued: "Approximately 10 minutes later the woman returns and begins to verbally abuse officer (Security Officer B). The woman stated she is leaving and started to verbally abuse officer (Security Officer B). Officer (Security Officer B) explained the situation to the head nurse from the ED...."

Regarding the statement by the Charge Nurse of not having been educated on documenting in the ED log any patient who leaves without being registered, the Risk Manager produced a copy of an email with the subject heading of "Important Registration Procedure" which had been sent to the ED staff, including Emergency Medical Technicians, Nurses and Unit Secretaries, on 7/22/2020. Among the recipients was the above-mentioned Charge Nurse. The email read, "If a person arrives at reception and indicates in any way that they want to be seen, they must be entered into the system. This includes those that change their minds and have not given their name.... We will still enter their name and a note about the encounter, then LPT (Left Prior to Treatment) in the record and OFF (taken off the tracker system) in the chart." The Charge Nurse did not follow these hospital ED instructions.

5. Hospital Policies

A review of facility policy "Triage Process" revealed the following: "All patients will be recepted into the Meditech System by the Triage Nurse, Paramedic, ED Tech or Unit Clerk....If a patient presents to the ED and decides to leave prior to triage.... the hospital should obtain or attempt to obtain in writing a waiver of right to a medical examination, an informed refusal of examination, or leaving AMA (Against Medical Advice)." This requirement is also stated in facility policy "EMTALA - Definitions and General Requirements."

A review of facility policy "Florida EMTALA Central Log Policy" revealed the following: "The hospital will maintain a Central Log containing information on each individual who requests emergency services or care....whether he or she left before a medical screening examination (MSE) could be performed, whether he or she refused treatment ....The logs must contain at a minimum, the name of the individual and whether the individual: refused....treatment ...." The hospital policy requires that ED presentations be documented in the ED log.


In summary, on 2/20/2021 patient #1 presented to the ED voicing complaints of difficulty breathing and a history of asthma. Since the patient's stated complaint suggested a potential COVID-19 case, the patient was directed by the receiving Security Officer to sit on a bench which was just outside of the doors of the ED entrance to await the arrival of ED staff to transport her into the ED proper. Facility policy had mandated direct observation of all presenting ED patients by a registered nurse (RN). Video review revealed that the sole person who was assigned to receive patients, a Security Officer, did not observe the patient during the approximately three-minute period in which he had observational responsibility. This failure had the potential to interfere with the prospect of the patient receiving an eventual medical screening examination by acting upon any emergent situation which might arise prior to receiving such an examination. During an interview of the Risk Manager at 3:40 PM on 3/01/2021, she confirmed the findings.