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Based on observation, interview, and record review, the hospital failed to ensure to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not the EMC existed for five of 21 sampled patients (Patients 3, 9, 10, 12, and 13). Cross reference to A2406.

2. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for nine of 21 sampled patients (Patients 1, 10, 12, 13, 14, 17, 19, 20, and 21). Cross reference to A2407.

3. The hospital failed to ensure the ED staff appropriately transferred nine of 21 sampled patients (Patients 1, 2, 5, 6, 10, 14, 19, 20, and 21). Cross reference to A2409.

Based on interview and record review, the hospital failed to ensure the Emergency Department Logs were maintained when the mode of arrival, chief complaint, and disposition were not documented in the Emergency Department Log for 19 nonsampled patients (Patients 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 41, 42, 43, and 44). This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED for treatment for their emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA - Central Log Policy dated March 2023 showed in part:

* All hospitals must maintain the Central Log in an electronic or paper format.

* The logs must contain at a minimum: the name of the individual; the date, time and means of individual's arrival; the individual's age; the individual's sex; the individual's record number; the nature of the individual's complaint; the individual's disposition; the individual's time of departure; and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired.

* A log entry for all individuals who have come to the hospital seeking medical attention or who appear to need medical attention must be made by the appropriate individual.

1. On 11/13/23, review of the Emergency Department Logs for June, August, and November 2023 showed the Emergency Department Logs were not completed in its entirety as the mode of arrival, chief complaint, and disposition were not documented in the Emergency Department Logs for Patients 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36.

On 11/15/23 at 1410 hours, during an interview with the Chief Quality and Patient Safety Officer, the Chief Quality and Patient Safety Officer acknowledged the findings and confirmed the Emergency Department Log had not been maintained.


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2. Review of the hospital's Emergency Department Logs for May and September 2023 showed the Emergency Department Logs were not completed in its entirety as the mode of arrival, chief complaint, and disposition were not documented in the Emergency Department Logs for Patients 41, 42, 43, and 44.

On 11/14/23 at 1443 hours, an interview and concurrent record review was conducted with LVN 1 and Quality Manager 1. Quality Manager 1 acknowledged there was missing information about the patients in the Emergency Department Logs.

Based on observation, interview, and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not the EMC existed for five of 21 sampled patients (Patients 3, 9, 10, 12, and 13) as evidenced by:

1. For Patient 12, the ED staff did not expedite the custodial patient care upon arrival to the ED as per the hospital's P&P.

2. The Department of Security Services/Public Safety did not consistently implement the P&P for screening the patients presenting to the ED for the ED services.

3. For Patient 13, the ED staff did not provide the interpreter service for Patient 13, did not assign the triage category to Patient 13 as ESI Level 2, and did not ensure the pain management for Patient 13 as per the hospital's P&Ps.

4. For Patient 9, the ED staff did not implement the P&P for triage of pregnant patients.

5. For Patients 3 and 10, the ED staff did not implement the P&P for the management of a suicidal patient.

a. For Patient 10, the ED staff did not notify the physician that Patient 10 was identified at risk for suicide, did not conduct a contraband search, did not conduct a thorough examination of the environment for items that could be harmful, including completing the Suicide Safety Checklist, and did not ensure the Close Observation Flowsheet was completed, which consisted of documenting the patient's location and the patient's behavior every 15 minutes.

b. For Patient 3, the ED staff did not consistently assess the patient for suicidal risk.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services.

Findings:

Review of the hospital's P&P titled EMTALA - Medical Screening Examination and Stabilization Policy dated March 2023 showed in part:

* An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)and the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

* If a law enforcement official requests hospital emergency personnel to provide medical clearance for incarceration, the Hospital has an EMTALA obligation to provide an MSE to determine if an EMC exists.

* Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screening by a physician or other QMP.

* There is no delay in the provision of an MSE or stabilizing treatment if: (i) there is not an open bed in the DED; (ii) there is not sufficient caregivers present to render the MSE and/or stabilizing treatment; and (iii) the individual's condition does not warrant immediate screening and treatment by a physician or QMP.

1. Review of the hospital's P&P titled Triage and Assessment of Patients dated October 2023 showed in part:

* All patients presenting to the Emergency Department seeking emergency care shall be initially assessed by an Emergency Department Physician or qualified Registered Nurse.

* This is a means to help expedite the care of the patient by decreasing patient delays, relieving congestion in critical treatment areas, regulating the flow of patient care, and assuring that patients will be seen based on their acuity.

* Triage involves a rapid patient assessment that provides an assignment of an acuity level for each patient presenting to the ED. The triage level is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care.

Review of the hospital's P&P titled Custodial Patients - County of Orange dated March 2021 showed in part:

* The hospital has under contract agreed to provide medical services to custodial patients.

* Field Referrals:

- A Law Enforcement Officer may present the requested medical care for a patient directly from the field rather than from the jail.

- The Emergency Department physician and nursing staff are to expedite custodial patient care, recognizing that minimal exposure to ancillary staff, other patients, and visitors is advantageous.

On 11/14/23 at 1045 hours, a tour of the ED was conducted with the Chief Quality and Patient Safety Officer.

During an observation of the exterior of the ED main entrance and ambulance bay, two Law Enforcement Officers were observed walking toward the ambulance bay and escorting Patient 12 in handcuffs. The patient was instructed to sit on a chair immediately outside of the ambulance bay entrance. Within a few minutes after arrival, one of the Law Enforcement Officers was observed entering the ED main entrance. Then, the Law Enforcement Officer was observed returning to the outside and completing a form.

During a concurrent interview with Registration Staff 1, Registration Staff 1 stated the Law Enforcement Officer had informed the Registration Staff of Patient 12's arrival. Registration Staff 1 stated when the Law Enforcement Officer presented with a custody patient, the Patient Custody Questionnaire had to be completed by the Law Enforcement Officer; once the Patient Custody Questionnaire form was completed, the Patient Custody Questionnaire form would be given to the Triage Nurse.

Review of a blank copy of the Patient Custody Questionnaire showed, "THIS FORM IS TO BE COMPLETED BY ARRESTING/TRANSPORTING OFFICER." The form showed various sections to be completed, including patient identification, arrest information, name of city police department, and officer identification. The form did not show a section for documenting if the custody patient was taken to the ED for the sole purpose of getting medical clearance for incarceration and/or if the custody patient required an examination or treatment for a medical condition.

On 11/14/23 at 1051 hours, Patient 12 was observed continued sitting outside of the ED with the Law Enforcement Officers; Patient 12 had not been attended to by any clinical staff and the patient had not been triaged.

In a concurrent interview with Registration Staff 1, Registration Staff 1 stated the custody patients would sit and wait outside of the ED until triaged by the nurse. When asked who would monitor the custody patients while they were outside waiting to be triaged, Registration Staff 1 stated the clinical staff would not monitor the custody patients. Registration Staff 1 stated there was at least one public safety officer outside the ED at all times and the Law Enforcement Officers would also monitor the patients.

In a concurrent interview, the Chief Quality and Patient Safety Officer stated the custody patient should not have been sitting outside of the ED awaiting to be triaged.

On 11/14/23 at 1105 hours, an interview was conducted with Triage Nurse 1. When asked if Patient 12 had been triaged, Triage Nurse 1 stated the custody patient had not been triaged. Triage Nurse 1 stated Patient 12 was there for a medical clearance.

On 11/14/23 at 1114 hours, Triage Nurse 1 was observed being outside and triaging Patient 12. During a concurrent interview, Triage Nurse 1 stated Patient 12 reported he had been punched by the police earlier that morning.

On 11/14/22 at 1534 hours, an interview and concurrent review of Patient 12's medical record was conducted with Quality Manager 2, the Clinical Informaticist, and the Clinical Analyst.

Patient 12's medical record showed Patient 12 came to the ED on 11/14/23 at 1056 hours.

Review of the ED Triage Aware Note dated 11/14/23 at 1142 hours, showed Patient 12's chief complaint was head injury. Patient 12 was triaged at 1114 hours. The patient was brought in for medical clearance. The patient stated the patient was punched in the face.

Review of the ED Provider Aware Note dated 11/14/23 at 1133 hours, showed Patient 12 had been brought for an "evaluation prior to booking." The patient was struck with fist by the officer on the "left side of face head no loss of consciousness denies any nose bleeding earache but does have some mild left facial pain." The patient had "some slight facial tenderness along the left intraorbital region for pain CT scan the patient refuses." The discharge diagnosis was facial contusion.

On 11/15/23 at 1412 hours, the Chief Quality and Patient Safety Officer acknowledged that Patient 12's initial assessment upon arrival to the ED should have been expedited.

2. Review of the hospital's P&P titled Manual Screening Using Hand-Held Metal Detector dated July 2023 showed in part:

* Weapons may include firearms, knives, needles, and metallic blunt objects.

* The Department of Security/Public Safety and Hospital staff trained in the usage of hand-held metal detectors (HHMD) will require screening for everyone entering the Emergency Department waiting room, except when not possible due to emergency patient care needs or in order to meet EMTALA or other applicable Emergency Department/Hospital regulatory requirements.

* The level of search detail will depend on the type of potential threat to the Hospital as determined by Security manager and appropriate hospital representative.

* The screening or patients and individuals will not be voluntary but exist as a condition of entering the Emergency Department.

* If an individual refuses or otherwise fails to comply with the security screening, the Department of Security Services and the House Supervisor will be notified to determine the appropriate action.

On 11/13/23 at 0920 hours, a tour of the ED was conducted with the Nursing Educator, Quality Manager 1, and the Director ED. Public Safety Officer 1 was observed being outside the ED main entrance. When asked about the process for screening individuals presenting to the ED, the Public Safety Officer provided conflicting information about the process. Initially, the Public Safety Officer stated that all individuals entering the ED required screening (e.g., patients and visitors). The Public Safety Officer stated that the ER Item's Log had to be completed for individuals that had been searched and weapons had been identified; the weapons would be stored in lockers that were located by the ambulance bay. In a subsequent interview, the Public Safety Officer stated individuals requesting to be seen in the ED, did not require screening prior to entering the ED.

Review of the ER Item's Log dated 10/24 through 11/13/23, showed at least four ED patients (Patients 37, 38, 39, 40) had been screened and their belonging logged in the ER Item's Log. The ER Item's log showed the following "Item Description," none of which were identified as weapons or items of potential threat to the hospital:

* For Patient 37, "Bag with wallet chain/ETC."

* For Patient 38, "Black Nike/Bag."

* For Patient 39, "5 Bags."

* For Patient 40, "Back Back [sic] Blue."

On 11/14/23 at 1051 hours, during an interview with Public Safety Officer 2, Public Safety Officer 2 stated not all individuals entering the ED had to be screened. Public Safety Officer 2 stated the screening was based on "judgement" of the Public Safety Officer.

Review of the ER Item's Log dated 11/14/23, showed that a baby "Stroller" had been logged in the ER Item's Log.

On 11/14/23 at 1055 hours, the Chief Quality and Patient Safety Officer acknowledged the hospital's P&P for screening was not being implemented consistently and there was a potential for delay in examining and/or treating the patient.

3. Review of the hospital's P&P titled Triage and Assessment of Patients dated October 2023 showed in part:

* The purposes are to provide for the initial assessment and categorization of a patient's condition when presenting to the Emergency Department and to ensure that every patient receives efficient and appropriate medical care based on his/her Emergency Severity Index (ESI) level, an evidence-based triage tool.

* A five-category ESI consists of ESI Levels or Triage Levels 1, 2, 3, 4, and 5. ESI Level 1 is assigned to a patient with an acuity of "Resuscitative/Life Threatening." ESI Level 2 is assigned to a patient with an acuity of "Emergent." or with conditions that require immediate care. ESI Level 3 is assigned to a patient with an acuity of "Urgent." ESI Level 4 is assigned to a patient with an acuity of "Semi-Urgent." ESI Level 5 is assigned to a patient with an acuity of "Non-Urgent."

* The Attachment B showed examples of ESI level 2 or Triage Level 2 (high-risk situations) include patient currently in pain or distress; or clinical observation and/or a self-reported pain rating of seven or greater on a scale of 0 to 10.

Review of the hospital's P&P titled Pain Management Assessment and Reassessment dated March 2023 showed in part:

* The pain assessment tools used at the hospital include the numeric 0-10 pain intensity scale. "The Numeric Intensity Scale is: 1-3 = Mild Pain, 4-6 = Moderate Pain, 7-10 = Severe Pain."

* When pain is identified, the patient is treated or referred for treatment.

Review of the hospital's P&P titled Interpreter Services for Patients (Limited English Proficiency, Deafness, Speech, Hearing Impairment, Visual Impairment or Blindness) dated April 2021 showed in part:

* [Name of hospital] endeavors to communicate information to patients in a comprehensive manner to insure informed consent, compliance, and to promote education.

* Non-qualified clinical or administrative staff may not serve as a medical interpreter.

* Language assistance and interpreter services will be provided 24 hours/7 days a week at no cost to the patient.

On 11/14/23 at 1045 hours, during a tour of the ED with the Chief Quality and Patient Safety Officer, Patient 13 was observed sitting in the ED lobby, the patient's head was down, and the patient's right hand was over his right ear.

In a concurrent interview, Registration Staff 1 stated Patient 13 presented to the ED with ear pain.

Review of the short registration form showed the section of "Reason for visit/Razon por su visita: dolor muy fuerte en el oido (very strong pain in the ear)." Registration Staff 1 confirmed Patient 13 was non-English speaking or Language A speaking only. When asked if an interpreter had been used when registering the patient, Registration Staff 1 stated no.

On 11/14/23 at 1122 hours, during an interview with Triage Nurse 1, Triage Nurse 1 stated Patient 13 was triaged by Triage Nurse 1. Triage Nurse 1 confirmed an interpreter was not used for Patient 13.

On 11/14/22 at 1510 hours, an interview and concurrent review of Patient 13's medical record was conducted with Quality Manager 2, the Clinical Informaticist, and the Clinical Analyst.

Review of the ED Triage Aware Note dated 11/14/23 at 1150 hours, showed the following:

* Patient 13 was triaged at 1114 hours.

* Patient 13's chief complaint was ear pain. "Pt (patient) states right ear pain 8/10 and difficulty hearing in the right ear."

* Patient 3 was categorized with an ESI Level of 4 (Semi-Urgent) which was not consistent with the hospital's P&P. As per the hospital's P&P, a patient with a self-reported pain level of 8 out of 10, should have categorized with an ESI Level of 2.

* The Arrival Information section showed the "Spoken Language Preferred:" and "Reading Language Preferred:" was non-English language (Language A).

* The sections of Safety and Nutrition Screening, Illness Risk, Abuse Screen, and Suicide Homicide Screening was conducted for Patient 13.

Further review of the nursing documentation did not show the ED staff had addressed the patient's pain, including communicating with the physician about the patient's severe pain level.

Review of the ED Provider Aware Note dated 11/14/23 at 1128 hours, showed Patient 13 was seen by the physician on 11/14/23 at 1128 hours. Patient 13 presented with complaints of the right ear pain. "The patient felt as if something blew into his ear while he was driving no other acute complaints. Symptom occurred this morning no sore throat or fever no direct trauma history."

Review of the section of Discharge/Admit/Transfer section of the Flowsheets-All Other dated 11/14/23 at 1214 hours, showed "D/c (discharge) instructions reviewed, and education provided...No further questions, concerns, or apprehension at this time. The instruction was reviewed with the patient. The patient verbalized understanding." The patient was discharged home on 11/14/23 at 1215 hours.

In a concurrent interview, the Clinical Informaticist and the Clinical Analyst confirmed there was no documentation showing an interpreter was used by the nursing staff and/or the physician that conducted the MSE for Patient 13.

The above findings were shared with Quality Manager 2, the Clinical Informaticist, and the Clinical Analyst.

4. Review of the hospital's P&P titled Obstetrical Patients, Triage Of dated April 2023 showed in part:

* All Obstetrical patients presenting to the Emergency Department will be triaged by the ED triage nurse utilizing an initial quick assessment tool, ED Rapid Triage for Obstetrical Patients form (Appendix A). This form provides a systematic, concise, and focused initial assessment of labor and other obstetric and non-obstetrical complaint in a pregnant patient presenting in the emergency department.

* The ED Rapid Triage for Obstetrical Patient form promotes faster response for medical screening evaluation and treatment to urgent situations that are potentially obstetrical-fetal condition or maternal-medical condition.

On 11/15/22 at 1100 hours, an interview and concurrent review of Patient 9's medical record was conducted with the Clinical Informaticist, the Clinical Analyst, and the Chief Quality and Patient Safety Officer.

Patient 9's medical record showed Patient 9 came to the ED on 6/7/23.

Review of the ED Triage Aware Note dated 6/7/23 at 1043 hours, showed Patient 9 presented to the ED with a chief complaint of "pregnancy problem" and "C/O (complaint of) NO FETAL TONE."

When asked to review the ED Rapid Triage Form for Patient 9, the Clinical Informaticist and the Clinical Analyst stated the form was not found. In a concurrent interview, the Chief Quality and Patient Safety Officer acknowledged Patient 9 had not been triaged as per the hospital's P&P.

5. Review of the hospital's P&P titled Suicide Risk Screening, Assessment, and Patient Management dated January 2021 showed in part:

* The purpose is to identify patients at risk for suicide and to assure that their immediate safety needs are met in the most appropriate care setting within the scope of services provided by the organization.

* Staff will address the patient's immediate safety needs and provide the most appropriate setting for safety.

* When a patient is identified at risk for suicide, the staff will ask the patient to remove all clothing (e.g. belts, shoe laces) and do a contraband search of his/her belongings in order to remove any items that could be harmful (sharp objects, alcohol, drugs, rope, plastic bags, etc.) out of the patient's reach. The screening staff member shall place the patient on "suicide precaution" immediately, and the attending physician will be notified.

* Prior to placing the patient at risk for suicide in any rooms and/or treatment areas, a thorough examination of the environment will be done to ensure that patients do not have access to items that could be harmful (sharp objects, plastic bags, cleaning solvents, etc.).

* If patient scores high lethality according to the Suicide Risk Screen, place the patient on a 1:1, notify physician, and obtain an order for this 1:1 as soon as possible.

a. On 11/15/22 at 1023 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Clinical Informaticist, the Clinical Analyst, and the Chief Quality and Patient Safety Officer.

Patient 10's medical record showed Patient 10 came to the ED on 8/20/23.

Review of the ED Triage Aware Note dated 8/20/23 at 0038 hours, showed Patient 10 was triaged at 0034 hours. Patient 10 was brought in by the patient's family member for suicide thoughts. The patient's family member stated the patient "tried hitting her head, hanging, and running into traffic." The patient had a history of cutting her wrist and inner thighs.

Review of the ED Provider Aware Note dated 8/20/23 at 0152 hours, showed the physician saw the patient on 8/20/23 at 0152 hours. The physician had reviewed and confirmed the nurse's notes for patient's medication, allergies, medical history, and surgical history. Patient 10 had suicidal ideation.

In a concurrent interview, the Clinical Informaticist and the Clinical Analyst confirmed there was no documentation of the following:

* The nursing staff notified the physician that Patient 10 was identified at risk for suicide.

* The nursing staff conducted a contraband search.

* The nursing staff conducted a thorough examination of the environment for items that could be harmful, including completing the Suicide Safety Checklist.

* The nursing staff ensured the Close Observation Flowsheet was completed, which consisted of documenting the patient's location and the patient's behavior every 15 minutes.

The findings were shared with the Chief Quality and Patient Safety Officer.


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b. Review of Patient 3's medical record showed the patient came to the ED on 5/20/23.

Review of Patient 3's ED Triage Aware Note dated 5/20/23 at 1151 hours, showed Patient 3 was triaged on 5/20/23 at 1151 hours. The Chief Complaint Quote section showed the patient felt "a little suicidal yesterday."

Review of Patient 3's CSSR Scale flowsheet with an entry date of 5/20/23 at 1337 hours, showed Patient 3 did not have any thoughts of killing himself in the past month.

Review of Patient 3's ED Provider Aware Note dated 5/20/23 at 1404 hours, showed Patient 3 was seen by the ED provider on 5/20/23 at 1404 hours. Patient 3 stated the patient felt suicidal yesterday, but the patient had no suicidal ideation today.

On 11/14/23 at 1021 hours, an interview and concurrent record review of Patient 3's medical record was conducted with LVN 1 and Quality Manager 1. LVN 1 and Quality Manager 1 acknowledged the above findings. Quality Manager 1 stated the manager would have thought the primary care nurse of the patient would have read the documentation of the assessment findings of the triage nurse for Patient 3.

Based on observation, interview, and record review, the hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for nine of 21 sampled patients (Patients 1, 10, 12, 13, 14, 17, 19, 20, and 21) as evidenced by:

1. For Patient 1, the ED staff did not implement the hospital's P&P related to the activation of code stroke in the ED.

a. The ED staff did not perform a point of care testing for blood sugar for Patient 1 as per the hospital's P&P.

b. The ED staff did not notify a neurologist after Patient 1 was evaluated of having a stroke as per hospital's P&P.

c. The ED staff did not monitor and assess Patient 1 consistently when the patient was receiving the alteplase (thrombolytic, a medication used to treat a stroke caused by a blood clot or other obstruction in a blood vessel) infusion as per the hospital's P&P.

2. The ED staff failed to use appropriate daily check log for the external contents of the adult crash cart.

3. The ED staff (RN 3) did not implement the hospital's P&P related to the use of glucometer when entering the operation ID to perform the quality control testing and check the patient's blood glucose level.

4. The ED staff did not implement the hospital's P&Ps related to reassessment of the patients based on the patient's ESI and/or the pain management and reassessment for Patients 13, 14, 17, 19, 20, and 21.

5. For Patient 12, the ED staff did not provide discharge instructions for the patient as per the hospital's P&P.

6. The triage nurse was not available at all times as per the hospital's P&P when Patient 10 had been taken care by the triage nurse.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Stroke Team, ED Activation Of dated March 2023 showed for all ED patients with signs and symptoms of stroke of less than 24 hours from the time of onset, activation of Stroke Team will run as follows:

* "CODE Stroke Team" will be activated as soon as an evaluation is made by the ED physician.

* Point of Care testing for Blood Glucose will be completed immediately. If patient arrived via EMS, it is ok to use EMS blood glucose result as long as it is documented in the EHR.

* Stroke documentation is completed in the EHR, except for the tPA Monitoring Record which is kept on paper and is continued in the ICU upon admission and if the patient is transferred for a higher level of care, a copy of the tPA Monitoring Record is transferred with the patient and all monitoring is continued throughout the transport.

* " Timeframe goals:... Arrival to Neurologist notification: 15 minutes."

Review of Patient 1's medical record showed the patient came to the ED on 10/16/23.

Review of Patient 1's ED Triage Aware Note dated 10/16/23 at 2334 hours, showed Patient 1 was triaged on 10/16/23 at 2322 hours. Patient 1 arrived in the ED in a private vehicle. The patient's chief complaint was right-sided weakness with headache. The onset of the complaint was 10/1623 at 2145 hours. Code stroke was called at 2335 hours.

a. Further review of Patient 1's medical record failed to show a documentation showing a point of care testing for blood glucose was performed for the patient.

On 11/14/23 at 1443 hours, an interview and concurrent interview was conducted with LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer. LVN 1 and the Chief Quality and Patient Safety Officer verified the above findings.

On 11/15/23 at 1039 hours, an interview was conducted with Quality Manager 1 and the Director ED. The Director ED was asked who would perform a POCT blood glucose for a patient when a code stroke was activated in the ED. The Director ED stated any ED staff who was available, would be able to perform a POCT blood glucose test for a patient. The Director ED was asked what the purpose of a POCT blood glucose test was for a patient during a code stroke. The Director ED stated to rule out if a patient was having a hypoglycemia. The Director ED stated hypoglycemia signs and symptoms could mimic a stroke condition.

b. Review of Patient 1's medical record did not show documented evidence showing a neurologist was notified for Patient 1 by an ED staff as per the hospital's P&P.

On 11/14/23 at 1443 hours, an interview and concurrent record review of Patient 1's medical record and hospital's P&P was conducted with LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer. LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer verified the above findings. Quality Manager 1 stated the hospital no longer had neurology services and the hospital's P&P had been recently updated to show the changes.

c. Review of the hospital's P&P titled Thrombolytic Therapy (IV) - Alteplase (Activase) dated November 2020 showed all the patients receiving will have a frequent monitoring of vital signs and frequent neuroassessments. This will be documented on the Stroke tPA Monitoring Record (Appendix D).

Review of the Stroke tPA Monitoring Record showed to monitor vital signs and neurochecks every 15 minutes for two hours, to start at the administration time of the bolus dose of the medication.

Review of Patient 1's MAR Report showed the following:

- On 10/17/23 at 0100 hours, alteplase 9 mg IV bolus (single dose of medication administered over a short period of time) was administered to the patient.

- On 10/17/23 at 0113 hours, alteplase 81 mg IV piggyback (a small bag of solution attached to a primary infusion line) was administered to the patient.

Review of Patient 1's Assessment and Cares ED showed the following;

- On 10/17/23 at 0100 hours, the bolus of the tPA was given to the patient,
- On 10/17/23 at 0105 hours, the infusion of the tPA was started for the patient,
- On 10/17/23 at 0143 hours, the infusion of the tPA was discontinued before transferring the patient to Hospital A.

Review of Patient 1's Vital Signs Measurement showed Patient 1's vital signs were assessed on 10/16/23 at 2334 hours; and 10/17/23 at 0112, 0128, and 0143 hours.

Review of the NIH Stroke Scale showed Patient 1's NIH Stroke Scale was 9 on 10/17/23 at 0100, 0113, 0118, and 0133 hours.

Further review of Patient 1's medical record failed to show the Stroke tPA Monitoring Record showing a frequent monitoring of vital signs and frequent neuroassessments was performed for Patient 1 as per the hospital's P&P.

On 11/15/23 at 1020 hours, an interview was conducted with Quality Manager 1. Quality Manager 1 verified the above findings. Quality Manager 1 stated there was no documentation to show a frequent monitoring of vital signs and frequent neuroassessments was performed consistently on Patient 1 during the administration of the alteplase.

2. Review of the hospital's P&P titled Crash Cart - Inspection, Availability, Maintenance, & Exchange dated April 2023 showed the availability of external items shall be monitored daily by nursing staff/ancillary department staff as evidenced by documentation on the Crash Cart Daily Log. The verification of cart supplies and defibrillator check can be done by any licensed or unlicensed staff person that has been verified competent to complete the cart check.

Review of the Adult Crash Cart External Contents Daily Check Log and the Pediatric Crash Cart External Contents Daily Check Log for the month of November 2023 showed the instructions include to verify the items in par level indicated by placing a check in the appropriate box.

Review of the Adult Crash Cart External Contents Daily Check Log showed the supplies included a CO2 (carbon dioxide) cable with an airway adapter and adult resuscitation bag (BVM with a CO2 detector).

Review of the Pediatric Crash Cart External Contents Daily Check Log showed the supplies included a CO2 cable and a pediatric resuscitation (bag/valve and mask).

As described above, the Adult Crash Cart External Contents Daily Check Log and the Pediatric Crash Cart External Contents Daily Check Log did not show the same items which would be verified as the contents on a crash cart.

On 11/13/23 at 0921 hours, a tour of the ED was conducted with the Nursing Educator. The external contents of the adult crash cart were observed including a bag-valve mask and a defibrillator. The Nursing Educator was asked how often the adult crash cart had been checked by the ED staff. Review of the daily check log form showed check marks from 11/1 to 11/13/23; however, the title of the form was the Pediatric Crash Cart External Contents Daily Check Log. When the Nursing Educator was asked why the Pediatric Crash Cart External Contents Daily Check Log was used for the daily check of the adult crash cart, the Nursing Educator stated the staff could have pulled the wrong log for the adult crash cart. The Nursing Educator acknowledged the daily check log for the adult and pediatric crash cart had different contents.


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3. Review of the Procedure section of the hospital's P&P titled Point of Care Testing, Accu-check Inform II Blood Glucose Monitor dated January 2021 showed the following:

* Turn on the Accu-Check Inform II meter.

* Enter the staff operator ID by means of scanning badge or manual entry.

* Note: If the staff operator ID is not accepted, attempt to re-enter it. If it is still rejected, contact the supervisor or Point of Care Coordinator. Do not attempt to perform tests under another operator's ID.

On 11/13/23 at 1135 hours, an interview was conducted with RN 3. When asked about the process of calibration of the glucometer, RN 3 stated RN 3 would enter the employee's identification number to calibrate the glucometer. When asked if RN 3 had calibrated the glucometer today, RN 3 stated RN 3's employee ID number has not been working for one week. RN 3 further stated RN 3 would ask the charge nurse or one of her peers to enter their employee ID number and then RN 3 would proceed with checking the patient's blood glucose level.

Review of the Accucheck section of RN 3's 2023 Annual Emergency Department RN Competency showed RN 3 was evaluated as having some experience and might require assistance; and RN 3 had a follow-up evaluation which showed the RN was competent in performing the task independently.

However, there was no documented evidence to show the evaluator's initial and the method on how to validate RN 3's competency; and there was no documented evidence to show the method on how to conduct the follow-up evaluation for RN 3's competency.

4. Review of the hospital's P&P titled Triage and Assessment of Patients dated October 2023 showed in part:

* Purpose: to provide for the initial assessment and categorization of a patient's condition when presenting to the Emergency Department. To assist emergency personnel in providing care based on a priority of need. To ensure that every patient receives efficient and appropriate medical care based on his/her Emergency Severity Index (ESI) level, an evidenced-based triage tool. To provide guidelines for the Registered Nurse follow when functioning in their capacity.

* Policy: The triage assessment will be completed by the bedside RN for patients who are immediately placed into the treatment area. Based on that initial assessment, the Triage Nurse will place the patient into one of five categories of the triage rating system. This is a means assuring that patients will be seen based on their acuity.

* Triage level 3: Conditions that could progress to a serious problems requiring but not immediate care, utilizing two or more resources, as defined by the ESI. Vital signs will be taken at least every two hours until evaluated by emergency physician.

* Triage level 4: Conditions that the patient presents with a condition that has a low potential for deterioration or complications. It is anticipated that one resource is needed to treat patient, as defined by the ESI. Vital signs will be taken at a minimum of every two hours until seen by emergency physician.

* Patients should be reassessed upon change in status. For Levels 3, 4, and 5, patients should be reassessed every two hours and with significant change in status.

Review of the hospital's P&P titled Pain Management Assessment and Reassessment dated March 2023 showed in part:

* Purpose: To assure that patients receive an assessment and management of their pain consistent with the scope of care, treatment, and service provided by the organization in its various care settings.

* Policy: The hospital recognizes the individual's right to appropriate pain assessment/management taking into account personal, cultural, and ethnic beliefs. The patient and family can expect the patient in pain to be assessed and treated promptly, effectively and for as long as pain persists. The pain assessment tools used at the hospital include the numeric 0-10 pain intensity scale. "The Numeric Intensity Scale is: 1-3 = Mild Pain, 4-6 = Moderate Pain, 7-10 = Severe Pain."

* Procedure:

- When pain is identified, the patient is treated or referred for treatment.

- Patient will be assessed at minimum every shift. Pain assessment may include severity, onset, quality, alleviating factors, and provoking factors if applicable. Pain assessment includes to ask the patient if he/she has a current complaint of pain or has chronic pain and to assess if there is a potential for pain.

- Patient is reassessed with new reports of pain, following procedures, or activities that are expected to cause pain. Pain is reassessed following medication given for pain that is consistent with route of medication administration.

* Points of Emphasis: The patient's self-report is the single most reliable indicator of the existence and intensity of acute pain. Neither behavior nor vital signs can substitute for a self-report.

a. On 11/13/23 at 1630 hours, an interview and concurrent record review of Patient 14's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 14's medical record showed the patient came to the ED on 7/2/23 at 0920 hours and transferred to other hospital on 7/2/23 at 1546 hours.

Review of the triage report dated 7/2/23, showed Patient 14 was brought in by from home with the chief complaint of flu like symptoms. The patient was triaged at 0925 hours. The patient's ESI level was three.

Review of Patient 14's nursing flow sheet dated 7/2/23 at 0925 hours, showed the patient's vital signs were assessed. The patient's oxygen saturation was 91% room air.

Review of the ED Provider Aware Note electronically signed by the physician on 7/2/23 at 1343 hours, showed Patient 14 was seen by the physician on 7/2/23 at 1146 hours. The patient's complaint was "shortness of breath." Patient 14 was on 2 liters of oxygen via nasal cannula at home at all times. However, when the patient's family member checked the patient's oxygen saturation level at home, the patient's oxygen saturation levels were in the 80's and the required 4 liters of oxygen via nasal canula to increase the patient's oxygen saturation to the mid 90's.

Review of Patient 14's Visit Record showed the nursing staff assessed Patient 14 on 7/2/23 at 0938 and 1522 hours.

Further review of Patient 14's medical record showed nursing reassessment including Patient 14's vital signs were not completed as per the hospital's P&P.

The Chief Quality and Patient Safety Officer verified the findings.

b. On 11/14/23 at 0940 hours, an interview and concurrent review of Patient 17's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 17's medical record showed the patient came to the ED on 7/10/23 at 1340 hours and left AMA on 7/10/23 at 1749 hours.

Review of the triage report dated 7/10/23 at 1349 hours, showed the patient was brought in by police for medical clearance, with chief complaint of abdominal pain. The patient's ESI level was four.

Review of the ED Provider Aware Note dated 7/10/23 at 1643 hours, showed Patient 17 was seen by the physician on 7/10/23 at 1644 hours. The patient was brought in by the police for medical clearance for an umbilical hernia (19.5 cm). The patient had abdominal pain with the pain level of seven out of 10.

Further review of Patient 17's medical record showed Patient 17's pain level was six out of 10 on 7/10/23 at 1730 hours. There was no documented evidence to show the nursing reassessment including pain level was performed every two hours as per the hospital's P&P.

There was no documented evidence to show Patient 17 was treated for pain as per the hospital's P&P.

The Chief Quality and Patient Safety Officer verified the findings.

c. On 11/14/23 at 1120 hours, an interview and concurrent record review of Patient 19's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 19's medical record showed the patient came to the ED on 10/8/23 at 0552 hours and transferred to another hospital on 10/8/23 at 0957 hours.

Review of the triage report dated 10/8/23 at 0553 hours, showed Patient 19 was brought in by ambulance to the ED with chief complaint of abdominal pain. Patient 19 was triaged on 10/8/23 at 0553 hours. The patient's pain level was 10 out of 10. The patient's ESI level was three.

Review of the ED Provider Aware Note dated 10/8/23 at 0556 hours, showed Patient 19 was seen by the physician on 10/8/23 at 0556 hours.

Further review of Patient 19's medical record showed Patient 19 received pain medication on 10/8/23 at 0824 and 0929 hours.

However, there was no documented evidence to show the nursing reassessment was completed every two hours, or the patient's pain was reevaluated as per the hospital's P&P.

The Chief Quality and Patient Safety Officer verified the findings.

d. On 11/14/23 at 1315 hours, an interview and concurrent record review of Patient 20's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 20's medical record showed the patient came to the ED on 10/11/23 at 1917 hours and was transferred to other hospital on 10/12/23 at 0608 hours.

Review of the patient's triage report dated 10/11/23 at 1920 hours, showed Patient 20 was brought in by ambulance with a chief complaint of suspected alcohol intoxication. The patient was triaged on 10/11/23 at 1920 hours. The patient's ESI level was three.

Review of the Flowsheets-Vitals showed Patient 20's vital signs was completed on 10/11/23 at 1920, 2155, 2339 hours; and 10/12/23 at 0154 hours.

However, there was no documented evidence to show the nursing reassessment were performed for Patient 20 every two hours as per the hospital's P&P.

The Chief Quality and Patient Safety Officer verified the findings.

e. On 11/14/23 at 1525 hours, an interview and concurrent record review of Patient 21's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 21's medical record showed the patient came to the ED on 10/13/23 at 2309 hours and transferred to other hospital on 10/14/23 at 1426 hours.

Review of the triage report dated 10/13/23 at 2321 hours, showed Patient 21 was triaged on 10/13/23 at 2245 hours. The patient's chief complaint was abdominal pain. The patient's pain level was five out of 10. The patient's ESI level was three.

Review of Patient 21's nursing flowsheet showed Patient 21's vital signs were completed on 10/13/23 at 2321 and 2359 hours; and on 10/14/23 at 0200, 0400, 0600, 0800, and 1400 hours. The patient's vital signs were not consistently checked every two hours as per the hospital's P&P.

In addition, the nursing flowsheet did not show the nursing assessment was consistently performed every two hours as per the hospital's P&P.

The Chief Quality and Patient Safety Officer verified the findings.


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f. On 11/14/22 at 1510 hours, an interview and concurrent review of Patient 13's medical record was conducted with Quality Manager 2, the Clinical Informaticist, and the Clinical Analyst.

Review of the ED Triage Aware Note dated 11/14/23 at 1150 hours, showed the following:

* Patient 13 was triaged at 1114 hours.

* Patient 13's chief complaint was ear pain. "Pt (patient) states right ear pain 8/10 and difficulty hearing in the right ear."

Further review of the nursing documentation did not show the ED staff addressed the patient's pain including communicating with the physician about the patient's severe pain level.

Review of the ED Provider Aware Note dated 11/14/23 at 1128 hours, showed Patient 13 was seen by the physician on 11/14/23 at 1128 hours. Patient 13 presented with complaints of the right ear pain.

Review of the section of Discharge/Admit/Transfer section of the Flowsheets-All Other dated 11/14/23 at 1214 hours, showed the patient was discharged home on 11/14/23 at 1215 hours.

There was no documentation showing the patient's pain level had been reassessed after the MSE or prior to being discharged home.

The above findings were acknowledged by the Clinical Informaticist and the Clinical Analyst.

5. Review of the hospital's P&P Custodial Patients - County of Orange dated March 2021 showed in part:

* [Name of Facility] has under contract agreed to provide medical services to custodial patients.

* Appropriate Aftercare Instructions should be completely written. Only very brief and general verbal instructions should be given to the patient. All written instructions should be given to the Law Enforcement Officer.

On 11/14/22 at 1534 hours, an interview and concurrent review of Patient 12's medical record was conducted with the Quality Manager 2, the Clinical Informaticist, and the Clinical Analyst.

Review of the ED Provider Note dated 11/14/23 at 1133 hours, showed Patient 12 had been brought the police for an "evaluation prior to booking." The patient was struck with fist by the officer on the "left side of face head no loss of consciousness denies any nose bleeding earache but does have some mild left facial pain...CT scan the patient refuses." The discharge diagnosis was facial contusion.

In a concurrent interview, the Clinical Informaticist and the Clinical Analyst confirmed there was no documentation showing Patient 12 had been given aftercare instructions as per the hospital's P&P.

6. Review of the hospital's P&P Triage and Assessment of Patients dated October 2023, showed in part:

* Triage Procedure:

- Availability of Triage: Triage is available on a 24-hour basis. All patients presenting to the Emergency Department seeking emergency care, except for those patients who are immediately placed in the treatment area, shall be initially assessed by an Emergency Department Physician or qualified Triage Nurse. The charge nurse is responsible for ensuring that an RN qualified to perform the triage assessment is available at all times.

On 11/15/22 at 1023 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Clinical Informaticist, the Clinical Analyst and the Chief Quality and Patient Safety Officer.

Patient 10's medical record showed Patient 10 came to the ED on 8/20/23.

Review of the ED Triage Aware Note electronically signed by Triage Nurse 2 showed Patient 10 was triaged on 8/20/23 at 0034 hours. Patient 10 was brought in by the patient's family members for suicide thoughts. The patient's family member stated the patient "tried hitting her head, hanging, and running into traffic."

Further review of Patient 10's medical record showed the patient was placed on suicide precautions and required 1:1 observation.

Review of the nursing progress notes documented by Triage Nurse 2 on 8/20/23 at 0219 hours, showed "Pt currently has no assign [sic] nurse and is being taken care by Traige [sic] nurse due to short staff. Currently No bed available pt is sitting in a chair with Sitter near by."

Review of the Discharge/Admit/Transfer documented by Triage Nurse 2 on 8/20/23 at 0607 hours, showed Patient 10 was transferred to psychiatric facility on 8/20/23 at 0550 hours.

Further review of Patient 10's medical record failed to show documented evidence the ED nursing staff conducted a contraband search and ensured the Close Observation Flowsheet was completed, which consisted of documenting the patient's location and the patient's behavior every 15 minutes. Cross reference to A2406, example # 5a.

In a concurrent interview, the Chief Quality and Patient Safety Officer confirmed the findings and stated the triage nurse should not have a patient assignment and the Chief Quality and Patient Safety Officer acknowledged the hospital's triage P&P had not been implemented.

Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred nine of 21 sampled patients (Patients 1, 2, 5, 6, 10, 14, 19, 20, and 21) as evidenced by:

1. The ED staff did not arrange the transportation properly for Patient 1 when transferring the patient to a higher level of care as per the hospital's P&P.

2. The ED staff did not complete the Transfer Summary and Certification forms when transferring Patients 1, 2, 5, 6, 10, 14, 19, 20, and 21 to other hospitals as per the hospital's P&P.

These failures had the potential to result in poor clinical outcomes and serious adverse event to the patients receiving ED services.

Findings:

1. Review of the hospital's P&P titled Transfer of Patients for Higher Level of Care/Specialty Care dated March 2023 showed once a transfer is accepted, under the direction of the ED Physician, the ED nursing staff/support staff will arrange transportation best suited to the medical needs of the patient.

Patient 1's medical record showed the patient came to the ED on 10/16/23 at 2321 hours.

Review of Patient 1's ED Provider Aware Note dated 10/17/23 at 0040 hours, showed a physician from Hospital A accepted the patient at 0130 hours.

Review of Patient 1's Assessment and Cares ED dated 10/17/23 showed the following:

- At 0145 hours, the patient left the ED with the paramedics.

- At 0154 hours, the patient was transferred to Hospital A. The ambulance for the patient had been waiting for approximately 20-30 minutes and Hospital A had accepted the patient. The paramedics did not want to wait, and the paramedics would take the patient to Hospital A.

On 11/14/23 at 1443 hours, an interview and concurrent record review of Patient 1's medical record and hospital's P&P was conducted with LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer. LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer acknowledged the above documentation. LVN 1, Quality Manager 1, and the Chief Quality and Patient Safety Officer was asked to describe the process when coordinating a transportation for a patient who required to be transferred to a higher level of care. The Chief Quality and Patient Safety Officer stated there should be an accepting facility/physician before a transportation would be arranged for the patient. The Chief Quality and Patient Safety Officer stated the mode of transportation for the patient would be determined by the ED physician. When the Chief Quality and Patient Safety Officer was asked about Patient 1's transportation to Hospital A, the Chief Quality and Patient Safety Officer stated the 911 transport was contacted by the ED staff. However, the patient was not yet ready to be transferred since there was no accepting physician for the patient.

On 11/14/23 at 1546 hours, an interview was conducted with the Director ED and Quality Manager 1. The Director ED acknowledged the ED staff activated the 911 transport for Patient 1 without an accepting physician/hospital for the patient.

On 11/15/23 at 0939 hours, a follow-up interview was conducted with the Director ED and Quality Manager 1. The Director ED was asked to describe the process on contacting a 911 transport for a patient requiring a transfer to a higher level of care facility. The Director ED stated all ED staff could call a transportation for a patient with the direction of the ED physician. The Director ED was asked who contacted 911 transport for Patient 1. The Director ED stated, according to RN 1 who was the charge nurse, the ED physician requested the unit secretary to call a 911 transport for the patient and the unit secretary was assisted by RN 2.

On 11/15/23 at 1020 hours, an interview was conducted with Quality Manager 1. Quality Manager 1 stated, according to OC-EMS, the 911 transport arrived in the ED on 10/17/23 at 0046 hours and the transport left the ED at 0151 hours.

2. Review of the hospital's P&P titled EMTALA-Transfer Policy dated March 2023 showed the following:

* The transferring physician is responsible for determining the appropriate mode of transportation, equipment, and attendants for the transfer in such a manner as to be able to effectively manage any reasonably foreseeable complication of the individual's condition that could arise during the transfer.

* The procedure for the transfers of individuals who are not medically stable includes the following:

- Send medical records including a documentation of the individual's vital signs which should be taken immediately prior to transfer and documented on the Transfer Summary and Certification form.

- The Transfer Summary and Certification must be completed for every patient who is transferred to another separately licensed hospital. The Transfer Summary and Certification form and the patient's medical record must be sent with the patient at the time of the transfer. The copy of the Transfer Summary and Certification form shall be retained by the transferring hospital and incorporated into the patient's medical record.

a. Patient 1's medical record showed the patient came to the ED on 10/16/23 at 2321 hours and transferred to Hospital A on 10/17/23 at 0154 hours.

Review of Patient 1's Transfer Summary and Certification form signed by the physician on 10/17/23 at 0136 hours and by the patient on 10/17/23 at 0135 hours, showed the section of "Transfer is in patient's best interests. The patient had an unstable medical condition, but the benefits of discharging or transferring the patient outweigh the risks to the patient" was checked. However, the form did not show a documentation of vital signs for Patient 1 in the Patient Condition section of the form.

On 11/14/23 at 1443 hours, an interview and concurrent record review of Patient 1's medical record and hospital P&P was conducted with LVN 1, Quality Manager 1 and the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer acknowledged there was no documentation of Patient 1's vital signs in the patient's Transfer Summary and Certification form.

b. Patient 5's medical record showed the patient came to the ED on 9/1/23 at 1050 hours and transferred to other hospital on 9/1/23 at 1547 hours.

Review of Patient 5's ED Provider Aware Note dated 9/1/23 at 1052 hours, showed the patient was transferred to another acute care hospital for admission for observation due to syncopal episode, elevated troponin level, and persistent hypoglycemia.

On 11/14/23 1049 hours, an interview and concurrent record review of Patient 5's medical record was conducted with LVN 1 and Quality Manager 1. LVN 1 and Quality Manager 1 acknowledged the above documentation. The LVN 1 and Quality Manager 1 was asked to show documentation of Patient 5's transfer summary and certification form. The Quality Manager 1 stated she would check the form for the patient from the medical records department.

On 11/15/23 at 1350 hours, a follow-up interview was conducted with Quality Manager 1. Quality Manager 1 acknowledged the manager was unable to find a documentation of Patient 5's transfer summary and certification form.

c. Patient 2's medical record showed the patient came to the ED on 5/19/23 at 0319 hours and transferred to other hospital on 9/1/23 at 0430 hours.

Review of Patient 2's ED Triage Aware Note dated 5/19/23 at 0339 hours, showed the patient had a chief complaint of pregnancy problem. The ED Triage Aware Note was signed by a licensed nurse on 5/19/23 at 0405 hours.

Review of Patient 2's Transfer Summary and Certification form showed the following:

* The section of "Transfer is in patient's best interests. The patient had an unstable medical condition, but the benefits of discharging or transferring the patient outweigh the risks to the patient" was checked.

* No time documented to show when the physician signed the Provider Certification section of the form.

* The section of "Appropriate medical records of examination and treatment of the patient were provided at the time of transfer as follows:" failed to show the physician's record, laboratory results, diagnostics, EKG, and nursing records were checked.

On 11/14/23 at 0930 hours, an interview and concurrent record of Patient 2's medical record was conducted with LVN 1 and Quality Manager 1. LVN 1 and Quality Manager 1 acknowledged the above findings. Quality Manager 1 was asked why there were no medical records provided at the time of transfer as described above. Quality Manager 1 stated the patient was in active labor and required to be transferred immediately to a higher level of care.

d. Patient 6's medical record showed the patient came to the ED on 9/6/23.

Review of Patient 6's ED Provider Aware Note dated 9/6/23 at 0231 hours, showed the disposition of the patient was transferred to Hospital B and the name of physician from Hospital B who accepted the patient for the transfer.

Review of Patient 6's Transfer Summary and Certification form signed by the physician on 9/6/23 at 0554 hours. The form included the receiving facility would be Hospital B and the name of accepting physician. However, the name of the accepting physician was not consistent to the information as described in the ED Provider Aware Note.

There were two different names of the accepting physician documented in Patient 6's medical record.

On 11/13/23 at 1625 hours, an interview and concurrent record of Patient 6's medical record was conducted with LVN 1 and Quality Manager 1. Quality Manager 1 acknowledged the accepting physician information for Patient 6 was not consistent as described on the above findings.


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e. On 11/13/23 at 1630 hours, an interview and concurrent record review of Patient 14's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 14's medical record showed the patient came to the ED on 7/2/23 at 0920 hours and transferred to other hospital on 7/2/23 at 1546 hours.

Review of Patient 14's Transfer Summary and Certification signed by the physician on 7/2/23 at 1500 hours, showed the following:

* The section of "Stable. The patient has an emergency medical condition, but the condition is stable" was checked.

* The section of "Transfer is in patient's best interests. The patient has an unstable medical condition" was checked.

* The section of Transfer Requirement did not show the name of the receiving facility.

* The section of "Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer" were left blank.

* The section of "The physician has determined that appropriate means of transportation for transfer" was left blank.

The Chief Quality and Patient Safety Officer verified the findings.

f. On 11/14/23 at 1120 hours, an interview and concurrent record review of Patient 19's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 19's medical record showed the patient came to the ED on 10/8/23 at 0552 hours and transferred to another hospital on 10/8/23 at 0957 hours.

Review of the Transfer Summary and Certification form showed the following:

* The physician signed the form on 10/8/23. However, the time was not documented.

* The section of "Stable. The patient has an emergency medical condition, but the condition is stable" was checked.

* The section of "Transfer is in patient's best interests. The patient has an unstable medical condition" was checked.

The Chief Quality and Patient Safety Officer verified the findings.

g. On 11/14/23 at 1315 hours, an interview and concurrent record review of Patient 20's medical record was conducted with the Chief Quality and Patient Safety Officer and Clinical Informaticist.

Patient 20's medical record showed the patient came to the ED on 10/11/23 at 1917 hours and was transferred to other hospital on 10/12/23 at 0608 hours.

Review of the Transfer Summary and Certification form signed by the physician on 10/12/23 at 0453 hours, showed the following:

* The section of "Transfer Requirements" of the Transfer Summary and Certification form did not show the name of the receiving physician.

* The Patient Transfer Consent section did not show the signature of the patient or legally responsible individual signing on patient's behalf.

The Chief Quality and Patient Safety Officer verified the findings.

h. On 11/14/23 at 1525 hours, an interview and concurrent record review of Patient 21's medical record was conducted with the Chief Quality and Patient Safety Officer and the Clinical Informaticist.

Patient 21's medical record showed the patient came to the ED on 10/13/23 at 2309 hours and transferred to other hospital on 10/14/23 at 1426 hours.

Review of the Transfer Summary and Certification form showed the physician signed the form on 10/14/23. However, there was no documented evidence to show the time physician signed the form.

The Chief Quality and Patient Safety Officer verified the findings.


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i. Review of the hospital's P&P titled 72 Hour Hold-Application and Patient Advisement dated March 2021, showed both copies of the 72-Hour Hold Form are placed on the patient chart if admitted to the hospital. If transferred, send the original and one copy to receiving facility and keep one copy for the emergency department record.

Review of the hospital's P&P Suicide Risk Screening, Assessment, and Patient Management dated January 2021 showed applicable patients and (where appropriate) their families - regardless of risk level - will be provided with information on how to access assistance in a crisis such as a crisis hotline. There is no defined time frame in which this information must be provided, but it should be provided before discharge or transfer from organization's care.

On 11/15/22 at 1023 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Clinical Informaticist, the Clinical Analyst, and the Chief Quality and Patient Safety Officer.

Patient 10's medical record showed Patient 10 came to the ED on 8/20/23 at 0022 hours.

Review of the ED Provider Aware Note dated 8/20/23 at 0152 hours, showed Patient 10 was medically "cleared for psych eval. Evaluated by CAT team. Placed on 5150. Patient was subsequently transferred for psych admission."

Review of the Transfer Summary and Certification form signed by the physician on 8/20/23 at 0539 hours, showed the following:

* Patient 10 was transferred to a behavioral health hospital on 8/20/23 at 0550 hours.

* The section of "Transfer is in patient's best interests. The patient has an unstable medical condition" was checked.

* The Patient's Request/Refusal/Consent to Transfer section failed to show the signature of the patient or the patient's legal responsible individual.

There was no documentation the 72-Hour Hold was provided at the time of transfer.

In a concurrent interview, the Clinical Informaticist and the Clinical Analyst confirmed the Patient's Request/Refusal/Consent to Transfer section was not signed by Patient 10 or by the patient's legal responsible individual. There was no documentation showing the patient's family member were not available to sign. The Clinical Informaticist and the Clinical Analyst stated the 72- Hour Hold form was not found in the patient's medical record. The Clinical Informaticist and the Clinical Analyst confirmed there was no documentation showing Patient 10 or the patient's family member was provided with the information on how to access assistance in a crisis such as a crisis hotline before transfer the patient as per the hospital's P&P.

The Chief Quality and Patient Safety Officer stated the patient's family members should have signed on the Patient's Request/Refusal/Consent to Transfer section of the Transfer Summary and Certification form. The Chief Quality and Patient Safety Officer acknowledged the findings.