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Based on interview, review of emergency department (ED) policies and procedures and the documentation found in 1 of 6 ED medical records (medical record # 6), it was determined that the hospital failed to ensure the implementation of a timely medical screening and treatment of pain per hospital policies.

Findings include:

1. The following policy was reviewed, "Emergency Medical Treatment & Active Labor Act (EMTALA) Obligations," effective date 09/02/2010. The policy reflected "DEFINITIONS: 1. Emergency Medical Condition ("EMC") - A condition manifesting itself by acute symptoms of sufficient severity (including severe pain...) such that the absence of immediate medical attention could reasonably be expected to: a. Seriously jeopardize the health of the individual...b. Result in serious impairment of bodily functions...3. Medical Screening Examination (MSE) - the process required to determine if an EMC does or does not exist....4. Qualified Medical Personnel (QMP) - a physician, a nurse practitioner...5. Stabilize - to provide such medical treatment of an EMC necessary to assure that no material deterioration of the EMC is likely to result from or occur...RESPONSIBILITIES: 1. Under EMTALA, any person who comes to the Hospital requesting, or a request is made on his/her behalf, examination or treatment for what is believed to be an EMC (based on the person's complaint, appearance, or behavior) must be provided a medical screening exam to determine if an emergency conditions exists."

The following policy was also reviewed, "Pain Management," effective date 06/26/2012. The policy reflected the following: "DEFINITIONS: 5. Acceptable Pain Level: a score of 4 or less OR as determined acceptable by the patient...2. STANDARDS: c. Pain Assessment: If pain is identified, pain assessment will be performed and pain will be addressed as follows:...ii. A maximum acceptable pain level is less than or equal to 4 or a level acceptable to the patient. iii. If pain level is greater than 4 or unacceptable to the patient, additional assessment will be multi-dimensional, using patient self-report when possible and family perceptions....iv...The effectiveness of pain management interventions will be assessed after a time period appropriate for the type of intervention."

2. Review of the medical record for Patient # 6 reflected the patient and spouse presented to the Emergency Department (ED) on 02/13/2013 at 0026 hours with complaint of "extreme pain." The nurse (I1) documented the pain as a numeric pain score of 8 (8/10), the patient had a blood pressure of 190/94. I1 also documented the patient acuity as "3."

Patient #6 was "placed on stretcher in back hall, next to triage, awaiting room." At 0115, the triage nurse (I2) documented "Pt family member up to triage desk multiple times, worried (the patient) may die from the amount of pain (he/she) is in. Patient assured that death from pain was unlikely, but that the MD was planning on seeing (him/her) up at triage and will order meds."

I2 documented at 0130 "[Patient] reported right groin pain that is severe and constant but increases even worse intermittently. [Patient] is grimacing reports [he/she] has had pain there before but it is much, much worse tonight, took a Vicodin at 2200 without relief. [Patient] is splinting [his/her] leg for comfort, strong palpable [dorsalis pedis] pulse."

I2 further documented at 0143 the patient's pain level was 10 (10/10). I2 documented "The patient was medicated at 0146 with pain meds per MAR, patient [family member] upset with wait time for treatment." The nurse received a verbal order from the ED physician (C3) to give the patient "Hydromorphone injections 1-2 mg." However, the chart lacked documentation of a physician medical screening exam completed before the order was given to medicate the patient.

I2 documented at 0219, "[Patient] appears more comfortable, but reports pain medicine is not helping. Meds ordered q 2 hrs, will speak with MD." I2 documented "[Patient] medicated per MAR" at 0250 after the patient stated his/her pain level was 10 and (his/her) blood pressure was 175/71. The patient was medicated again at 0415 with Hydromorphone 1 mg after (he/she) complained of a pain level of 7 and a blood pressure of 187/86.

I1 documented at 0457, "[Patient] slightly better after pain medications received out in triage. [Spouse] remains unhappy, [regarding] wait time, and pain management. [Patient] resting on stretcher, waiting for MD evaluation."

The assigned ED physician (C3) documented a thorough assessment of the patient on 02/13/2013 at 0725.

The patient's pain level at 0737 was documented as 3. This was the first time since admission to the ED that the patient stated (his/her) pain level was an acceptable pain level with a "score of 4 or less" per hospital policy. The patient had been in the emergency department over 7 hours before the medical record reflected documentation of pain management that complied with the hospital policy.

In addition, the patient's medical screening completed by the ED physician was not documented by the nurses or physician until the patient had been in the ED for more than 6 hrs.

3. An interview with two RNs who triaged and provided care to Patient #6 took place on 04/22/2013 at 0640 in the ED. The interview with an ED nurse, I1, reflected Patient #6 was admitted to the ED complaining of severe pain and accompanied by his/her spouse. Since the ED was full and the patient was having severe pain, the patient was placed on a stretcher in the hallway "right behind the triage space" so the nurses could closely monitor the patient. I2 stated that the (spouse) approached him/her several times expressing concern that Patient #6 could die since he/she was in so much pain. I2 stated that he/she informed the (spouse) that the physician would see the patient soon.

I2 stated that the patient's spouse continued to request pain medication for the patient from nurses who walked past Patient' #6's hallway stretcher. I2 was able to obtain a verbal order for an analgesic from the assigned ED physician. I2 then medicated the patient approximately 1 hour after the patient arrived in the ED. I2 stated "The patient's spouse appeared very unhappy with the long wait considering how much pain the patient was having."

According to I2, the patient was more comfortable after receiving the analgesic, but the pain continued. I2 discussed the patient's condition with the physician again. The nurse was able to treat the patient's pain two more times over the next 2 1/2 hours.

I1 and I2 remembered that the ED was extremely busy that night. Neither I1 or I2 were aware of the time the ED physician conducted the medical screening examination.

An interview with the ED Nurse Manager, I3, was conducted on 04/22/2013 at 0710. I3 stated that the ED received 4 trauma patients during the time that Patient #6 was in the ED.

An interview with ED Medical Director, I9, was conducted on 04/22/2013 at approximately 1400. I9 reflected that he/she was "on-call" and available to come to the ED and provide medical assistance on the night in question. He/she did not receive a call requesting additional medical assistance during the night shift.

The medical record lacked documentation of a timely medical screening exam for Patient #6 as directed by hospital policy, "Emergency Medical Treatment & Active Labor Act (EMTALA) Obligations." The patient was triaged by nursing personnel on 02/13/2013 at 0026 hours. The nurse documented at 0457, "waiting for MD evaluation." The ED MD evaluation was documented at 0725. The ED medical record reflected a seven hour gap between 0026 hours of the ED triage nurse assessment and 0725 hours medical screening examination documentation of the ED provider.

The hospital failed to provide adequate medical personnel qualified in emergency care to meet the emergency needs anticipated by the facility per this regulation.