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Based on staff interview, emergency department (ED) log, medical record and policies and procedures (P&P) review, the hospital failed to provide an appropriate medical screening examination conducted by an individual who was determined qualified by hospital bylaws or rules and regulations, to determine whether or not an emergency medical condition existed. The ED nurses failed to appropriately assess and prioritize patients during triage in accordance with established hospital policies and standards for 8 of 20 ED patients reviewed (Patients 19, 14, 17, 1, 2, 3, 8 and 10).

Findings:

1. The Medical Staff Rules and Regulations (dated September 2008), indicated in Article 11 titled "Emergency Medical Treatment and Active Labor Act (EMTALA)", that "The medical staff of (hospital's name) will define those classifications of staff who may conduct medical screening examinations in accordance with EMTALA provisions, to include Emergency Department licensed physicians, nurse practitioners, and physician assistants in accordance with their privileges; and in the Family Maternity Center licensed physicians and certified nurse midwives in accordance with their privileges.

In an interview on 2/28/13 at 10 a.m. the Director of Compliance (AS 1) confirmed that triage RNs were not qualified to perform MSEs in the hospital (not authorized per the Medical Staff Bylaws or Rules and Regulations).

Review of the Department of Emergency Medicine policy #1202 "Initial Nursing Assessment- Triage" (January 1, 2013) indicated that "All patients will have an initial screening assessment performed by a qualified registered nurse (RN)... Any person seeking medical care who is brought to the attention of the ED staff member will have a nursing assessment initiated. A subsequent medical screening exam (MSE) will be performed as appropriate by a provider (a physician or other provider privileged by the hospital to conduct MSE) to determine if an emergency medical condition exists... The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into emergent, urgent or non-urgent categories.

? Emergent: patient should be brought into the Emergency Department for care without delay because of the acuity of the injury or illness and the increased risk for loss of life or limb or profound disability if waiting is required.
? Urgent: patient must be seen in the Emergency Department and should be re-evaluated during the waiting period.
? Non-Urgent: Patient may safely wait for an extended period of time provided they are re-assessed per policy."

The policy further indicated that the initial evaluation shall include medical history, subjective- chief complaint including a pain assessment utilizing the 0-10 pain scale and objective-nursing assessment.

The P&P indicated that "...The nurse's assessment shall be the main guiding factor in determining the appropriate classification (triage category) for a patient..." The P&P listed examples of conditions for each classification (emergent, urgent, non-urgent). The policy did not include patients presenting for psychiatric care in any of the three triage categories.

A review of policy #1203 titled "Assessments of the Emergency Department Patient" (January 1, 2013) indicated that the goal of ongoing vital signs shall be obtained based on patient's triage category:
? emergent or critical patients every 5-15 minutes until stable; then every 1 hour, or sooner if needed, and prior to admission or transfer;
? urgent patients every 2 hours, and prior to admission, transfer or discharge;
? non-urgent patients every 4 hours and prior to discharge.

Review of the ED record showed that Patient 19, a 32 year old male, was brought to the ED by an ambulance on 2/14/13 at 3:28 a.m.

Review of the Initial Assessment by a Registered Nurse, RN 1, indicated that RN 1 evaluated Patient 19 in ED room #3 on 2/14/13 at 3:28 a.m., documenting the following: Patient 19 was "BIBA (brought in by ambulance) for bizarre behavior. Seen at (name of a nearby hospital, Hospital 2)- AMA (Against Medical Advice)? Medics relate pt (patient) became paranoid (paranoia -exhibiting or characterized by extreme and irrational fear or distrust of others) enroute to hospital. c/o (complaining of) pain 10/10 (no location or description of pain was documented). Denies suicidal ideation." The Initial Assessment form by RN 1 indicated that Patient 19 was only alert to person (and not to time, place, situation). The triage category was documented as "Urgent".

Review of the ambulance report showed that the report was completed and forwarded to the hospital (Hospital 1) on 2/14/13 at 4 a.m. The report documented the following: On 2/14/13 at 2:47 a.m. the dispatcher received a call related to an assault/shooting. The ambulance crew arrived at the scene at 2:53 a.m. and found the police (PD) at the scene. According to the PD, Patient 19 was knocking on residents' doors at the scene and was yelling that he had been shot. Patient 19 was uncooperative with the PD but calmed down upon arrival of the ambulance because he recognized the paramedics from his previous ambulance trip to Hospital 2's ED (the report was not specific as to date/time of the previous ED trip). Patient 19 told the ambulance crew that he left Hospital 2 because they were "shooting things" into him and he was scared. The paramedics noted that "Pt (patient) appears to be having a psychiatric crisis at this time." The report showed the police released the patient to paramedics and the patient agreed that he would be seen at Hospital 1. The chief complaint was documented as "Psych/behavioral crisis." The paramedic documented that upon arrival to Hospital 1's ED Patient 19 was placed in ED room #3 and report was given to the ED staff.

Review of the Department of Emergency Medicine policy #1206 (effective January 1/2013) titled "Suicide Risk/Psychiatric Patient Evaluation and Care" indicated that the hospital's Emergency Department (ED) "provides medical/behavioral screening and management of patients experiencing acute psychiatric complaints. Focused medical examination is accomplished in a manner which identifies patients at risk for suicide or acute psychiatric condition." The policy further indicated that all patients presenting to the ED with psychiatric complaints will be triaged as "Emergent." The policy directed the nursing staff to assess and document the patient's current coping ability, any recent traumatic events/stressors, and psychiatric symptoms/history while completing the initial nursing-triage assessment.

Review of ED record showed no documentation that Patient 19 was provided with focused medical examination by a qualified person in a manner which would identify the patient's acute psychiatric condition as per policy above. The patient was not assigned "Emergent" triage category per policy to ensure medical screening exam occurred without a delay and an appropriate psychiatric evaluation was provided as necessary. There was no documented assessment of the patient's recent traumatic events or stressor or psychiatric symptoms/history by the triage or ED nurse as per policy.

Review of the ED nursing notes showed a note by RN 1 on 2/14/13 at 4:55 a.m. indicating that: Patient 19 refused to have vitals retaken; the patient was "alert and oriented to person and place"; the patient was unwilling to wait any longer to be evaluated; the patient was given risks, complications, "up to and including death and patient accepts," and that Patient 19 signed an AMA form. RN 1 noted that the ED physician was "aware of patient."

The ED record contained a form titled "Release From responsibility from Discharge" signed by Patient 19 and co-signed as witnessed by RN 1 on 2/14/13 at 4:55 a.m. The content of the form included a statement that the patient was leaving the hospital "against the advice of, and without the consent of the attending Doctor and of the Hospital Administration..."

Review of the Department of Administration policy #1206 (effective 04/05) titled "AMA and Elopement" indicated, the policy was that when patients leave the premises prior to being released or discharged by the provider, the hospital is obligated to assure that they understand the significance of their action or, if there is a question of their competence, that they are detained. The procedure section indicated that competent patients have the right to reject care and that when patient wishes to leave AMA, the physician should be notified. The policy directed to document on the progress record: time the patient left, physician notified, form signed, or document that patient refused, mode of transportation, and any additional information.

Further review of Patient 19's ED record showed that Patient 19 was not provided a medical screening examination by qualified ED provider and that ED provider did not document that he was notified, or in any way was "aware" of the patient and the patient's condition. The 2-page section for documentation of medical screening exam by the ED provider was blank, with the exception of one field checked indicating that the patient "eloped," and was not authenticated by the ED provider.

In a collaborative interview on 11/13/12 at 2:45 p.m., the Director of Standards and Compliance (AS 1), the Deputy Director of Nursing Services (AS 2) and the ED Nursing Director confirmed that psychiatric patients should be triaged as emergent and promptly provided with an appropriate medical screening exam by the ED provider, to evaluate if emergency medical condition exists, as per the policy.

In a telephone interview with RN 1 on 2/28/13 at 3 p.m., with the ED Director, AS 1 and AS 2 present, RN 1 stated that he was the charge nurse on 2/14/13 night shift and confirmed he triaged/assessed Patient 19 upon arrival to the ED in room #3. RN 1 confirmed that he received a report from medics regarding Patient 19's bizarre behaviors and was aware of Patient 19's visit to Hospital 2 earlier, but stated that he did not see the ambulance written report. RN 1 confirmed that he documented that Patient 19 was only alert to person and "somewhat" to place: the patient only knew that he was in a hospital, but did not know which one. RN 1 stated that he asked Patient 19 if he was suicidal and the patient denied, therefore RN 1 did not consider the patient to have psychiatric acute problems. RN 1 stated that he had no specialized training in evaluating psychiatric conditions and did not ask the patient about circumstances prior to arrival to the hospital, or if the patient felt like hurting others. RN 1 recalled that Patient 19 was a transient travelling by bus.

During the above interview RN 1 was asked to explain the statement in documentation that the ED provider was "aware" of the patient. RN 1 explained that when Patient 19 was about to leave AMA, RN 1 had the discussions with Patient 19 about the risks of him leaving in a hall area near the nursing station, where the ED physician (MD 10) was also standing. RN 1 assumed that MD 10 was overhearing RN 1's conversation with Patient 19 about him leaving AMA. RN 1 confirmed that he did not actually speak with the physician about Patient 19's chief complaint and history and that the patient was leaving the ED. RN 1 was asked if he had any recent training related to ED patient care and triage and if the training included evaluation of psychiatric patients. RN 1 stated that he was recently provided with training that included triage of patients presenting to the ED but psychiatric patients were not discussed. RN 1 was not aware of any policies specific to evaluating patients presenting for psychiatric care.

RN 1 was asked about Patient 19's pain documented by RN 1 as 10/10 (on a scale 0-10 pain, with 0 no pain and 10 the worse pain experienced by a patient). RN 1 was not able to explain what kind of pain the patient reported (location or description of the pain) or that any interventions for the pain were provided.

Review of the Emergency Medicine P&P #1201 titled "Standards of Care" (effective January 1, 2013) indicated that "Standards of practice or care shall be observed." The P&P in part indicated, that "Registered Nurse performs a comprehensive nursing assessment and develops and implements patient treatments consistent with objectives of multidisciplinary treatment..." All data collected will be obtained and documented through interview process, patient health history, observation, physical examination, record review, diagnostic reports and consultation reports. The patient assessment includes chief complaint and present physical and emotional status, method of arrival, special dietary needs, vital signs, pain assessment, focused review of affected systems and medical history, medications, allergies, etc (and other things)." The P&P indicated, that "...Assessments and supportive data are thoroughly documented... assessments and patient needs are communicated to the healthcare provider(s) who are responsible for the care and treatment of the patient... the nursing process is used on ongoing basis to reflect the patient's current condition and treatment plan..."

The P&P #1201 indicated, that "The goal for initiation of the Initial Assessment is as soon as possible and ideally no longer than 15 minutes from patient presenting to the Emergency Department" and will include sign-in date/time, complaint, vital signs, medications, allergies, pain assessment, past medical history/social history, physical exam of affected systems, physical exam of potentially affected systems and known chronic conditions, any testing necessary to rule out the presence of "legally defined emergency medical condition", triage category and adequate documentation of all above.

2. Review of the ED log for February 2013 showed that on 2/13/13 at 2:06 p.m. Patient 17 presented to the ED with chief complaint documented as "allergic reaction." The ED could not find any ED record for this patient to determine if the patient was evaluated in the ED per the hospital policies. On 2/28/13 at 3 p.m. AS 1 confirmed that there was no documentation found for the evaluation or the disposition for Patient 17.

3. Review of ED triage nursing documentation showed that Patient 14, a 57 year old, arrived to the ED on 2/8/13 at 11:50 a.m. by an ambulance with a chief complaint of "back pain." The record showed the patient was roomed in the ED upon arrival. The ED RN assessment documented that Patient 14 complained of lower back pain and left hip pain increased in the past week and throbbing, and the patient reported that he was unsteady on his feet and falling for a month. The pain level the patient reported was documented as 10/10. The patient was noted as "homeless." The patient was assigned triage category as "non-urgent."

Review of the Department of Emergency Medicine policy #1202 "Initial Nursing Assessment- Triage" (January 1, 2013) indicated that severe pain was emergent. Review of the ED policies showed no specific policy for evaluation of severe pain. There was an ED triage protocol specific for a lower back pain, which allowed for triage of nontraumatic and stable patients with back pain to be triaged as "non-urgent" but the protocol did not provide any guidance for addressing pain as reported by a patient based on the severity of the pain.

Patient 14's ED record showed that at 12 p.m. an ED nurse documented the patient was reporting pain in his left hip and lower back level 10/10. The nurse also documented that the patient was resting comfortable in no acute distress. There was no documentation that the ED was consulted regarding the patient reports of severe 10/10 pain.

In an interview with ED Nursing Department Manager on 2/28/13 at 2 p.m., the Manager stated that although a patient may report severe pain, some patients are not believable and additional signs and symptoms are considered to corroborate the patient complains of pain.

The record showed that Patient 14 was seen by a provider at 2:09 p.m. and the ED provider determined that the pain was of chronic nature and was more bothersome than severe. The ED provider documented diagnosis of bursitis (inflammation in the joint area) of left hip and plan to treat the pain with antiinflammatory medications. The orders showed that Toradol (an antiinflammatory medications) was ordered at 2:50 p.m. and was administered by injection at 3 p.m. The nursing notes showed the patient was discharged (at "1300" 1 p.m. ?) home (will take a bus) following the injection of Toradol. There was no evaluation of the patient's response to the pain medication or the pain level prior to discharge.

The Emergency Medicine P&P #1201 titled "Standards of Care" (effective January 1/2013) indicated, that "7. Patient response to medical and nursing interventions is evaluated, documented and pertinent findings communicated to the appropriate healthcare provider... the patient response to therapy, medications, treatments, diagnostic procedures, etc., are evaluated and documented... outcome standards are monitored and evaluated to determine if nursing interventions are effective in patient care... the patient will receive age appropriate care by competent providers, consistent with diagnostic condition, assessment and treatment goals..."



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4. Patient 1 was a 10-month old child presented to the emergency room at 9:38 a.m. for fever and vomiting, and no bowel movement or urination for 3 days. The initial nursing assessment at 9:50 a.m, classified Patient 1 as 'non-urgent' and instructed the mother to return to the waiting room. Review of the medical record revealed Patient 1 left the facility and did not receive an MSE. The nurses' documented at 1:00 p.m. DNA (did not answer) when called, 2.5 hours after the initial assessment was completed. Records showed 4 additional attempts when the nurses called out for the patient at 5:00 p.m., 6:50 p.m., 7:00 p.m. and 8:48 p.m.

On 2/27/13 at 3:00 p.m., an interview was conducted with the Director of the Emergency Services regarding pediatric assessments and how the ER nurses addressed care with children. The Director informed the Department, "The assessment form and triage classification used in the ER is the same for children and adults". The Director also provided a policy titled, "Age related documentation: Pediatric", as the guideline for pediatric patients in the ER.

The policy indicated, "Pediatric patients have specific assessments and related documentation requirements, and depends on the assessment of the Registered Nurse. Documentation shall include (in part): a full set of vital signs, including blood pressure and pulse oximetry and pain assessment. Additionally, head circumference if less than 2 years old and length in emergent situations (via Broselow tape)".

Review of the initial assessment for Patient 1 revealed no blood pressure recording and no head circumference. There was no evidence of a nursing protocol for pediatric patients presented to the emergency room for fever, vomiting, decreased bowel/urination, triage classification or timeliness of assessments.

5. Patient 8 was a 2.5 month old child presented to the emergency room at 11:23 p.m. for vomiting and not eating for 3 days. The initial nursing assessment at 11:30 p.m., classified Patient 8 as 'urgent' and instructed the mother to return to the waiting room. Review of the medical record revealed Patient 8 left the facility and did not receive an MSE. The nurses' documented at 2:22 a.m., DNA when called, 2.7 hours after the initial assessment was completed. Records showed 2 additional attempts when the nurses called out for the patient at 3:00 a.m. and 3:05 a.m.

The initial assessment for Patient 8 revealed no blood pressure, no pain assessment and no head circumference. There was no documentation of a reevaluation within a 2-hour period when Patient 8 was classified as urgent. There was no evidence of a nursing protocol for pediatric patients presented to the emergency room for vomiting/not eating, triage classification or timeliness of assessments.

6. Patient 10 was a 5 month old child presented to the emergency room at 7:30 p.m. for coughing and wheezing for 3 days, with a possible heart problem. The initial nursing assessment at 8:08 p.m. classified Patient 10 as 'urgent' and placed the patient in a room. At 8:40 p.m., a MSE was conducted and Patient 10 was treated for bronchospasm. He was discharged home at 11:48 p.m.

The initial assessment for Patient 10 revealed no blood pressure, no head circumference, no pain assessment, and no measurement of length. There was no evidence of a nursing prototcol for pediatric patients presented to the emergency room for coughing, wheezing or a possible heart condition.

7. Patient 2 was presented to the emergency room on 2/15/13 at10:26 a.m., with complaint of pain to both legs and feet. He stated his pain was 10 of 10 and was not able to walk. The record revealed Patient 2's history of hypertension and venous stasis ulcers, and was scheduled for vascular surgery within the month. The initial nursing assessment indicated Patient 2's pain level as '10' and classified him as 'non-urgent'. Review of the policy #1202 for Initial Nursing Assessment-Triage, indicated "severe pain was classified as emergent".

8. Patient 3 was presented to the emergency room on 2/15/13 at 2:53 p.m. with complaint of cough, fever and chest pain with deep breathing. She stated her pain level was 10 of 10 and instructed to return to the waiting room. The initial nursing assessment at 3:30 p.m., indicated Patient 3's pain as '10' and classified her as 'non-urgent'. Patient 3 left the facility at 4:00 p.m. per staff and did not receive a MSE.