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Based on protocol, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 1 of 20 (Patient #8) sampled patients.

The findings included:

1. Review of the "Standard Workflow for Waiting Room Coordinator" protocol, implemented in May 2021, revealed a patient assigned as a "Level 3" for a MSE should have their "Vs Q 3 (vital signs every 3) Hours or more if necessary."

2. Medical record review revealed Patient #8 presented to the ED on 12/30/2021 at 23:03 with an elevated blood pressure (BP) of 170/127. A MSE was initiated at 23:23 and the patient was escorted back to the ED waiting room. At 04:50 AM, Patient #8 signed out before receiving additional treatment. There was no documentation from 23:03 to 04:50 the patient's BP was reassessed or treated and no documentation the patient had been informed of the elevated BP.

Refer to A2406

Based on protocol, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment were provided an appropriate and continuing medical screening examination (MSE) for 1 of 20 (Patient #8) sampled patients.

The findings included:

1. Review of the "Standard Workflow for Waiting Room Coordinator" protocol, implemented in May 2021, revealed a patient assigned as a "Level 3" for a MSE should have their vital signs assessed every 3 Hours or more if necessary.

2. Medical record review revealed Patient #8 presented to the ED on 12/30/2021 at 23:03.
Registered Nurse (RN) #1 performed the triage assessment for Patient #8 at 23:23 and documented the patient's chief complaint was abdominal pain, with nausea, vomiting and diarrhea for 2 days, and the patient's co-workers had Covid-19. The triage assessment revealed Patient #8's blood pressure was elevated at 170/127.

Record review revealed Patient #8 had a history of Essential Hypertension and took Losartan (a medication to treat Hypertension) 25 milligrams as needed.

The MSE was performed by Family Nurse Practitioner #1 on 12/30/2021 at 23:23 with the "Plan" to "... Patient MSE initiated, instructed patient to wait in ER room for further evaluation as soon as possible..."
There was no documentation in the MSE that the patient's elevated blood pressure was re-evaluated or addressed.

Record review revealed the patient had blood work obtained on 12/30/21 23:28.

Review of the "Patients Leaving Before Completing Treatment" form revealed the patient signed out against medical advice (AMA) on 12/31/2021 at 04:50 AM.

There was no documentation the patient was notified of the elevated blood pressure or that the blood pressure was re-evaluated.

In an interview on 5/11/2022 at 2:38 PM the Quality and Patient Experience Director verified the patient should have had additional vital signs (including blood pressure) re-evaluated.