HospitalInspections.org

Based on medical record review, review of hospital policy, and staff interview, the Acute Care Hospital's (ACH) administrative staff failed to follow their policies for care of patients during admission to the inpatient (IP) child/adolescent behavioral health unit (BHU) to ensure staff followed hospital policy to protect and promote each patient's rights. Failure to follow their policies for patient care resulted in the following:

1. A patient being admitted to the inpatient unit without an appropriate safety check for contraband (see A0144); and,

2. A patient being able to cause significant injury to them self while receiving care in the IP setting (see A0144).

The cumulative effect of this systemic failure and deficient practice resulted in the ACH's administrative staff's inability to ensure the patient rights were maintained and were adequate to meet patient care needs.

Based on medical record review, review of hospital policy, and staff interview the Acute Care Hospital's (ACH) administrative staff failed to ensure hospital staff provided care in a safe setting to 1 of 10 patients reviewed (Patient #1). The effects of the failures and deficient practices resulted in hospital staff missing contraband during Patient #1's body search, allowing a razor blade to be snuck into the inpatient (IP) child/adolescent behavioral health unit (BHU), and causing self-harm injuries. The effects of these failures and deficient practice could have also resulted in injuries to other patients and/or staff, or death of Patient #1. The ACH's administration identified an average daily census of 11 patients treated on the IP child/adolescent BHU.

Findings include:

1. Review of the policy "Inpatient Behavioral Health Policy to Screen Patients," Last Revised 5/24, revealed in part:

a. "Purpose: ...committed to providing a safe environment for patients, visitors and colleagues. For this reason, no weapons or other items deemed as potentially dangerous are allowed in any inpatient behavioral health unit ... This search will include the use of a security wand, a hand-held metal detecting device, to assist in providing a safe environment for the patients, team members and visitors... The handheld security wand is utilized to deter and prevent the bringing of weapons or other dangerous items into the behavioral health programs, thereby reducing the potential for violent incidents."

b. "Any patient who is being admitted to an inpatient behavioral health unit will be
scanned with a security wand prior to entry and while still in triage ... They will be required to change into scrubs prior to entering the unit ..."

c. " ...Upon admission patient and patients ' belongings will be screened by use of a metal detecting wand ..."

2. Review of the policy "Acuity Precautions- Behavioral Health," Last Revised 2/29/24, revealed in part:

a. " ...The goal is to establish a safe environment and practice to support patients. When assessed as self-injurious or as having suicidal ideation, additional safety precautions and assessments may occur to keep patients safe and engage resources as needed ..."

b. " ...Any patient indicating an inability to remain safe in the hospital and/or displaying behaviors and/or statements that will indicate immediate risk will be placed under 1:1 supervision ..."

c. " ...A body search will be completed prior to entering the behavioral health unit ... to remove any potentially dangerous items from patient's belongings. The body search and any contraband found will be documented on the body check/belongings sheet ... Public safety shall be notified if any weapons or contraband are found ..."

d. " ...General Safety Precautions ... All personal hygiene products will be kept in the nurse's station and/or in locked closets. When patients utilize the products, they will be returned and accounted for following use ..."

e. " ...Acuity Level: ... Level Red. These patients may not leave the unit except for medical procedures ... Two team members must accompany the patient to the procedure ... Patients on this level are NOT eligible for off unit activities ... Room search will be performed daily ... Two team members will be present to complete the room search ... All room items, including bathrooms and mattresses, should be checked and anything identified as a risk will be addressed at the time of the search ..."

3. Review of Patient #1's medical record revealed:

a. On 4/15/24 at 3:13 PM, Patient #1 presented to UnityPoint Health (UPH), Des Moines Methodist (DMM) Blank Children's Hospital ED with their mother for multiple left arm lacerations due to self-harm using a razor blade to cut. Patient #1 had a diagnosis of severe major depressive disorder (MDD), generalized anxiety with panic attacks, and depressive type psychosis (serious mental illness with loss of contact with reality).

b. On 4/15/24 at 3:29 PM, Patient #1's had a Columbia Suicide Screening completed with a suicide risk level of high. Patient #1 identified thoughts of killing them self by cutting. ED staff placed Patient #1 on suicide and safety checks, assigned them a sitter for continuous 1:1 visual checks, and Patient #1's belongings were placed at the nurse's station.

c. On 4/15/24 at 3:34 PM, the ED provider evaluated Patient #1, and recommended IP BHU due to the severity of their lacerations and acute change.

d. On 4/15/24 at 4:59 PM, Social Worker (SW) RR assessed Patient #1, and noted Patient #1 was evasive and denied knowing where the razor blade went after they used it to cut them self. Patient #1 told SW RR, they considered telling SW RR something, but wasn't sure if they wanted to. SW RR followed up with Patient #1, and Patient #1 verbalized they didn't know why they struggled with suicidal ideation (SI) (thoughts). SW RR recommended Patient #1 be admitted to an IP BHU due to the severity of cutting to their arm requiring 53 sutures, report of feeling they wanted to die, and not knowing if they could be safe at home.

e. On 4/15/24 at 5:57 PM, patient history, exam, and ED course were discussed with MD SS, inpatient psychiatry, who agreed to accept Patient #1 to UnityPoint Health's (UPH) IP child/adolescent BHU due to their suicidal ideation and significant injury.

f. On 4/15/24 at 7:20 PM, the ED provider repaired Patient #1's lacerations. Patient #1 had a post-procedure diagnosis of deliberate self-cutting with left forearm lacerations. Patient#1 had two very shallow vertical lacerations, 8 centimeters (cm) each to the right forearm, and eight horizontal gaping lacerations to the left forearm, three of the lacerations measured 3.5 cm with exposed subcutaneous (found under the skin) fat, and one significant 9 cm x 2 cm and 0.5 cm deep gaping laceration went vertically down the forearm with exposed fat and muscle. The ED provider repaired the lacerations with 53 sutures. Patient #1 had a depressed mood and withdrawn behavior. Patient #1 had multiple prior admissions to different BHU's, and stayed in a long-term BH facility in Illinois at the end of 2023.

g. On 4/15/24 at 8:26 PM, ED staff gave a handoff report on Patient #1 to an IP BHU nurse.

h. On 4/15/24 at 9:07 PM, Patient #1 departed from the ED to the IP child/adolescent BHU.

i. On 4/15/24 at 9:35 PM, Patient #1 admitted to the IP Child/Adolescent BHU due to extremity (limb) laceration, multiple lacerations by self-harm with a razor blade, and self-mutilating behavior. Patient #1 was placed on elopement (run away), safety, and suicide precautions, and every 15-minute rounding (visual checks). Patient #1 was placed on acuity level red.

j. On 4/15/24 at 10:07 PM, Staff searched Patient #1's room.

k. On 4/15/24 at 10:19 Patient #1 had a Columbia Suicide Screening completed by RN VV, and remained at a risk level of high, and noted Patient #1's reason for admission as suicide attempt by trying to cut an artery.

l. On 4/15/24 at 11:12 PM, RN OO and BH Counselor (BHC) K completed Patient #1 skin assessment and body search, and signed by MD SS.

m. On 4/16/24 at 1:15 PM, BHC M noted Patient #1 wrote on their white board in their room "How did I end up here again?" "Am I done for?" and "I can't keep doing this I just want to die?" BHC M tried to speak to Patient #1 about the comments, and told Patient #1 it needed to be erased.

n. On 4/16/2024 at 4:42 AM, MD SS completed Patient #21's history and physical assessment. MD SS noted Patient #21 denied knowing what they did with the razor blade after they used it to cut them self, reported they often felt hopeless, and had increased SI on a daily basis. MD SS noted Patient #21's mood as incongruent (emotional state or reaction seems to conflict with the situation they are in), with a near constant, small smile not reflective of their mood, poor judgment, and psychomotor retardation (slowed thoughts and physical movement).

o. On 4/16/2024 at 6:54 PM, Patient #1 had new self-harm bruising to their forehead not present at admission, and Patient #1 reported hitting their head on the wall.

p. On 4/18/24 at 2:20 AM, staff completed a room check.

q. On 4/18/24 at 10:45 AM, a family medicine resident evaluated Patient #1 for nursing concerns of Patient #1 pulled out some of their sutures, and had multiple sutures pulled out.

r. On 4/18/24 at 1:00 PM, staff completed a room check.

s. On 4/18/24 at approximately 6:40 PM, BHC B met with Patient #1 in their room for a 1:1 visit. Patient #1 smiled, told BHC B they had to tell BHC B something, and admitted to having something on them, but refused to disclose it while continuing to smile. Patient #1 refused to give the item to BHC B, so BHC B instructed Patient #1 to accompany them to the common area to their assigned nurse. Patient #1 refused, and went into their bathroom. BHC B immediately took Patient #1's toiletries from the bathroom, and blocked the door from closing. BHC B yelled out for help, RN A came to Patient #1's room, and both staff opened the bathroom door. Staff observed Patient #1 cut their right arm with a razor blade. Patient #1 then attempted to hide the razor blade behind their back, and refused to give it to staff. Two public safety officers (PSO) arrived to assist staff. BHC B asked Patient #1 to hand over the razor blade, and Patient #1 used the razor blade to cut their right arm two additional times. Patient #1 was placed in a physical hold by a PSO, and the razor blade was secured in a specimen cup.

t. On 4/18/24 at 7:10 PM, RN A completed a face to face assessment, and noted RN A and BHC B discovered while Patient #1 was in their bathroom, they made numerous deep cuts on their right forearm with a razor blade they reported having hidden in their bra since admission to the hospital. RN A and BHC B entered Patient #1's bathroom, and RN A applied pressure to the wounds. After Patient #1 made two additional cuts to their right arm, a physical hold was initiated by a PSO to Patient #1's left wrist in order to prevent Patient #1 from further harming them self. The physical hold was maintained until Patient #1 verbalized they would stop attempting to harm self. Patient #1 had seven new lacerations on their right forearm. After the physical hold ended, Patient #1 agreed to allow a family medicine resident to assess the lacerations.

u. On 4/18/24 at 6:45 PM, staff completed a room check.

v. On 4/18/24 at 7:50 PM, RN A made Patient #1 a 1:1 supervision while awake, placed them in a safety gown, and RN A and RN OO removed all Patient #1's jewelry, which included two earrings, and one nose ring.

w. On 4/18/24 at 8:23 PM, five of the seven new lacerations to Patient #1's right arm were sutured by a family medicine resident, for a total of 14 new sutures.

x. On 4/18/24 at 10:10 PM, Patient #1 spoke to BHC J, and reported their goal with the razor blade was to do enough to cause pain, but not enough to kill them self. Patient #1 also commented about planning to use the razor blade on their thigh, so no staff saw it, or just hit an artery.

y. On 4/18/24 at 10:39 PM, RN A attempted to contact Patient #1's mother, to inform them of Patient #1's new self-harm incident. RN A left a voice message requesting a return call. RN A reported the incident to the house supervisor, BHU supervisor, and the on-call psychiatrist.

z. On 4/19/24 at 5:05 AM, MD SS completed an assessment on Patient #1, and based on the severity of Patient #1's self-harm, acting out, manipulative behavior, and lack of insight, they remained a 1:1 supervision, level red acuity level, continued wearing the safety gown, and continued with their current programming. MD SS instructed Patient #1 to make a list of all hidden items in their home, and their parents would search their entire home.

aa. On 4/20/24 at 4:55 AM, MD SS completed an assessment on Patient #1. Patient #1 continued with 1:1 supervision while awake, but MD SS allowed Patient #1 to wear scrubs, and be out of the safety gown. Patient #1 continued as an acuity risk level of red.

bb. On 4/22/24 at 7:23 AM, MD SS discontinued Patient #1's 1:1 supervision.

cc. During the remainder of Patient #1's hospitalization they were caught continuing self-harming behaviors such as continuing to pick at their sutures, making their previous lacerations bleed, and had an incident where they broke off a medal clip from a pen and attempted to hide it in their waistband, but was observed by a PSO.

dd. Hospital staff failed to wand Patient #1 for metal contraband, and failed to conduct a thorough body search at the time of their admission. Hospital staff failed to have Patient #1 remove their bra to search it for contraband, and only had Patient #1 pull the bra bands away from their body to shake it, to see if anything fell out. Hospital staff allowed Patient #1's toiletries to remain in their bathroom between use, and continue wearing jewelry after admission that could have been used to self-harm. Hospital staff failed to use their panic button (device worn by all staff) to call for staff assist when Patient #1 went into their bathroom. Hospital staff were aware of Patient #1 self-harming behaviors, and Patient #1 had self-harming behaviors throughout their hospitalization such as picking and pulling out old sutures, causing themselves to bleed, and hitting their head.

4. During an interview on 5/7/24 at 8:55 AM, Patient #1's family member reported not understanding how Patient #1 was able to sneak a razor blade through two hospitals.

5. During an interview on 5/13/24 at 9:30 AM, RN Q reported doing a modified body search in the pediatric ED on BH patients, and explained they don't put hands on the patient. RN Q reported behavioral health patients remove their clothing, and change into hospital safety scrubs. RN Q reported patients wearing bras with underwire are required to remove their bra, otherwise the patient is allowed to wear their bra. RN Q reported they don't use a metal detector in the ED, and patients place their belongings in a belonging bag with a patient label, and place it in a secure file cabinet. RN Q recalled Patient #1 came into the ED with a large cut on their left forearm with multiple little cuts. RN Q reported they removed all safety risk items from Patient #1's ED room, placed them in safety scrubs, and assigned a sitter who stayed with Patient #1 for 1:1 supervision. RN Q denied searching Patient #1 for contraband.

6. During an interview on 5/13/24 at 9:00 AM, SW RR recalled Patient #1 came into the ED with a severe self-injury cut on their left arm with several smaller less severe cuts on the same arm. SW RR reported Patient #1 attempted to take their own live, which resulted in Patient #1's admission to UPH's IP Child/Adolescent BHU. SW RR recalled recommending Patient #1 needed IP BHU. SW RR denied any involvement in searching Patient #1 for contraband, and recalled being called to the ED after Patient #1 had been changed into scrubs. SW RR reported when a patient is a risk for self-harm, they are stripped down, placed into hospital scrubs, and assigned a sitter while in the ED. SW RR reported they would have recommended IP BHU staff continue the same safety precautions for Patient #1, such as having a sitter at all times.

7. During an interview on 5/13/24 at 4:00 PM, RN OO recalled Patient #1's admission process, and reported having Patient #1 remove their top, but not their bra. RN OO had Patient #1 shake their bra while wearing it. RN OO recalled Patient #1 telling them after cutting them self, they held onto the razor blade while shaking their bra at admission. RN OO acknowledged they failed to use the metal detector wand on Patient #1 during their admission process. RN OO reported working on the day Patient #1 used the razor blade to cut them self. RN OO recalled holding pressure to Patient #1's arm while RN A contacted family medicine, BHC B went to get a specimen cup, and PSOs were present. RN OO reported Patient #1 made seven cuts to their right arm before staff physically restrained them, and removed the razor blade.

8. During an interview on 5/13/24 at 10:30 AM, BHC K acknowledged assisting the RN during Patient #1's admission, and body search. BHC K recalled having Patient #1 shake their bra, and run their fingers along the edges of the bra, but they didn't remove the bra. BHC K acknowledged they didn't follow policy during Patient #1's admission, as they failed to use the metal detector wand to search Patient #1 for contraband. BHC K recalled Patient #1 being on the same safety precautions as most of the other patients on the unit, and Patient #1 stayed on acuity level red their entire hospitalization. BHC K reported Patient #1 required daily room searches.

9. During an interview on 5/9/24 at 8:30 AM, MD SS recalled Patient #1 being involved in serious self-harm behavior, and caused significant lacerations to them self requiring over 50 sutures. MD SS reported Patient #1 had chronic self-harm and suicidal thoughts, and required treatment. MD SS reported Patient #1 had a pocket in their bra where they hid the razor blade during admission to the hospital. MD SS reported feeling the incident with Patient #1 having the razor blade could have been prevented, only if the ACH changed the way they do things on admission.

10. During an interview on 5/9/24 at 9:00 AM, Licensed Mental Health Counselor (LMHC) O recalled Patient #1, and reported they also worked with Patient #1 during previous hospitalizations. LMHC O reported Patient #1 focused on self-harm injuries and SI. LMHC O reported developing individual programming for Patient #1, and explained patients are typically programmed for group therapy, but Patient #1 had individualized programming due to staff 's familiarity with Patient #1's needs. LMHC O reported Patient #1 being programmed to be out of their room from 8:00 AM to 8:00 PM to be engaged in their programming after their cutting incident on the unit.

11. During an interview on 5/9/24 at 12:00 PM, BHC B reported on 4/18/24 while in the day area, Patient #1 asked to talk to them, and Patient #1 told BHC B they needed to tell them something. BHC B reported going to Patient #1's room with Patient #1, they sat down on seperate beds, across from one another, and Patient #1 started out the conversation telling BHC B their frustration with their mother. BHC B reported Patient #1 hesitated about telling them what they wanted to tell BHC B, but Patient #1 did finally say they had something on them from home. Patient #1 refused to disclose to BHC B what they had, so BHC B told Patient #1 they needed to talk to their nurse. BHC B recalled as they walked to the door of the room, Patient #1 went into the bathroom, BHC B grabbed the toiletries from the bathroom, and blocked Patient #1 from closing the bathroom door. BHC B yelled out into the hallway for a nurse, while trying to get Patient #1 to come out of the bathroom. BHC B reported another patient heard them yell for help, and went to get a nurse. BHC B reported RN A came to Patient #1's room, and they opened the bathroom door. BHC B reported Patient #1 had new cuts present to their right arm. RN A quickly put pressure on the cuts, and when staff asked Patient #1 to hand over the razor blade from behind their back, they immediately made two more cuts to her right arm, and the PSO initiated a physical hold on Patient #1. BHC B reported obtaining the razor blade from Patient #1, and placed it in a specimen cup. BHC B acknowledged they failed to push their panic button to alert staff of their need for assistance.

12. During an interview on 5/15/24 at 2:30 PM, RN A recalled Patient #1, and reported they had a hard time keeping them self safe. RN A reported Patient #1 came to the BHU for significant cuts to their left arm, and after being admitted to the BHU, they kept trying to pull their sutures out and self-harm. RN A reported Patient #1 needed 1:1 supervision at times due to their continued self-harming behavior, such as picking at their sutures.

13. During an interview on 5/15/24 at 11:00 AM, PSO ZZ reported working on the BHU when Patient #1 used a razor blade to self-harm, and recalled a BHC ran in and out of Patient #1's room, so PSO ZZ asked if they needed anything. PSO ZZ reported seeing staff gripping Patient #1's arm with blood running down, and PSO ZZ called for other officers' assistance.

14. During an interview on 5/15/24 at 3:10 PM, MD TT reported Patient #1 being able to sneak the razor blade onto the BHU is concerning, the ACH learned from the incident, and staff have taken appropriate steps to try and prevent something like this from happening again. MD TT reported Patient #1 had a rigorous individualized plan based on their injuries and history, and hospital staff were very aware and paying close attention to them.

15. During an interview on 5/13/24 at 3:30 PM, BHC F recalled Patient #1, and reported Patient #1 didn't see the point in trying anymore, voiced SI and self-harm thoughts, and had severe self-harm tendencies.

16. During an interview on 5/9/24 at 9:30 AM, RN N recalled Patient #1 had no interest in getting better, and they had individualized programming to focus on safety planning. RN N reported Patient #1 would pick at their sutures and try to pull them out. RN N explained that any time a patient is able to sneak contraband into the BHU, they should learn from it, and make changes.

17. During an interview on 5/13/24 at 1:00 PM, RN I recalled Patient #1 hid things in their sweatshirt sleeves, and required staff to keep a close watch on them. RN I reported any patient admitted to the BHU has the potential for self-harming behaviors, and staff are monitoring for cues as well as changes in mood and behaviors.

18. During an interview on 5/15/24 at 3:30 PM, BHU Manager reported feeling the BHU is appropriately staffed. BHU Manager reported 1:1 supervision can be implemented at any time depending on a patient's presenting symptoms, behaviors, and safety risks, but explained that a doctor's order must be obtained after a 1:1 has been implemented and/or to be discontinued. BNU Manager reported a patient has never been denied a 1:1 supervision due to staffing issues, but explained they try other interventions prior to using 1:1 supervision. BHU Manager reported they don't currently do audits to ensure room checks are being completed appropriately. BHU Manager reported they found that staff weren't doing complete body searches on all patients being admitted to the BHU, and weren't having patients remove all their clothing completely, but this process has been standardized and guidelines made clear after Patient #1 snuck the razor blade onto the unit. BHU Manager explained patients now remove all clothing including undergarments on admission for the body search. BHU Manager acknowledged BHC B failed to press their panic button when Patient #1 went into their bathroom and used a razor blade to cut them self. BHU Manager explained an individual plan is developed for patients who come in with complex diagnoses, and are frequently admitted to the BHU. The therapists develop plans particular to that patient instead of as a group with the other patients on the unit, and the patient is placed at a separate desk away from other patients.

19. During an interview on 5/15/24 at 4:15 PM, BHU Director reported the wording in the policy for doing body searches on admission wasn't clear on what clothing should be removed. BHU Director acknowledged BHU staff failed to use the metal detector wand to search Patient #1 on admission, and failed to remove all Patient #1's clothing including their undergarments during the body search which resulted in Patient #1 being able to sneak a razor blade onto the BHU. BHU Director also acknowledged that BHU staff failed to press their panic button worn when working on the unit to alert other staff of their need for assistance, and staff failed to remove the weapon from Patient #1's hand immediately when they realized they had it.

Based on hospital policy, medical record review, family interview and staff interview, hospital administrative staff failed to ensure hospital staff followed hospital policies for the care of patients in their emergency department (ED) due to inadequate staff available to meet the emergency needs of patients. Failure to follow the hospital's policies in the ED resulted in:

1) a failure of ED staff to complete timely assessment and treatment of patients (see A1112); and,

2) a failure of ED staff to report changes in condition of patients in a timely manner to an ED provider (see A1112).

The cumulative effect of this deficient practice resulted in the failure of a patient experiencing stroke symptoms and a pediatric patient experiencing complications from a tonsillectomy, including low blood volume, not receiving timely assessment and treatment by a medical provider.

Based on hospital policy, medical record review, family interview and staff interview, hospital administrative staff failed to ensure hospital staff followed hospital policies for the care of patients in their emergency department (ED) due to inadequate staff available to meet the emergency needs of patients for 2 of 21 (Patient #17 and #37) sample patients that presented to the ED requesting medical care.

Failure to ensure adequate ED staff were available to meet the emergency needs of patients resulted in a patient experiencing stroke symptoms and a pediatric patient experiencing complications from a tonsillectomy, including low blood volume, not receiving timely assessment and treatment by a medical provider.

Hospital Capabilities:

The acute care hospital had three campuses (Iowa Methodist "Downtown," Methodist West, and Iowa Lutheran). Between the three campuses, the hospital had a Dedicated ED (DED) on each campus. The Methodist West campus had 15 emergency department rooms. The Iowa Methodist "Downtown" campus had 26 emergency department rooms, plus 12 additional pediatric emergency department rooms in a separate emergency department area. The Methodist West and Iowa Lutheran campuses had Level III Trauma designations, while Iowa Methodist Medical Center "Downtown" had a Level I Trauma center designation. The Iowa Methodist Medical Center "Downtown" Emergency Department had a dedicated pediatrics DED (and associated children's hospital) known as "Blank Children's Hospital (under the same CCN)." Each DED was staffed with at least a physician as the provider on duty, along with a mix of additional physician assistants and nurse practitioners providing coverage to each department. The Iowa Methodist "Downtown" campus offered a 23 hour observation unit, which was considered part of the Emergency Department, and was staffed by mid-level providers, who are also scheduled on different shifts at the Iowa Methodist Emergency Departments.

The Methodist West campus DED saw an average of 287 ED visits per month. The Iowa Methodist "Downtown" campus DED saw an average of 3628 ED visits per month.The hospital, across all campuses, had a total of 758 licensed beds, 29 operating rooms, 8 endoscopy rooms, and 7 cardiac catheterization procedure rooms. 24 Hour on-call, specialist and surgeons.

The Methodist West campus had 15 Emergency Department beds and was staffed at all times with an emergency department dedicated physician. The Emergency Department also had mid-level coverage, in addition to the physician coverage, during the peak hours. The DED was staffed with a variety of nurse and patient care technicians. The hospital staffed a Patient Access (registration) individual dedicated to the Emergency Department. The ED staff had access to a wide variety of specialties and subspecialties on-call including neurologists, surgeons and pediatricians.

Findings include:

1. Review of policy, "Use of Triage Protocol Order Sets in The Emergency Department," last revised 12/21, revealed in part:

a. " ...Purpose: To provide for timely care of patients presenting to the emergency department who meet specified criteria; and to allow for rapid diagnostics and appropriate treatment of those patients."

b. "...Policy Statement: Nursing-initiated triage order sets are intended to enhance rapid diagnostics and treatment to ED patients. They do not delay a MSE... After a patient has undergone ED triage and while awaiting a MSE a registered nurse (RN) initiates an approved ED Triage Protocol Order Set in EPIC based upon the criteria in the following procedures ...Widely recognized standards and/or evidence-based guidelines are used to develop triage order sets which are regularly reviewed (at least every three years) by the UnityPoint Health Emergency Medicine Clinical Service Group. Current order sets are found by searching "ED Triage Protocol" in the EPIC order sets ...."

c. "...Procedure: The nurse may initiate an ED Triage Protocol order set following the triage assessment. Criteria for when a specific ED Triage Protocol may be initiated are recorded at the top of each protocol set in EPIC... Each patient condition is unique and there may be a need due to the patient's clinical condition to modify these procedures. The nurse and physician collaborate to manage the patient's condition on a case-by-case basis, and the rationale for any changes is documented in the patient's medical record ...."

2. Review of policy, "Transfer and Emergency Examination-EMTALA," last revised 9/21, revealed in part:

a. " ...Medical Screening Procedure- Initial Assessment When an individual requests examination or treatment, the patient registrar will notify an Emergency Department nurse of the individual's arrival and will inform such nurse of the individual's complaints and symptoms, as well as any observations made by the registrar. Individuals who arrive at Unity Point Hospital Des Moines (UPHDM) by either ground or air ambulance will be examined by a nurse upon arrival ...."

b. " ...Medical Screening Procedure-Examination -The individual shall be examined according to Emergency Department protocol and procedures. The Medical Screening Examination provided shall be within the Capability and Capacity of the UPHDM hospital's Emergency Department (including ancillary services routinely available to the emergency department). The Medical Screening Examination shall be recorded in the individual's medical record ...."

c. " ... Stabilize-To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from a facility; or with respect to a woman in Labor, to deliver (including the placenta)" ...
"...Medical Screening Examination in Emergency Department ..."

3. Review of Policy "Emergency Department Standards of Practice Guidelines," last revised 7/7/2023, revealed in part:

a. "Policy Statement: Health care consumers presenting to the emergency departments ... will receive nursing care consistent with the Emergency Nursing Scope and Standards of Practice outlined in the Emergency Nursing Association (ENA), Third Edition (2023) ..."

b. "...Responsibilities... It is the responsibility of the ED RN to complete and accurately document nursing care provided ...It is the responsibility of the ED Patient Care Technician (PCT) to complete and accurately document any patient care provided by the PCT ...."

c. "...Standards of Practice and Documentation Guidelines ...
... ENA Standard of Practice: Assessment: The emergency nurse collects pertinent data and information relative to the patient's health or information ...."
"...Primary Assessment - All patients regardless of chief complaint or triage acuity level will have a primary assessment Circulation, Airway, Breathing and Disability (CABD) completed by the triage RN, primary RN, or ED paramedic ...." "...Secondary Assessment(s) - All patients will have at least one secondary assessment related to the body system of the patient's chief complaint ...." "...Alerts - The following alerts should be initiated by calling 777, requesting the type of alert and location of the patient ...."... Cardiac Alert - segment elevation myocardial infarction (STEMI) on electrocardiogram (EKG) or at provider direction ... "... Stroke Alert - Stroke-like symptoms within 24 hours of last known well (LKW) or at provider direction..."
"...Trauma Alert - Level 1 or Level 2 based on trauma criteria or at provider direction. Level 3 at IMMC only..."

d. "...Additional Guidelines, Reassessment of primary and secondary assessments should occur as needed throughout the ED visit depending on clinical judgment and change in patient condition ..."
"...PCT's may obtain and document vital signs. PCT's should report vital signs to the primary RN ...."

e. "...Assessment and Reassessment .......Reassessment, Vitals and Monitoring ...."
Vitals must include: heart rate, respiratory rate, blood pressure, and oxygen saturation. A temperature should be obtained on arrival and reassessed as needed.

"...Clinical Situation/VITALS REASSESSMENT GUIDELINES ..."

" ...Patient's assigned Emergency Services Indicator (ESI 1 level), Vitals assessed every 5-15 minutes until stable then every hour as needed. ESI 2 level, Vitals assessed every 15 minutes until stable then every hour and as needed. ESI 3 level, Vitals assessed every 2 hours and as needed (PRN). Monitoring according to patient needs and nursing judgment. ESI 4 level and 5 Vitals upon arrival, at discharge and PRN. ESI levels 3, 4 and 5: Re-assessment and vital signs will occur as needed with changes in patient condition, before and after titration of medications, or other conditions as clinically indicated. Abnormal vital signs require physician notification and repeat vital signs prior to patient discharge, admission, or transfer..."

" ...Additional Guidance:

Communicate change in patient condition, abnormal vital signs, and critical values to the ED provider, or, if the patient is a boarder, should communicate with the admitting provider.
For inpatient borders, vitals should follow "Routine Vital Signs for Adult Inpatients on Medical Surgical Units" from time of bed request or per physician order.
Critical care patients should have vitals at least every 1 hour or per order.
Abnormal Vitals to be reported to ED provider:
Systolic BP: > 180 or < 90 millimeters of mercury (mmHg); Diastolic BP: > 110 mmHg; Heart Rate: > 130 beats per minute; Respiratory Rate: < 8 or > 30 breaths per minute: O2 Saturation: < 90%; Temp: < 96 F (35.6 C) or > 100.4 F (38 C); Acute mental status changes ..."

4. Patient #17 medical record review, family and staff interviews revealed the following:

a. On 6/3/24 at 1:00 PM, during an interview, a family member reported the patient complained of weakness and an inability to lift themselves out of the bathtub. Family called 911, and emergency medical services (EMS) took the patient to the hospital's downtown campus ED. Family reported they arrived at the hospital at 1:00 PM; they found the patient sitting unaccompanied, in a wheelchair in the ED waiting room. Per family interview, Patient #17 appeared lethargic, a little sleepy, slightly disoriented, sitting hunched over and the patient's head was down. The family member recalled the patient told them that the patient's left side was losing more sensation 15-20 minutes after the family member's arrival at the ED. The family reported that there were approximately 25-35 additional people in the ED waiting area. A hospital staff (Patient Care Technician-PCT) came out and took the patients' blood pressure two or three times while the patient was in the ED waiting room. The family member reported that the first time the PCT took the patient's blood pressure, the patient told the PCT that they could not feel their left side. The PCT stated she would mention the concern to staff. The family member reported "a gal" came out to take the patient to get some blood work completed between 3-5 PM. The patient told the female staff person that got the patient for blood work about not being able to feel the left side. The PCT came and took VS again and patient #17 again stated that the patient could not feel the left side and felt worse. The family member reported that at about 7:00 PM that night, hospital staff wheeled the patient into an exam room. Fairly soon after the patient got into the exam room, hospital staff took the patient for a CT scan.

b. On 6/3/24 at 3:00 PM, during an interview, another family member explained the following: " ED felt very compartmentalized and not clear who was in charge, and what were the next steps for orders and patient care." Felt like no one was on site taking care of patient in the ED, no one in control of the situation, making decisions and ordering testing.

c. On 1/8/24 at 11:57 AM, Patient #17 arrived at the hospital ED by ambulance emergency medical services (EMS) with a complaint of syncope (brief loss of consciousness). The EMS trip report indicated the patient had the following abnormally high blood pressures (BPs) : 176 (systolic)/72 (diastolic) at 11:22 AM; 167/86 at 11:30 AM; 203/148 at 11:40 AM; 185/149 at 11:47 AM; and 169/64 at 11:53 AM.

d. On 1/8/2024 at 12:17 PM, Staff W ED RN initiated triage. At 12:19 PM, Staff W ED RN documented, vital signs (VS) as follows: temperature 36.4 degrees Celsius (C), 97.5degrees Fahrenheit (F); heart rate 67 beats per minute (BPM); respiratory rate (RR) 16 breaths per minute; oxygen saturation (O2 Sat) 98% on room air; blood pressure (BP) 138/109 millimeters of mercury (mmHg). Patient #17 denied any pain.

e. During an interview, on 5/8/24 at 2:30 PM, Staff W ED RN explained the different levels of triage, noting patients were given a triage level 1-5, 1 being the highest acuity level and 5 being minor. Staff W ED RN, recalled triaging Patient #17 and determined an acuity level 3, due to weakness. Patient #17 was returned to the waiting room following triage. Patient #17 should have had the patient's vital signs checked every two hours based on the identified acuity level 3.

f. On 1/8/2024 at 4:03 PM Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70 BPM; O2 sat 99% on room air; BP 152/80.

Record review of Patient #17's medical chart on 5/7/2024 failed to reveal the evidence of rounding notes completed while Patient#17 remained in the ED waiting area, as indicated by nursing staff during interviews. Review of the record revealed an approximately 3.5-hour void in documentation of VS on Patient #17 (between 12:19 PM and 4:03 PM).

g. On 5/7/2024 at 11:00 AM Staff JJ Clinical Informatics after review of the record, confirmed the staff failed to include rounding notes completed by nursing staff.

h. During an interview on 5/8/24 at 9:30 AM Staff S ED PCT explained patients were assigned an acuity level following triage. Patient's assigned a level 3 acuity and sent to the waiting room required vitals completed every two hours. Staff S/ED PCT, further explained if the ED was busy with 30 or more patients, staff prioritized by acuity level and completed higher levels first. If extremely busy, staff should call back to the shift lead to request help to ensure everyone received appropriate care and vital signs. If a patient had a different or additional complaint VS should be taken and reported to the triage nurse. Staff S ED PCT denied remembering Patient #17 and denied remembering any of the events that occurred in the ED waiting room on 1/8/24.

A review of daily patient census and staffing schedule revealed the total patient census for the ED on 1/8/24 was 118 patients. Patients arrived in th ED on 1/8/24 as follows: 16 patients arrived between 9:00 AM and 11:00 AM; 20 patients arrived between 11:00 AM and 1:00PM with 15 patients arriving by ambulance; 7 patients arrived between 1:00 PM and 3:00 PM; 6 patients arrived between 3:00 PM and 5:00 PM; 18 patients arrived between 5PM-7PM. Patients arriving between 11AM-1PM consisted of stroke, overdose, unresponsive, chest pain, and loss of consciousness. While Patient #17 waited in the ED waiting area, 51 patients arrived. During this time, 11 RNs and 4 PCTs worked in the ED. Physicians and mid level providers scheduled between the hours of 11:00 AM to 7:00 PM included 2 physicians and 1 ARNP during day shift and 2 physicians and 1 ARNP during evening and night shift.

i. On 5/7/24 at 10:41 AM, during an interview, Staff V ED RN Nurse Manger reported the average wait time for a patient to be seen in the ED was 30 to 40 minutes for triage and 45 minutes from triage until the patient was placed in an ED room. In a later interview on 6/5/24 at 9:30AM, Staff V ED RN Nurse Manger explained hospital administrative staff used a staffing matrix to meet staffing needs; they did not have staff on call for busy time periods to address surge and patients with higher acuity needs. They staffed 11 nurses and 4 PCT's from 7:00 AM to 7:00 PM, and added 2 more nurses between the hours of 11:00 AM to 11:00 PM. Staff V, recalled if a PCT needs assistance in the ED waiting area, the PCT was supposed to call the shift leader to request additional staffing. If there were any staff available, they would send them to the waiting area to assist with rounding.

j. On 1/8/2024 at 6:25 PM, Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70; RR 16; O2 sat 97% on room air; BP 180/106 mmHg. Staff S ED PCT documented she notified the triage nurse of Patient #17's elevated BP reading. Documentation showed Staff S ED PCT reported the elevated BP to the triage nurse.

k. On 1/8/24 at 6:54 PM, Staff Y ED RN documented they placed Patient #17 in a fast track (FT). ED staff ordered labs including complete blood count (CBC) with differential, complete metabolic panel (CMP), urinalysis (UA), respiratory film array panel and Covid testing.

l. On 1/8/24 at 6:56 PM, Staff Y ED RN documented a neurological assessment and determined the patient was displaying stroke-like symptoms including arm drifting, slurred or inappropriate words; talking like the patient's mouth was full of food, left hand grip weak, left foot dorsiflexion and plantar flexion weak and decreased left lower extremity sensation (symptoms indicative of a stroke). Staff Y ED RN documented the patient failed the stroke screening assessment and the nurse ordered the patient to be nothing by mouth (NPO) and ordered a bed-side swallow study.

m. On 1/8/2024 at 7:00 PM, Staff Y ED RN, documented VS, HR 68 bpm, RR 16, BP 182/98 elevated O2 Sat 98%.

n. On 1/8/2024 at 7:20 PM, Staff T ED ARNP and documented that around 11:00 AM today (1/8/24) the patient noticed weakness in left arm and leg. The patient's family member said the patient was quite a bit worse than over the past several weeks. The patient stated the patient could not make a fist or lift the patient's left leg; the left leg felt heavy.

o. On 1/8/24 at 7:40 PM, Staff T, ED ARNP completed the stroke scale and placed orders for chest x ray CT head with contrast stroke alert only, CT angiography of the head. CT of head and CT angiography were completed on 1/8/24 at 7:51 PM.

p. During an interview, on 5/14/24 at 10:00 AM, Staff Y ED RN recalled staff brought Patient #17 to Fast Track (FT) bed. Staff Y reported they noted changes with Patient #17's VS, specifically elevated BP and neurological assessment for stroke symptoms. Staff Y ED EN informed Staff T ED ARNP of the concerns. Staff Y ED RN, recalled they took Patient #17 to obtain a CT, and the CT was positive. Staff T ED ARNP, then called the stroke alert. Patient #17 was outside of the window to receive Thrombolytics (TPA) therapy. Staff Y ED RN, stated "Patient #17 then moved to a room for higher acuity level of care."

q. During an interview on 5/7/24 at 11:30 AM Staff T ED ARNP recalled examining Patient #17 in a FT room and asking Staff U ED DO, to further evaluate the patient. Patient #17 was moved to a room for higher acuity level of care in the ED. Staff T ED ARNP and Staff U ED DO, called the stroke alert at 7:42 PM, and Staff U ED DO, became the primary physician, implementing stroke protocol. Patient #17's care was turned over to internal medicine, as the patient was admitted to the hospital.

r. On 1/9/24 at 7:57 AM, Staff X Hospitalist documented Patient #17's history (hx) of diabetes mellitus type 2 (DM 2), obstructive sleep apnea (OSA), gastroesophageal reflux disorder (GERD), hypertension (HTN), cerebral vascular accident (CVA), anxiety/depression, benign prostatic hypertrophy (BPH) and noted Patient #17 admission on 1/8/24 with bilateral strokes. They further noted Patient #17 presented following four weeks of weakness with acute worsening of left-sided weakness. A head computed tomography (CT) was unremarkable. Computed tomography angiography (CTA) of the head and neck showed no large vessel occlusion (LVO) but noted multifocal areas of mild to moderate arterial narrowing of the posterior circulation. A magnetic resonance imaging (MRI) showed infarct (stroke) of the right pons, left posterior limb of the internal capsule/left anterior thalamus, left temporal periventricular parenchyma. Patient was on Plavix prior to arrival; Aspirin was added to the regimen.

s. On 1/9/24 at 3:06 PM, Staff HH Neurologist documented Patient # 17's history of a right corona radiata ischemic stroke, memory problems, under control diabetes, hypertension and hyperlipidemia. Staff HH Neurologist noted Patient #17 presented to the ED for evaluation of left-sided weakness. The patient's last well known normal was 11:00 AM on 1/8/2024. Staff HH Neurologist documented Patient #17 was out of the window for thrombolytics. A CTA (scan) of the head and neck showed no evidence of LVO (large vessel occlusion). An MRI showed Patient #17's brain demonstrated acute to subacute infarct in right pons, left posterior limb of internal capsule/anterior thalamus and left temporal periventricular parenchymal. Staff HH Neurologist noted Patient #17 scored 10 on the National Institute of Health Stroke Scale (NIHSS)(subtle left facial droop, left arm and leg drift, sensory changes). Patient #17 took Plavix prior to admission. Staff HH Neurologist, ordered the following:
- P2Y12 platelet function assay and Transesophageal Echocardiogram (TEE) for further evaluation
- Continued dual antiplatelet therapy (DAPT) for the time
- Continued Atrovastatin (medication to lower blood cholesterol levels) 80 mg orally nightly
- Follow-up P2Y12 results
- Allowed permissive hypertension with goal LDL (type of blood cholesterol level)<70 and HbA1c (type of blood test related to blood sugar levels)<7
- Physical therapy (PT), occupational therapy (OT) and speech therapy (ST)
-Stroke education
He further noted Patient #17 likely needed a 30-day cardiac event monitor at discharge and follow up with Neurology would occur the next day.

t. During an interview, on 5/8/24 at 8:10 AM, Staff X Physician recalled they saw patient #17 the second day. They explained standing orders for a typical stroke protocol included imaging, management of BP, platelet therapy, and anticoagulation therapy. Patient #17 had Bilateral strokes during inpatient admission, while waiting for rehab therapy recommendations and admission. A bed request was put in at the time of admission, but they could not recall if the patient had left the ED yet. Staff X Physician, could not confirm the patient boarded in the ED while waiting for a bed to become available in therapy and a rehab admission.

u. During an interview, on 5/14/24 at 3:00 PM, Staff HH Neurologist recalled they saw Patient #17 and, as a supervising physician, also oversaw resident notes. Staff HH Neurologist recalled confusion amongst the staff and physicians regarding exact time of onset of Patient #17's symptoms of dizziness and confusion. Patient #17 arrived at the ED reporting symptoms had been on-going for days to weeks prior. Staff HH Neurologist explained TPA therapy should be initiated within a 4.5 hour time frame, unless the exact time of symptom onset was known. Due to ongoing weakness and not knowing the actual onset of symptoms, the decision to initiate TPA therapy was difficult. The patient's report of four weeks of symptoms put Patient #17 outside the TPA therapy window.

According to the ED staffing matrix, the ED was appropriately staffed on 1/8/24. However, hospital staff could not provide evidence to explain why Patient #17 had to wait almost 7 hours in the ED waiting room and over 7 hours to be assessed by a provider in the ED. ED staff could not explain why Patient #7 failed to be assessed every 2 hours at a minimum and why none of the staff responded with any urgency to the Patient's complaints of weakness, increased feeling of unwellness, and loss of sensation on the left side of the patient's body.

5. Review of Patient #37, a pediatric patient, medical record revealed the following:

a. On 5/1/24 at 9:30 PM, Staff CC ED RN and Staff BB ED RN documented the following: "Arrive to Methodist West ED via private vehicle...chief complaint post-op problem (Patient #37) underwent a tonsillectomy and adenoidectomy (T&A) on 4/22/24 by pediatric Ear Nose and Throat (ENT) physician...Patient woke up covered in blood on 4/30 (4/30/24) and the ENT physician told them if the bleeding stops that is okay, but if reoccurred to come to the ED. Patient woke up again tonight (5/1/24) covered in blood. Bleeding from the throat has stopped since the patient arrived in the ED. Family reports no new spitting up of blood."

b. On 5/1/24 at 9:46 PM, Staff CC ED RN and Staff BB ED RN documented a triage assessment on Patient #37 as follows: vital signs (VS) were heart rate (HR) 142 beats per minute (bpm- elevated), respirations 22 per minute, BP- 99/58, oxygen saturation level of 100%, wt (weight)-25 lbs (pounds), temp 98.6 (degrees Fahrenheit).

c. On 5/1/24 10:56 PM, ED staff documented, "Family signed Refusal of Medical Screening Exam; "too long of wait for treatment".

d. On 5/8/24 at 4:00 PM, during an interview, a family member reported they asked a person at the front desk how long of a wait it would be, and the front desk told the family member there was a 3 to 4 hour wait for a bed (exam room). The family member asked a nurse if they should take the patient to another hospital, as they had been told by the ENT surgeon that the patient needed to be seen immediately. The nurse (identified as Staff BB ED Triage Nurse) informed the family that they could not tell the family member to take the patient to another hospital, encouraged them to stay, but expressed her understanding that a 3 to 4 hour wait was too long for a child. The family member confirmed they signed a form to refuse treatment.

e. A review of daily patient census revealed the following: a total patient census for the ED on 5/1/24 was 71 patients; 62 patients arrived between 7:00 AM and 11:00 AM; 19 patients arrived between 11AM and 3:00 PM; 32 patients arrived between 3:00 PM and 7:00 PM; 28 patients arrived between 7:00 PM and 11:00 PM; 24 patients arrived between 11:00 PM and 3:00 AM. Review of the ED staffing schedule revealed the ED had 1 physician and 1 mid-level working at all times and 5 nurses and 1 to 2 PCTs working at all times during the 24 hour shift.

f. On 5/1/24 11:26 PM Patient #37 arrived at a second hospital ED, Hospital SS via private vehicle.

On 5/1/24 at 11:30 PM, Staff RR, ED RN, Triage Note-"(Patient #37) had tonsillectomy/adenoidectomy and tubes placed 4/22/24 with pediatric ENT Staff PP. Last night, the patient had a little bleeding but stopped, tonight the patient had another episode of bleeding that was worse."

g. On 5/2/24 at 12:48 AM, Staff QQ ED Physician documented the following: "(Patient #37) presented after tonsils and adenoids removed on 4/22/24, late last night (Patient #37) had a small amount of post tonsillar bleeding, resolved spontaneously, seems to be doing fine, tolerating P.O. (by mouth) today, took Ibuprofen, however this evening woke after another episode of bleeding, blood in the naris (nose), large blood clot was spit out of the mouth, however bleeding is now stopped, recommended to go to the emergency department by Ear Nose and Throat (ENT) for evaluation and potentially IV fluids. Previous treatment: outpatient surgery. Post op course: Fluctuating. Incision complaints: moderate Bleeding. Risk factors consist of age. Therapy today: none. MSE completed."

PLAN: "(Patient #37) with post tonsillar bleed, appears not to be bleeding currently, will keep an eye on (Patient #37) in the ED, patient appears pale, recommendation from ENT to get IV(intravenous) fluids, will place IV, do screening blood work (complete metabolic profile (CMP), complete blood count (CBC) with differential) and give Dextrose 5% and Sodium Chloride 0.9% with Potassium Chloride 20 milliequivalents per liter (mEq/L) per 1000 mL(milliliters)- 250 cc(cubic centimeters) bolus."

h. On 5/2/24 4:15 AM Staff QQ ED Physician documented Physician Notes as follows: "Patient with no further bleeding in the emergency department however is profoundly anemic with hemoglobin 7.3 (normal 11.5-13.5; indicative of anemia or low blood volume), discussed with ENT and will admit to PEDS (pediatric) Hospitalist, type and screen pending, ENT will see in the a.m. and reevaluate."

i. On 5/2/24 at 4:28 AM, Staff PP ENT documented the following progress notes: "(Patient #37) was admitted earlier this morning with a postoperative bleed. We are evaluating Patient #37 today to assess how they have done over the course of the day. Patient #37 has been doing quite well and has had no further bleeding. There have been no concerns regarding their airway since admission. I spoke to the family a couple of nights ago and noted that Patient #37 had a brief bleed at that time, but we had followed up that morning and they had no further issues. It was only in the middle of the night that they began bleeding again at which time the family brought them in. Again, the last 12 hours have been uneventful. Patient 37 has had no further bleeding or concerns. Patient #37 is feeding and doing quite well. We will monitor them overnight and see how Patient #37 does. If there is no further bleeding tomorrow depending on how they are feeling and the family is comfortable, we will start considering discharge home. Order for Pediatric Admission placed."

j. During an interview, on 5/9/24 at 8:10 AM, Staff BB ED RN (West campus ED triage nurse), recalled the patient. Staff BB reported they recalled that "it was a very busy evening" and they believed "the wait times were getting to be long". Staff BB reported the patient had a little bit of blood on their pajamas or in their hair. Family said the bleeding had stopped. Staff BB did not remember seeing the patient bleeding. The family never asked for a tissue or notified staff that the bleeding had started again. Staff BB explained that if the patient's condition worsened, she would have called the charge nurse to direct Staff BB to get the patient seen immediately by a provider. Staff BB, did ask the charge nurse what acuity level the patient should be, and Staff BB reported the charge nurse told her a Level 3. Level 3 would be brought back before a Level 4 patient. Since the waiting room was busy there was a PCT rounding for the patient's vitals. The PCT documents those vitals in the patients' electronic records. When asked if they explained to the family that the patient had a possible EMC and should stay and let the patient to be seen, Staff BB responded that they encouraged them to stay to see a provider. When the family asked how long it would be before the patient could be seen, Staff BB reported they told the family that wait times were always changing and they could not provide that information. Staff BB reported they explained the Refusal of Medical Treatment form and had a family member sign it.

k. During an interview, on 5/9/24 at 8:40 AM, Staff CC ED RN (West Campus ED Triage nurse), recalled Patient #37 and recalled that night (5/1/24) being horribly busy. Staff CC ED RN explained there were a lot of patients boarding (in the ED) and no beds were opening up. Staff CC ED RN recalled the family came up to the desk voicing their frustration, because their provider told them to rush the child in and then they had to wait for their child to be seen. The family said they were going to take the patient to a different ED. Staff CC ED RN reported that Staff BB explained that Patient #37 needed to be seen, but if they were leaving they could sign the Refusal of Medical Exam form. The family did sign the form. Staff CC ED RN did not recall staff stating a time frame for the wait to be seen by a provider. Staff usually state that they cannot give an estimate of the time frame, and patient were taken into the ED rooms according to their acuity level.

Per the hospital's staffing matrix, the hospital ED was adequately staffed on 5/1/24 (when Patient #37) was in the ED; however, ED staff reported the ED was busy with long wait times for medical assessment by a provider.

The hospital's ED failed to have enough physicians/mid-level providers to meet the emergency needs of patients and provide timely assessment and treatment.