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A. Based on review of seventeen (17) out of thirty (30) medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that pain assessments and reassessments are conducted in accordance with facility policies and procedures.

Findings include:

Reference #1: Facility policy titled "Vital Sign Monitoring" states, "... Nursing assessment of all Emergency Department patients shall include blood pressure, pulse, respirations, temperature and pain assessment.. F. Medicated Patients: 1. Patients who have had medications administered should have vital signs repeated at least once, and prn based upon response to medication..."

Reference #2: Facility policy titled " Pain Assessment" states, " ...1. Emergency Department (ED) Pain Assessment ... c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record... d. If pain is present, assessment includes location, rating, description, pain indicators, scale used and interventions implemented, as appropriate for the patient... 4. Reassessment of Pain a. After administration of pharmacological and/or non-pharmacological interventions, a reassessment is completed within 60 minutes..."

1. Review of Medical Record #1 on 5/7/19, revealed the following:

a. The patient arrived in the ED on 3/27/19 at 5:39 PM with complaints of diffused abdominal pain, nausea and chills.

b. A full triage was completed at 6:16 PM.

c. Initial set of vital signs were taken at 6:16 PM.

d. There was no evidence within the medical record that a pain assessment was done.

2. Review of Medical Record #4 on 5/8/19, revealed the following:

a. The patient arrived in the ED on 3/27/19 at 5:56 PM with complaints of hallucinations.

b. A full triage was completed at 6:32 PM. Initial set of vital signs were taken at 6:11 PM. There was no pain assessment documented.

c. At 10:00 PM, the ED Vital Sign flowsheet indicated a pain level of ten (10) out of ten (10), utilizing the 0-10 Numerical Rating Scale (NRS). The pain assessment did not include a description or location of the pain.

d. Review of ED Medication Administration Record (MAR) indicated that the patient received pain medication at 10:00 PM.

(i) There was no evidence that a pain reassessment was performed.

3. Review of Medical Record #5 on 5/8/19 revealed the following:

a. The patient arrived in the ED on 2/24/19 at 10:50 AM with complaints of increasing abdominal pain after gall bladder surgery.

b. A full triage was completed at 11:14 AM. A pain level of eight (8) out of ten (10) was identified, utilizing the 0-10 NRS.

c. Review of the nurse's notes indicated that at 12:15 PM, the patient received pain medication.

d. There was no evidence that a pain reassessment was performed.

4. Review of Medical Record #8 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 12/10/18 at 2:24 PM with complaints of abdominal pain.

b. A full triage was completed at 2:27 PM. Initial set of vital signs were taken at 2:49 PM. Pain assessment indicated a pain level of six (6) out of ten (10), utilizing the 0-10 NRS.

c. At 5:20 PM, the patient received IV (intravenous) pain medication. The next pain assessment was completed at 7:07 PM.

(i) Pain was not reassessed sixty (60) minutes after pharmacological intervention.

5. Review of Medical Record #9 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 12/10/18 at 10:26 AM with complaints of abdominal pain.

b. A full triage was completed at 10:47 AM and initial vital signs were taken. Pain Screening indicated a pain level of two (2) out of ten (10), utilizing the 0-10 NRS.

c. The patient received IV pain medication at 11:28 AM.

(i) There was no evidence that a pain reassessment was performed.

d. The patient received pain medication at 2:49 PM.

(i) There was no evidence that a pain reassessment was performed.

e. The patient received pain medication at 3:30 PM.

(i) There was no documented evidence of pain assessment and reassessment.

6. Review of Medical Record #12 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 12/10/18 at 5:58 PM with complaints of suicidal ideation.

b. A full triage was completed at 6:19 PM and initial vital signs were taken. There was no pain assessment documented.

7. Review of Medical Record #13 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 12/10/18 at 8:14 PM with complaints of chest pain.

b. A full triage was completed at 9:04 AM. An initial set of vital signs were taken at 8:44 PM. There was no pain assessment documented.

c. Review of ED MAR indicated that the patient received IV pain medication at 8:57 PM.

d. There was no documented pain reassessment sixty (60) minutes after pharmacological intervention.

8. Review of Medical Record #14 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 1/1/19 at 10:18 PM with complaints of abdominal pain.

b. A full triage was completed at 10:20 PM. Vital signs were taken at 10:32 PM. Pain assessment indicated a pain level of five (5) out of ten (10), utilizing the 0-10 NRS.

c. There was no evidence that pain was addressed.

9. Review of Medical Record #15 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 2/24/19 at 5:28 PM with complaints of leg swelling and pain in the left leg.

b. A full triage was completed at 6:21 PM and initial vital signs were taken. There was no pain assessment documented.

c. Review of the ED MAR indicated that at 10:30 PM, the patient received pain medication.

(i) There was no documented pain assessment prior to the administration of medication or a reassessment after intervention.

10. Review of Medical Record #16 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 3/27/19 at 5:05 PM with complaints of left sided swollen neck glands.

b. A full triage was completed at 5:19 PM and initial vital signs were taken. Pain was assessed zero (0) out of ten (10) except when the patient moves his/her neck.

c. Review of the ED MAR indicated that at 6:15 PM, the patient was given pain medication.

d. There was no documented pain reassessment sixty (60) minutes after pharmacological intervention.

11. Review of Medical Record #17 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 3/27/19 at 7:24 PM with complaints of a fall, abdominal pain and emesis.

b. A full triage was completed at 7:43 PM and an initial set of vital signs were taken. There was no pain assessment documented.

c. Vitals signs were taken subsequently at 8:09 PM, 10:14 PM and 11:41 PM. There was no pain assessment documented with each set of vital signs.

12. Review of Medical Record #18 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 3/27/19 at 8:30 PM with complaints of supraventricular tachycardia.

b. A full triage was completed at 8:46 PM and initial vital signs were taken. There was no pain assessment documented.

13. Review of Medical Record #19 on 5/8/19 revealed the following:

a. The patient arrived in the ED on 4/20/19 at 6:29 PM with complaints of attempting to kill his/herself by inhaling acetone, and if that did not work, would drink it mixed with bleach.

b. A full triage was completed at 6:36 PM.

c. Initial set of vital signs were taken at 7:14 PM.

d. There was no evidence of a pain assessment.

e. Review of ED Provider Notes on 4/21/19 at 6:30 AM states, "Patient complained of headache, given Tylenol with some improvement in pain. ..."

f. Review of the MAR indicated that the patient received Tylenol on 4/21/19 at 9:32 AM.

(i) There was no documented pain reassessment sixty (60) minutes after pharmacological intervention.

14. Review of Medical Record #20 on 5/9/19 revealed the following:

a. The patient arrived in the ED on 4/20/19 at 5:45 AM with complaints of chest pain.

b. A full triage was completed at 6:21 AM and initial vital signs were taken. The Head to Toe Assessment under HEENT [Head Eye Ear Nose and Throat] indicated that the patient had a headache; under Cardiac: Chest pain; under Genitourinary symptoms: pain with urination.

(i) There was no documented pain assessment for each area of concern.

c. Review of the ED MAR indicated that at 6:20 AM, the patient received pain medication.

(i) There was no documented pain reassessment sixty (60) minutes after pharmacological intervention.

15. Review of Medical Record #21 revealed the following:

a. The patient arrived in the ED on 4/20/19 at 11:40 PM with complaints of depression.

b. A full triage was completed at 11:44 PM.

c. Initial set of vital signs were taken at 12:05 AM.

d. There was no evidence of a pain assessment.

16. Review of Medical Record #22 revealed the following:

a. The patient arrived in the ED on 5/7/19 at 10:15 AM with complaints of a kidney stone since 4/23, and lower back pain for one month.

b. A full triage was completed at 10:33 AM.

c. Initial set of vital signs were taken at 10:19 AM.

d. There was no evidence of a pain assessment.

17. Review of Medical Record #24 on 5/8/19 revealed the following:

a. The patient arrived in the ED on 5/7/19 at 1:01 AM with complaints of hypertension (high blood pressure).

b. A full triage was completed at 1:46 AM and initial vital signs were taken. There was no pain assessment documented.

18. The above findings were confirmed by Staff #9.

B. Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure implementation of the policy and procedure on patients who leave the Emergency Department without being seen.

Findings include:

Reference #1: Facility policy titled "Left Without Being Seen" states, "... 1. The staff member discovering the patient's absence will notify the physician, the Charge Nurse, and the Clinical Nursing Coordinator... 2. The staff member discovering the patient's absence will enter the time of discovery, make three attempts to locate the patient, including immediate premise, and document their efforts in the patient's electronic medical record (EMR)..."

Reference #2: Facility policy titled "Emergency Nursing Standards of Care" states, "... Patients who decide to leave prior to being seen by a physician will have a brief triage addendum discussing why the patient left at the time of the elopement is identified (call name 3 times over 15-30 minutes and document not answer)."

1. Review of three (3) out of three (3) Medical Records (#27, #28 and #30), revealed the following:

a. Patient #27 arrived in the Emergency Department (ED) on 3/20/19 at 7:48 PM.

(i) Triage was started at 7:49 PM.

(ii) At 8:12 PM, the ED Event Log stated, "ED disposition was set to Left Without Being Seen."

(iii) Review of the medical record did not contain a triage addendum discussing why the patient left.

b. Patient #28 arrived in the ED on 4/9/19 at 2:41 PM.

(i) A full triage was completed at 2:59 PM.

(ii) At 4:57 PM, the ED Event Log stated, "ED disposition was set to Left Without Being Seen."

(iii) Review of nursing ED Notes states, "Pt [patient] was called 3x times in tirage [sic] no answer." This was electronically sign by the nurse at 4:57 PM.

(iv) There was no documented evidence that the patient was called three (3) times over 15-30 minutes.

c. Patient #30 arrived in the ED on 4/17/19 at 5:32 PM.

(i) Triage was started at 5:33 PM.

(ii) At 6:45 PM, the ED Event Log stated, "ED disposition was set to Left Without Being Seen."

(iii) Review of medical record did not contain a triage addendum discussing why the patient left.

2. The above findings were confirmed by Staff #3 and Staff #9.


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C. Based on staff interview, medical record review and review of facility documents, it was determined that the facility failed to implement its Patient Leaving Against Medical Advice (AMA) and Elopement/Missing Persons policies and procedures.

Findings include:

Reference #1: Facility policy and procedure titled "Patient Leaving Against Medical Advice (AMA)" states, " ...In instances of a patient who wants to leave against medical advice (AMA), the following actions will be taken immediately by the licensed healthcare professional responsible for the patient. ...3. Obtain the signature of the patient ...If the patient refuses to sign the release, document the refusal on the release form. If the departure against medical advice occurs in the Emergency Department, the appropriate EMTALA documentation must also be signed by the patient ..."

Reference #2: Facility policy and procedure titled "Elopement/Missing Person" states, " ...3. If the missing person is a patient who has eloped or wandered, nursing staff will: a. Immediately initiate a search of the unit and surrounding area. b. Notify the charge nurse, the nursing manager or off-shift nursing supervisor and the patient's physician. c. Ensure notification of the patient's family ...e. Nursing will ensure continuous communication with the patient's physician and family until it is determined that the patient is safe or a Missing Person's Report is filed with the appropriate law enforcement agency. ...9. Security will complete an incident report, procure copies of repots from all involved law enforcement/security agencies and forward same to the respective Risk Management Department. ..."

1. Upon review of Medical Record #26 on 5/9/19, the following was noted:

a. The patient arrived in the Emergency Department (ED) on 5/7/19 at 10:15 AM with complaints of a kidney stone on 4/23 and lower back pain for a month.

b. The ED Provider Notes-ED Notes at 10:40 AM stated, " ...The patient declines to have further medical evaluation and treatment and wishes to leave the Emergency Department. ... The patient voluntarily accepts these risks and a signed AMA form documenting our conversation was obtained. ..."
(i) There was no evidence of an AMA form/consent.

2. The above findings were confirmed by Staff #9.

3. Upon review of Medical Record #29 on 5/9/19, the following was noted:

a. The patient arrived in the ED on 3/30/19 at 7:52 PM. The patient was brought in by police; he/she was fighting with his/her parents and made a suicidal statement.

b. The ED Triage Notes at 8:20 PM stated, " ...Pt [patient] went toward bathroom and then went up the ramp out of sight of staff, security searching for pt."

c. At 9:01 PM, the ED Event Log stated, "ED disposition was set to Left Without Being Seen."

4. During an interview on 5/9/19 at 12:10 AM, Staff #4 stated that security was notified of the missing patient, but there was no evidence of the outcome of the patient search or if there was further reporting per policy and procedure.

5. The above findings were confirmed by Staff #3.

A. Based on review of medical records, staff interviews, and review of the Emergency Department (ED) Log, it was determined that the facility failed to ensure that all entries in the log are accurate.

Findings include:

1. Review of three (3) out of three (3) medical records (Medical Records #11, #20 and #26) on 5/9/19, revealed the following:

a. The ED log disposition for Patient #11 was blank.

(i) Review of medical record revealed that the patient left after triage.

(ii) Upon interview with Staff #3, it was confirmed that the disposition should be Left Without Being Seen (LWOBS).

b. The ED log disposition indicates that Patient #20 eloped.

(i) The ED Provider Notes on 4/20/19 at 6:07 AM stated, "... The patient voluntarily accepts these risks and a signed AMA form documenting our conversation was not obtained as patient left refusing to sign AMA paperwork."

(ii) Upon interview on 5/8/19, Staff #3 confirmed that the patient disposition should be "AMA refused to sign."


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c. Upon review of Medical Record #26 on 5/8/19, the ED log indicated that the patient eloped on 5/7/19.

(i) The ED Provider Notes - ED Notes on 5/7/19 at 10:40 AM stated, " ...The patient voluntarily accepts these risks and a signed AMA [Against Medical Advice] form documenting our conversation was obtained."

(ii) Upon interview on 5/8/19, Staff #9 confirmed that the ED log disposition should have read left AMA.

2. The above findings were confirmed by Staff #9.

B. Based on observation, staff interview, medical record review and review of facility documents, it was determined that the facility failed to ensure that an accurate Labor and Delivery (L&D) Triage Log is maintained.

Findings include:

1. A request was made to Staff #4 on 5/9/19 for the Labor and Delivery Triage Logs for the months of April and May of 2019. The triage log sheet was provided.

a. Review of the L&D Triage Log entries revealed the following:

(i) There was no evidence of a L&D Triage Log for the dates 4/1/19 or 4/11/19.

(ii) From 4/2/19 to 4/30/19, forty-five (45) out of two hundred and fifty-five (255) log entries were incomplete. Documentation regarding the patients name, time arrived, time in room, time seen by RN, time seen by Resident and/or MD and time discharged/admitted were missing.

(iii) From 5/1/19 to 5/9/19, fourteen (14) out of eighty (80) log entries were incomplete. Documentation regarding the patients name, time arrived, time in room, time seen by RN, time seen by Resident and/or MD and time discharged/admitted were missing.

2. The above findings were confirmed by Staff #4 and Staff #33.

Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that all Emergency Department (ED) patients receive an appropriate medical screening exam (MSE), which includes classification from the triage nurse based on the Emergency Severity Index (ESI).

Findings include:

Reference: Facility policy titled "Triage" states, "... Procedure: 1. Triage Nurse assessment shall include rapid, systemic collection of data related to the patient's chief complaint. Patients will receive a triage evaluation to determine the nature, seriousness, and level of acuity of their complaint. 2. The Triage Nurse obtains baseline information to include: a. Chief complaint b. History of present illness c. Allergies to food or medication d. Complete set of vital signs including: blood pressure, pulse... respiratory rate, pulse oximetry, and temperature. e. Pain assessment ... 3. Assessment will determine urgency of patient's need for emergency care. a. Gathers pertinent assessment data to determine an accurate rating according to ESI five levels triage standard..."

1. On 5/8/19, review of twelve (12) out of thirty (30) Medical Records (#1, #5, #6, #11, #12, #14, #15, #16, #17, #21, #23 and #27) on 5/9/19, revealed the patients were assigned an ESI level prior to a full triage evaluation, without a set of vital signs (to include blood pressure and pain assessment).

2. Upon interview on 5/8/19 at 10:03 AM, Staff #34 (triage nurse), stated his/her tasks are to complete a quick triage, pulse oximetry with heart rate; asks the complaints of pain with onset; if they have traveled; and if presenting with deficits, the patient will be assessed for signs and symptoms of stroke.

3. Upon interview, Staff #9 confirmed that ESI levels are established during quick triage. The triage nurse will assess the patient's chief complaint, heart rate, respirations and pulse oximetry; then an ESI will be given and the patient will be directed to the appropriate area based on ESI level assigned for full triage.

4. The above findings were confirmed by Staff #3.

Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment that will unduly discourage individuals from remaining for further evaluation.

Findings include:

Reference: Facility policy titled "Emergency Care & Transfer of Individuals with Emergency Medical Condition (EMTALA)" states, "... 3. ED personnel may not delay screening or stabilization services in order to inquire about an individual's method of payment or insurance status and may not seek, or direct a individual to seek, authorization from the individual's insurance company for screening or stabilization services... will not engage in any actions that discourage individuals from seeking emergency medical care such as by demanding that emergency department patients pay before receiving treatment..."

1. Review of seven (7) out of seven (7) medical records (#1, #6, #7, #10, #12, #16 and #27) on 5/9/19, indicated that full registration was completed prior to full triage.

a. Patient #1 arrived in the ED on 3/27/19 at 5:39 PM.

(i) A full triage was completed at 6:16 PM.

(ii) The Medical Screening Exam (MSE) was completed at 7:25 PM.

(iii) The full registration was completed at 5:51 PM.

b. Patient #6 arrived in the ED on 3/27/19 at 7:35 PM.

(i) A full triage was completed at 8:21 PM.

(ii) The MSE was completed at 9:24 PM.

(iii) The full registration was completed at 8:12 PM.

c. Patient #7 arrived to the L&D Unit for triage on 5/7/19 at 6:42 AM.

(i) The Consent For Treatment, Payment and Health Care Operations Including Admission And Medical Treatment Authorization, was signed by the patient at 6:43 AM.

(ii) The MSE was completed at 8:20 AM.

(iii) Interview with Staff #32 on 5/7/19 at 12:07 AM stated, when a patient arrives to the Labor and Delivery Unit (L&D) Triage, they are asked the reason for the visit, photo identification, and insurance card, then he/she informs the Triage nurse of the patient's arrival.

(iv) Staff #7 confirmed that a full registration was completed on Patient #7 prior to triage or MSE.

d. Patient #10 arrived to the L&D Unit for triage on 5/7/19 at 8:56 AM.

(i) The Consent For Treatment, Payment and Health Care Operations Including Admission And Medical Treatment Authorization, was signed by the patient at 8:56 AM.

(ii) The MSE was completed at 10:32 AM.

(iii) Interview with Staff #32 on 5/7/19 at 12:07 AM stated, when a patient arrives to the Labor and Delivery Unit (L&D) Triage, they are asked the reason for the visit, photo identification, and insurance card, then he/she informs the Triage nurse of the patient's arrival.

(iv) Staff #7 confirmed that a full registration was completed on Patient #10 prior to triage or MSE.

e. Patient #12 arrived in the ED on 12/10/19 at 5:58 PM.

(i) A full triage was completed at 6:19 PM.

(ii) The MSE was completed at 6:49 PM.

(ii) A full registration was completed at 6:10 PM.

f. Patient #16 arrived in the ED on 3/27/19 at 5:05 PM.

(i) A full triage was completed at 5:19 PM.

(ii) The MSE was completed at 6:10 PM.

(iii) The full registration was completed at 5:14 PM.

g. Patient #27 arrived in the ED on 3/20/19 at 7:48 PM.

(i) A full registration was completed at 7:53 PM.

(ii) The patient Left Without Treatment before full triage or before the MSE was conducted.

2. At 1:45 PM, upon interview, Staff #9 confirmed that insurance and patient identification information are obtained during full registration.

3. The above findings were confirmed by Staff #3.


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Based on medical record review and staff interview, it was determined that the facility failed to ensure that the Emergency Department Patient Transfer form is completed in its entirety for all patients transferred out of the Emergency Department (ED).

Findings include:

1. Upon review of Medical Record #19 on 5/9/19, the following was noted:

a. The Emergency Department Transfer Form was incomplete.

(i) The "Receiving Hospital Admitting Office Notified" with date and time, were blank.

(ii) The "Receiving Hospital Emergency Department Notified" with date and time, were blank.

(iii) The "Signature" with date and time, were blank.

(iv) The "Departure date and time" were blank.

b. The "Emergency Care and Transfers Individuals With Emergency Conditions (EMTALA)- Physician Certification Consent For Transfer" was incomplete.

(i) The "Name of Physician Certifying Transfer" was blank.

(ii) The "Physician's Signature" and the date/time were blank.

(iii) The "Patient (or Legally Responsible Individual Signing on Patient's Behalf)" was blank.

(iv) The "Witness" to the Patient's Signature with date and time, were blank.

2. Upon review Medical Record #21 on 5/9/19, the following was noted:

a. The Emergency Department Transfer Form was incomplete.

(i) The "Receiving Hospital Admitting Office Notified" with date and time, were blank.

(ii) The "Receiving Hospital Emergency Department Notified" with date and time, were blank.

(iii) The "Signature" with date and time were blank.

(iv) The "Departure date and time" were blank.

b. The "Emergency Care and Transfers Individuals With Emergency Conditions (EMTALA)- Physician Certification Consent For Transfer" was incomplete.

(i) The "Name of Physician Certifying Transfer" was blank.

(ii) The "Physician's Signature" and the date/time were blank.

(iii) The "Patient (or Legally Responsible Individual Signing on Patient's Behalf)" was blank

(iv) The "Witness" to the Patient's Signature with date and time, were blank.

3. The above findings were confirmed by Staff #4.