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Based on record reviews and interview, the hospital failed to ensure that an appropriate medical screening examination was provided within the capability of the emergency department (ED) by failing to triage patients upon arrival to the ED to determine if an emergency medical condition existed as required by hospital policy for 11 of 17 sampled patients (#F2, #F4, #F5, #F6, #F7, #F9, #F10, #F12, #F13, #F14, #F15). Findings:

Patient #F2
Review of Patient #F2's ED medical record revealed that he was a 21 year old male who presented to the ED on 09/18/12 at 1531 (3:31pm) and LWBS at 1632 (4:32pm). Review of the information sheet completed by Patient #F2 revealed he had "dehydrated numbness in legs neck and fingers". Further review revealed no documented evidence that he was triaged upon his arrival to the ED and prior to his leaving without being seen 26 minutes after he had arrived.

Patient #F4
Review of Patient #F4's medical record revealed that she was a 76 years old female who presented to the ED on 09/16/12 at 2208 (10:08pm) and LWBS on 09/16/12 at 2250 (10:50pm). Review of the information sheet completed by Patient #F4 revealed the reason for her visit was "BP (blood pressure) low". Further review revealed no documented evidence that she was triaged upon her arrival to the ED and prior to her leaving without being seen 42 minutes after she had arrived.

Patient #F5
Review of Patient #F5's medical record revealed that she was a 22 months old female who presented to the ED on 09/16/12 at 2027 (8:27pm) and LWBS on 09/16/12 at 2234 (10:34pm). Review of the information sheet completed by Patient #F5's attendant revealed she was "stabed (stabbed) in back of throat then had a nose bleed and choking". Further review revealed no documented evidence that she was triaged upon her arrival to the ED and prior to her leaving without being seen 2 hours and 7 minutes after she had arrived.

Patient #F6
Review of Patient #F6's ED medical record revealed that she was a 22 year old female who presented to the ED on 09/15/12 at 1241 (12:41pm). Further review revealed that her chief complaint was foot pain. Further review revealed she was triaged at 1309 (1:09pm), 28 minutes after she had arrived rather than upon her arrival as required by hospital policy.

Patient #F7
Review of Patient #F7's medical record revealed she was a 7 years old female who presented to the ED on 09/15/12 at 2111 (9:11pm) and LWBS on 09/15/12 at 2229 (10:29pm). Review of the information sheet completed by Patient #F7's attendant revealed she had a "sprained or fractured ankle (left)". Further review revealed no documented evidence that she was triaged upon her arrival to the ED and prior to her leaving without being seen 1 hour and 18 minutes after she had arrived.

Patient #F9
Review of Patient #F9's medical record revealed that she was a 19 years old female who presented to the ED on 09/15/12 at 1354 (1:54pm) and LWBS on 09/15/12 at 1611 (4:11pm) and 1622 (4:22pm) (name listed twice on the ED Central Log with 2 different times of LWBS). Review of the information sheet completed by Patient #F9 revealed that her complaint was "risen under arm pit. hole in back left tooth". Further review revealed no documented evidence that she was triaged upon her arrival to the ED and prior to her leaving without being seen 2 hours and 17 minutes after she had arrived.

Patient #F10
Review of Patient #F10's ED medical record revealed that he was a 23 months old male who presented to the ED on 09/15/12 at 1309 (1:09pm). Further review revealed that his chief complaint was diarrhea. Further review revealed that he was triaged at 1343 (1:43pm), 34 minutes after he had arrived rather than upon his arrival as required by hospital policy.

Patient #F12
Review of the ED record for Patient #F12 revealed the patient was a 6 year old female who arrived at the ED on 09/18/12 at 11:31 (11:31 a.m.) with a presenting complaint of fever. Review of the Emergency Department Nursing Medical Record revealed the patient was triaged on 09/18/12 at 11:55 (11:55 a.m.), 24 minutes after arriving at the ED, rather than upon arrival as required by hospital policy.

Patient #F13
Review of the ED record for Patient #F13 revealed the patient was a 3 year old female who arrived at the ED on 09/17/12 at 18:55 (6:55 p.m.) with a presenting complaint of a laceration to the head. Review of the Emergency Department Nursing Medical Record revealed the patient was triaged on 09/17/12 at 19:23 (7:23 p.m.), 28 minutes after arriving at the ED, rather than upon arrival as required by hospital policy.

Patient #F14
Review of the Emergency Department (ED) record for Patient #F14 revealed the patient was a 33 year old female who arrived at the ED on 09/16/12 at 21:28 (9:28 p.m.) and LWBS at 10:50 p.m. The record revealed no documented evidence of a triage assessment upon arrival to the ED and prior to leaving without being seen 1 hour and 22 minutes after she had arrived.

Patient #F15
Review of the ED record for Patient #F15 revealed the patient was a 4 year old male who arrived at the ED on 09/16/12 at 2117 (9:17 p.m.) with a presenting complaint of facial pain after being hit in the face. Review of the Emergency Department Nursing Medical Record revealed the patient was triaged on 09/16/12 at 22:27 (10:27 p.m.), 1 hour and 10 minutes after arriving at the ED, rather than upon arrival as required by hospital policy.

In a face-to-face interview on 09/19/12 at 2:10pm, Assistant Director of Nursing (ADON) SF2 indicated that the process for triaging patients who present to the ED was for the RN (registered nurse) to triage the patient upon arrival. She further indicated that if a patient was in acute distress, the RN would bring the patient directly to the ED room, and if the patient was not in acute distress, the RN would take the patient to the triage room to be triaged. SF2 indicated that the triage RN also performs direct care to patients in the ED, and there were 2 RNs scheduled in the ED. She further indicated that during peak times, she would assist in ED, and at night a LPN (licensed practical nurse) could be pulled to assist with skills in order to allow the RN time to perform patient triage. SF2 indicated that a patient should be triaged within 15 minutes upon arrival. After reviewing the hospital policy, SF2 indicated that according to hospital policy, patients should be triaged upon their arrival to the ED. She further indicated that she couldn't explain the delay in patients being triaged or not being triaged at all prior to leaving without being seen.

In a face-to-face interview on 09/19/12 at 3:20pm, ADON SF2 indicated that all of the nursing staff had been educated after the last survey on the medical screening exam requirements and the revised hospital policies. Review of the list of RNs who could be assigned to work in the ED and the signature list for the mandatory education that was to be completed by 09/10/12 that was presented by ADON SF2 during this interview revealed 5 of the 20 RNs had not received the education as evidenced by no documentation of their signature on the sign-in sheet for education.

Review of the hospital policy titled "Triage", Reference #2005, effective 07/24/12, and presented by ADON SF2 as the current policy, revealed, in part, "...The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories. ... All patient information is documented in the patient's medical record. ... In the event the Triage RN is unable to do triage, a call shall be placed to the Nursing Supervisor to assist with triage, until the Triage RN is available..."

Review of the hospital policy titled "EMTALA Guidelines For Emergency Department Services", Reference #2302, revised 08/17/12, and presented as a current policy by ADON SF2, revealed, in part, "...Medical Screening Exam (MSE): Performed by the ED Physician. The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. ... All patients presenting to Hood Memorial Hospital Emergency seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated (MSE) ... All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. ...Medical Screening Exams (MSE): Medical Screening Exams should include at a minimum the following: Emergency Department Log entry including disposition of patient Patient's triage record ... Complete documentation of the medical screening exam..."

Based on record reviews and interviews, the hospital failed to maintain a complete and accurate emergency department central log on each individual who came to the emergency department. The emergency department log did not contain all required elements according to the hospital's policy for 11 of 17 sampled patients and 4 of 4 random patients reviewed for completion of the emergency department central log (#F1, #F2, #F4, #F5, #F7, #F8, #F9, #F13, #F14, #F15, #F16, #RF1, #RF2, #RF3, #RF4). Findings:

Patient #F1
Review of Patient #F1's medical record revealed that she was a 6 month old female who presented to the Emergency Department (ED) on 09/18/12 at 1735 (5:35pm). Review of the ED Central Log revealed that Patient #F1 LWBS (left without being seen) on 09/18/12 at 1930 (7:30am), while the medical record revealed there was no answer from Patient #F1 when called at 1846 (6:46pm).

Patient #F2
Review of Patient #F2's medical record revealed that he was a 21 year old male who presented to the ED on 09/18/12 at 1531 (3:31pm) and LWBS at 1632 (4:32pm). Review of the ED Central Log revealed no documented evidence of Patient #F2's chief complaint, triage acuity, mode of arrival, and the name of the physician that are all elements required to be entered in the log by the hospital policy.

Patient #F4
Review of Patient #F4's medical record revealed that she was a 76 years old female who presented to the ED on 09/16/12 at 2208 (10:08pm) and LWBS on 09/16/12 at 2250 (10:50pm). Review of the ED Central Log revealed no documented evidence of Patient #F4's chief complaint, triage acuity, mode of arrival, and the name of the physician that are all elements required to be entered in the log by the hospital policy.

Patient #F5
Review of Patient #F5's medical record revealed that she was a 22 months old female who presented to the ED on 09/16/12 at 2027 (8:27pm) and LWBS on 09/16/12 at 2234 (10:34pm). Review of the ED Central Log revealed no documented evidence of Patient #F5's chief complaint, triage acuity, mode of arrival, and the name of the physician that are all elements required to be entered in the log by the hospital policy.

Patient #F7
Review of Patient #F7's medical record revealed she was a 7 years old female who presented to the ED on 09/15/12 at 2111 (9:11pm) and LWBS on 09/15/12 at 2229 (10:29pm). Review of the ED Central Log revealed no documented evidence of Patient #F7's chief complaint, triage acuity, and mode of arrival that are all elements required to be entered in the log by the hospital policy.

Patient #F8
Review of Patient #F8's medical record revealed that he was a 78 years old male who presented to the ED on 09/15/12 at 1940 (7:40pm) and was discharged home. Review of the ED Central Log revealed no documented evidence of Patient #F8's chief complaint that was a required element to be included in the log by the hospital policy.

Patient #F9
Review of Patient #F9's medical record revealed that she was a 19 years old female who presented to the ED on 09/15/12 at 1354 (1:54pm) and LWBS on 09/15/12 at 1611 (4:11pm) and 1622 (4:22pm) (name listed twice on the ED Central Log with 2 different times of LWBS). Review of the ED Central Log revealed no documented evidence of Patient #F9's chief complaint, triage acuity, mode of arrival, and the name of the physician that are all elements required to be entered in the log by the hospital policy.

Patient #F13
Review of Patient #F13's medical record revealed that she was a 6 year old female who presented to the ED on 09/17/12 at 18:55 (6:55 p.m.) and was discharged at 21:44 (9:44 p.m.). Review of the ED Central Log revealed no documented evidence of Patient #F13's triage acuity, a required entry in the log by the hospital policy.

Patient #F14
Review of Patient #F14's medical record revealed that she was a 33 years old female who presented to the ED on 09/16/12 at 21:28 (9:28 p.m.) and LWBS on 09/16/12 at 10:50 p.m. Review of the ED Central Log revealed no documented evidence of Patient #F14's chief complaint, triage acuity, mode of arrival, and the name of the physician that are all elements required to be entered in the log by the hospital policy.

Patient #F15
Review of Patient #F15s medical record revealed that he was a 4 year old male who presented to the ED on 09/16/12 at 21:17 (9:17 p.m.) and was discharged at 00:45 (12:45 a.m.). Review of the ED Central Log revealed no documented evidence of Patient #F14's triage acuity, a required entry in the log by the hospital policy.

Patient #F16
Review of Patient #F16's medical record revealed that he was a 24 year old male who presented to the ED on 09/16/12 at 00:07 (12:07 a.m.) and signed out against medical advice (AMA) at 0107 (1:07 a.m.). Review of the ED Central Log revealed no documented evidence of Patient #F2's chief complaint, a required entry in the log by the hospital policy.


Patient RF1
Review of the ED Central Log revealed Patient RF1 was a 69 year old female who arrived at the ED on 09/15/12 at 06:04 (6:04 a.m.) by ambulance with a presenting complaint of Fall and was discharged on 09/15/12 at 10:23 a.m. There was no documented evidence of the triage acuity, a required entry in the log by the hospital policy.

Patient RF2
Review of the ED Central Log revealed Patient RF2 was a 65 year old male who arrived at the ED on 09/16/12 at 19:49 (7:49 p.m.) and was discharged on 09/16/12 at 23:15 (11:15 p.m.) There was no documented evidence of the presenting complaint, a required entry in the log by the hospital policy.

Patient RF3
Review of the ED Central Log revealed Patient RF3 was a 16 year old male who arrived at the ED on 09/17/12 at 22:05 (10:05 p.m.) and was discharged on 09/17/12 at 23:55 (11:55 p.m.) There was no documented evidence of the presenting complaint, a required entry in the log by the hospital policy.

Patient RF4
Review of the ED Central Log revealed Patient RF4 was a 16 year old male who arrived at the ED on 09/19/12 at 09:05 (9:05 a.m.) a presenting complaint of Seizure and was discharged on 09/19/12 at 10:44 a.m. There was no documented evidence of the triage acuity, a required entry in the log by the hospital policy.

In a face-to-face interview on 09/19/12 at 2:10pm, Assistant Director of Nursing (ADON) SF2 indicated that the blanks on the ED Central Log were probably due to the missing information not being documented in the patient's medical record, because the log was automatically generated from information in the computer and was not entered by a staff member. She further indicated that she had pulled an ED Central Log and noticed that there were blanks, and as a result she had sent a memo to staff members reminding them about the need to have a complete and accurate ED Central Log.

In a face-to-face interview on 09/19/12 at 3:20pm, ADON SF2 presented the memo that she sent to the staff as noted in the previous interview. Review of the memo dated 08/22/12 revealed that it was summary of problems that were identified during the previous survey and not a result of a review of incomplete and inaccurate entries in the ED Central Log. After review of the memo that she presented, SF2 indicated that the memo was a result of her review of the log but confirmed that the memo didn't look like it was generated as a result of the review of the log.

In a face-to-face interview on 09/19/12 at 3:50pm, ADON SF2 indicated that after further review, she had seen the ED Central Log when the CMR (ED computer software system) personnel were at the hospital doing education on the new system and not as a result of her printing the log to review for completion. She further indicated that the memo dated 08/22/12 was not a result of her addressing the incomplete and inaccurate ED Central Log with the ED staff.

Review of the hospital policy titled "Emergency Department Central Log", Reference 2300, effective 08/17/12, and presented as the current policy by ADON SF2, revealed, in part, "...1. The central log is now maintained electronically in the CMR system. The central log will include an entry for every patient that comes to Hood Memorial Hospital ED seeking treatment. 2. The patient entry into the central log is captured upon initial quick registration by the ED clerk/ED nurse. ... 3. The Electronic Central Log components include: a. Arrival Time b. Visit ID c. Patient Name d. Presenting Complaint e. Triage Acuity f. Age g. Sex i. MOA (Mode of Arrival) j. Physician k. Disposition-Discharge, admitted, expired, transferred, AMA (against medical advice), LWBS, Elopement.. l. D/C (discharge) Date Time m. Diagnosis. ... 5. The Electronic Central Log will be reviewed on a monthly basis by the Director of Nurses or designee during her absence to monitor for completeness, missing information or gaps in entries..."



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