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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Emergency Services was out of compliance.

A-1104 - (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. Based on observations, interviews and record review, the facility failed to establish policies and procedures for patients receiving care in the Emergency Department (ED) waiting room. Additionally, the facility failed to ensure patients treated in the ED waiting room were monitored in three of four medical records reviewed (Patient #2, #3, and #6).

Based on observations, interviews and record review, the facility failed to establish policies and procedures for patients receiving care in the Emergency Department (ED) waiting room. Additionally, the facility failed to ensure patients treated in the ED waiting room were monitored in three of four medical records reviewed (Patient #2, #3, and #6).

Findings include:

Facility policy:

The Emergency Department Assessment/Reassessment policy read, all patients' vital signs will be repeated prior to discharge.

1. The facility failed to ensure processes were established to ensure patients received safe care in the ED waiting room.

a. On 1/17/23, policies in regards to patients receiving care in the waiting room were requested from the facility.

i. On 1/17/23 at 2:15 p.m., an interview was conducted with the director of quality (Director) #1. Director #1 stated there was no policy to dictate care performed in the emergency department waiting room.

ii. On 1/17/23 at 2:30 p.m., an interview was conducted with the director of the ED (Director) #2. Director #2 stated the process for treating and monitoring patients in the waiting room was the same as patients treated in an ED room.

Director #2 further explained patients with an emergency severity index (ESI) score (a score used to determine a patient's severity or acuity of condition) of 3, 4, or 5 would potentially be appropriate to receive care in the waiting room. Director #2 stated there was not a policy on the triage or ESI process to demonstrate the facility's process in determining the acuity of a patient.

2. The facility failed to ensure patients were assessed and monitored while receiving care in the ED waiting room.

a. On 1/17/23 at 10:45 a.m., an observation was conducted of the ED waiting room. Observations revealed Patient #2 was receiving intravenous (IV) fluids in the waiting room.

i. Review of Patient #2's medical record revealed vital signs were obtained for the patient at 9:53 a.m. Patient #2 was discharged at 11:56 a.m. There was no additional documentation of vital signs or reassessment for the patient prior to discharge.

b. Additional medical record reviews revealed similar findings.

i. On 12/17/22 Patient #3 presented to the ED with complications from a wound VAC (a method of decreasing air pressure around a wound to assist the healing). The medical record revealed the patient received their care in the ED waiting room. At 11:09 p.m., vital signs were obtained on the patient. At 12:54 a.m., Patient #3 was discharged. There was no evidence additional vital signs were obtained while the patient received care in the waiting room.

ii. On 12/12/22, Patient #6 presented to the ED with back and abdominal pain. Patient #6 was diagnosed with kidney stones. According to Patient #6's record, she received care in the ED waiting room. Review of Patient #6's medical record revealed vital signs were obtained at 7:43 a.m. Patient #6 was discharged at 11:51 a.m. There were no additional vital signs documented in the patient's record.

c. On 1/17/23 at 2:30 p.m. an interview was conducted with Director #2. Director #2 stated the process for treating and monitoring patients in the waiting room was the same as patients treated in an ED room. Director #2 further stated it was the expectation for patients to have vital signs obtained prior to discharge.

The record reviews were in contrast to facility policies and interviews which stated vital signs were to be obtained prior to discharge.