HospitalInspections.org

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Based on interview, record review, document review, and review of the hospital's policies and procedures, the hospital failed to ensure adequate and qualified staff for the provision of emergency care.

Failure to provide adequate and qualified staff for the delivery of emergency care places patients at risk for delays in treatment and suboptimal outcomes.

Findings included:

1. Failure to assume care of patients seeking emergency services.

Cross-reference A 1112

Due to the scope and severity of deficiencies cited under 42 CFR 482.55, the Condition of Participation for Emergency Services WAS NOT MET.
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Based on observation, interview, and document review, the hospital failed to accept care of patients arriving by ambulance and provide a triage and continual monitoring at the time of arrival on hospital property in 5 of 32 patients reviewed (Patients #1, #17, #26, #27, #32).

Failure to ensure timely triage, monitoring, and prioritization of the MSE risks delays in treatment and suboptimal outcomes.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment & Labor Act (EMTALA)," policy number 13340714, last approved 03/21/23, showed that the triage, MSE, or necessary stabilizing treatment are not to be delayed. The record must reflect continued monitoring according to the patient's needs and must continue until they are stabilized or appropriately transferred or discharged.

Review of the hospital's policy titled, "Triage - Emergency Center," policy 8478585, last revised 09/08/20, showed that upon presenting to the ED, patients shall be evaluated to determine the appropriate priority in which they will be seen for an emergency medical exam (MSE). A patient may be triaged either as a walk-in at triage or at the bedside.

The hospital uses the 5 category Emergency Severity Index (ESI) triage system to prioritize resources. The levels include:

Level 1 - Life threatening
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Routine
Level 5 - Non-Urgent

2. The investigator reviewed medical records and prehospital patient care records (PCRs) for patients who received care in the ED with the Director of Quality (Staff #9). The documentation showed the following:

PATIENT #1

a. Emergency medical service (EMS) documentation showed that Patient #1 arrived at the hospital via ambulance on 11/21/23 at 2:56 PM. The hospital documentation showed that hospital staff acknowledged Patient #26's ED arrival at 2:59 PM. Patient #1 complained of a ground-level fall and subsequent left shoulder pain. The patient remained on the emergency medical services (EMS) gurney without nursing care, hospital monitoring, triage, or MSE until 4:03 PM, 1 hour and 4 minutes after arrival at the hospital. Patient #1 was assigned an initial ESI of 3. After the patient's MSE, the patient's listed diagnosis was a shoulder dislocation and fracture.

b. The investigator selected additional patients to review from the same date and timeframe as Patient #1's encounter. The 2 additional medical records showed the following:

On 11/21/23 at 3:01 PM, Patient #14 arrived by private vehicle and entered the ED waiting area with the primary complaint of abdominal pain. The hospital immediately assumed care and the patient was triaged by a nurse at 3:02 PM and assigned an ESI 3 by 3:04 PM. The patient was prioritized by ESI, per hospital protocol and received a medical screening exam at 3:50 PM.

By contrast, Patient #1 had arrived 2 minutes earlier but was not triaged and assigned a priority until 4:03 PM. The patient's ESI priority was evaluated as equivalent to Patient #14 (both ESI 3). However, Patient #1 received her triage and ESI approximately an hour later than Patient #14 and subsequently was prioritized for MSE after Patient #14 and did not receive an MSE until 4:15 PM.

Additionally, on 11/21/23 at 3:17 PM, Patient #15 arrived by private vehicle and entered the ED waiting area with the primary complaint of wrist pain after a fall. The hospital immediately assumed care and the patient was triaged by a nurse at 3:18 PM and assigned an ESI of 4. During this time, Patient #1 continued to wait in the breezeway of the hospital without being prioritized for a MSE or monitored for change in condition.

PATIENT #17

c. EMS documentation showed that Patient #17 arrived at the hospital via ambulance on 01/12/24 at 10:27 AM. The hospital documentation showed that hospital staff acknowledged Patient #17's ED arrival at 10:32 AM. Patient #17 complained of a fall on ice and a subsequent ankle injury. The patient remained on the emergency medical services (EMS) gurney without nursing care, hospital monitoring, triage, or MSE until 11:12 AM, 40 minutes after arrival at the hospital. Patient #17 was assigned an ESI of 3. The MSE was completed, and the patient was diagnosed with a fractured lower extremity.

The investigator selected an additional patient to review from the same date and timeframe as Patient #17's encounter. The additional medical record showed that on 01/12/24 at 10:31 AM, Patient #18 arrived by private vehicle and entered the ED waiting area with the primary complaint of heart palpitations. The patient was triaged and prioritized as an ESI 3 at 10:36 AM, 5 minutes after arrival. In contrast, Patient #17 arrived within a minute of Patient #18 but care was not assumed or prioritized for 40 minutes.

PATIENT #26

d. EMS documentation showed that Patient #26 arrived at the hospital via ambulance on 01/21/24 at 4:34 PM. The hospital documentation showed that hospital staff acknowledged Patient #26's ED arrival at 4:38 PM. Patient #26 complained of a recent fall and subsequent head injury. By 5:37 PM, 59 minutes after the initial request for emergency services, the patient remained in the hospital breezeway and continued to wait to be triaged and prioritized for an MSE. The patient told ambulance staff that her pain was increasing, and she was also having pain on the right side of her chest. The patient requested to be taken to a hospital that could provide care.

The ambulance staff checked-in with the charge nurse again to verify that they couldn't assume care for Patient #26. Upon confirmation, the ambulance staff transported the patient to another hospital in the area to receive care. The hospital and ambulance documentation both indicated that the patient was at the hospital but that the hospital did not assume care, triage to prioritize the MSE, or provide monitoring for changes in condition.

PATIENT #27

e. EMS documentation showed that Patient #27 arrived at the hospital via ambulance on 01/24/24 at 1:04 PM. The hospital documentation showed that hospital staff acknowledged Patient #27's ED arrival at 1:06 PM. Patient #27 arrived at the ED via ambulance with the primary complaint of a witnessed seizure (disrupted brain activity that leads to involuntary movements or loss of consciousness) and fall.

The ambulance documentation showed that the ambulance staff held the patient in the breezeway until 1:41 PM, 35 minutes. The ambulance documentation also showed that the patient's condition improved while she awaited care and the ambulance staff handed over care to the charge nurse and the hospital assumed care at that time. Hospital documentation of a triage, monitoring, or MSE could not be found. The patient's disposition was updated to left without being seen and before triage at 9:43 PM by an ED nurse, 8 hours and 37 minutes after patient arrived.

PATIENT #32

f. On 01/30/24 at 2:50 PM, the investigator conducted observations in the ED and reviewed the medical record and prehospital PCR of Patient #32. The observations, interviews, and documentation showed the following:

EMS documentation showed that Patient #32 arrived at the hospital via ambulance on 01/30/24 at 2:35 PM. The hospital documentation showed that hospital staff acknowledged Patient #32's ED arrival at 2:38 PM. Patient #32 arrived at the ED via ambulance with the primary complaint of an unwitnessed fall and head injury.

On 01/30/24 at 2:50 PM, the investigator observed Patient #32 on an ambulance gurney in the ED breezeway with an emergency medical service (EMS) staff member (Staff #17). Staff #17 stated that her patient had not been triaged by a nurse.

On 01/30/24 at 3:00 PM, the investigator interviewed the charge nurse (Staff #16) on duty regarding Patient #32 observed on a gurney in the breezeway. Staff #16 confirmed that the hospital had not assumed care of Patient #32 in the breezeway because they were waiting for a bed and a nurse to become available. Staff #16 also confirmed that the patient had not been triaged or assigned an ESI number to prioritize his MSE. The investigator asked to interview the triage nurse for the patients arriving by ambulance. Staff #16 informed the investigator that they did not have a position of triage nurse for patients arriving by ambulance. Staff #16 confirmed that the hospital was not currently on diversion status.

The EMT stayed with the patient in the breezeway without a triage, monitoring, or MSE until 4:25 PM, 1 hour and 47 minutes after arriving at the hospital.

3. On 01/22/24 at 4:00 PM, the investigator interviewed the registrar (Staff #14). Staff #14 confirmed that the patient arrival time recorded by registration reflected the time the patient arrived in the ambulance bay or entered through the waiting room entrance.

4. On 11/23/24 beginning at 10:30 AM, the investigator interviewed the Quality Manager (Staff #9). Staff #9 confirmed the patient timelines found in the medical record for arrival, triage, ESI, and MSE for Patients #1, #14, #15, #17, #26, #27 and #32.

5. On 01/22/24 at 12:15 PM, the investigator interviewed 2 ED physicians (Staff #7, Staff #8) regarding patient care concerns in the ED. Staff #7 stated that they were concerned about their patients that remained in the ambulances and breezeway because they hadn't been evaluated and weren't being monitored by their triage nurse or a provider. Staff #8 verbally agreed with this concern and added that some charge nurses would try to go out to the ambulances to visually assess a patient, but they often had their own patients and weren't able to go to the ambulances.

6. On 01/22/24 at 12:20 PM, the investigator interviewed the charge nurse (Staff # 12) who verified the concerns presented by Staff #7 and Staff #8 and stated that there wasn't a nurse available to care for all the patients who came by ambulance.
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