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Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring, and treatment for 2 of 21 (Patient #1 and 21) sampled patients.

The findings included:

Refer to A 2406.

Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition (EMC) were provided an appropriate and ongoing medical screening examination (MSE), monitoring, and treatment for 2 of 21 (Patient #1 and 21) sampled patients. .

The findings included:

1. Review of the hospital's policy "Emergency Medical Treatment and Active Labor (EMTALA)" revealed, "...Emergency Medical Condition [EMC] means..A medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain, psychiatric disturbances and/or symptoms of substance abuse] such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions; or...Serious dysfunction of any bodily organ or part...Medical Screening Examination [MSE] is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred...EMTALA Requirements...Provide an appropriate medical screening examination by a qualified medical professional, within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists...Note that an MSE is not an isolated event but it is an on-going process. Thus, the medical record must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, discharged, admitted or appropriately transferred..."

Review of the hospital's policy "Emergency Services Standards of Care Policy" revealed, "...Patients who present to Emergency Services will be provided an appropriate initial assessment by qualified personnel as defined by "Triage Assessment of Patients by Emergency Severity Index (ESI)," and follow the below...A Complete set of vital signs includes...Temperature...Heart Rate...Respiratory Rate...Blood Pressure...Pulse Oximetry...Pain...Notify ED physician, MLP (mid-level practitioner), or attending physician of continued or new abnormal vital signs or pain scale >5 as soon as possible...Procedure...ESI Level 3, 4, or 5 will have vital signs documented at least every 4 hours. Abnormal vital signs will be reassessed within 2 hours...Normal Vital Sign Ranges...Adults (> [greater than] 15 yrs [years])...HR [heart rate] (awake)...60-100...Resp. [respiratory] Rate...12-16...Blood Pressure Systolic Minimums...120 mm [millimeters] Hg [mercury]..."

Review of the hospital's policy "TRIAGE ASSESSMENT OF PATIENTS BY EMERGENCY SEVERITY INDEX (ESI)" revealed, "...Triage will involve a rapid, directed patient assessment which provides an assignment of an acuity level for each patient arriving in the unit...All EMS [emergency medical services] patients are to be triaged and assessment discussed with a provider before being placed in the waiting room due to bed availability in the department. Discussion should be documented in the EMR [electronic medical record]...High Risk Situation? Or Confused/Lethargic/Disoriented? Or Severe Pain/Distress..."

Review of the hospital's policy "Pain Management Program Policy" revealed, "...PURPOSE...To promote...A hospital-wide commitment to high quality, evidence-based, safe pain management for all patients...POLICY...To control or relieve the physical and psychosocial consequences associated with pain while maintaining the patient's level of function and overall quality of life...PROCEDURE/SPECIAL INSTRUCTIONS...The patient's self report of pain is accepted as the most reliable marker of the presence and extent of pain...Pain will be assessed on initial assessment...an ongoing reassessment of pain is performed on a regular basis utilizing appropriate, reliable, and valid pain assessment tools...Patient-specific pain management outcomes will be established and if not achieved will elicit a review and modification of the pain management plan..."

2. Medical record review for Patient #1 revealed the patient was a 61-year-old female and arrived at the Hospital's ED on 9/14/2021 at 4:59 AM via EMS. The patient's chief complaints were vomiting, weakness, and abdominal pain for 8 hours. The patient reported she had not felt well for the past week. EMS documentation revealed an intravenous (IV) access was started prior to arrival at the hospital's ED.

A triage assessment performed by Registered Nurse (RN) #1 began on 9/14/2021 at 5:10 AM. RN #1 assigned Patient #1 an acuity level of 3. RN #1 documented Patient #1 had gastrointestinal symptoms of abdominal pain, nausea, and vomiting. RN #1 documented Patient #1's pain level as a 9, on a scale of 0-10 with 10 being the most severe. Patient #1's vital signs were as follows: temperature 100.8 degrees Fahrenheit, heart rate 111, respiratory rate 22, blood pressure 172/96, and oxygen saturation level 99%. After triage, Patient #1 was taken to the waiting room. There was no documentation Patient #1's EMS assessment was discussed with a provider upon arrival to the hospital's ED or before the patient was placed in the waiting room.

Patient #1 received ondansetron (medication given to prevent nausea & vomiting) 4 milligrams intravenous (IV) push on 9/14/2021 at 5:28 AM for nausea/vomiting while in triage. There was no documentation of a reassessment of Patient #1's nausea/vomiting after the patient received the medication.

An electrocardiogram (EKG) was performed on 9/14/2021 at 6:10 AM which revealed sinus rhythm with a heart rate of 91 and showed abnormal R-wave progression (common EKG reading which could suggest an old anterior myocardial infarction [heart attack]) , early transition, and probable left ventricular hypertrophy (enlargement and thickening of the walls of the heart's main pumping chamber). There was no documentation an ED provider was notified of the abnormal findings of the EKG. There was no documentation Patient #1 received treatment for these abnormal findings.

A lipase level was drawn on 9/14/2021 at 6:14 AM with a result of 69 units/liter and a reference range of 13-44. (Lipase is an enzyme primarily produced by the pancreas, and an elevated level may indicate injury to cells in the pancreas). An alkaline phosphatase level was drawn with a result of 125 international units/liter and a reference range of 32-92 (elevated level may indicate damage to the liver). A carbon dioxide level was drawn with a result of 19 millimoles/liter and a reference range of 22-28. There was no documentation the ED provider was notified of the lab results. There was no documentation Patient #1 received treatment for the abnormal lab results.

A chest x-ray was performed on Patient #1 on 9/14/2021 at 6:15 AM which revealed bilateral pulmonary hyperinflation, consistent with underlying chronic obstructive pulmonary disease, in the lungs. Multiple surgical clips and many loops of gas-filled bowel were seen in the left upper quadrant of the abdomen on the x-ray.

The "Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment" dated 6/14/2021 at 6:25 AM was signed by Patient #1. The "Notice of Patient Rights and Responsibilities" dated 9/14/2021 at 6:25 AM was not signed by Patient #1, and "Unable to finish" was handwritten in the blank for the patient's signature. The "Notice of Communication Accessibility Services" dated 9/14/2021 at 6:25 AM was not signed by Patient #1, and "Pt [patient] unable to finish" was handwritten in the blank for the patient's signature.

Patient #1 received a normal saline bolus of 1000 milliliters IV on 9/14/2021 at 7:24 AM in the hospital ED's waiting area.

Patient #1's vital signs were taken again on 9/14/2021 at 8:31 AM and were as follows: temperature 96 degrees Fahrenheit, heart rate 110, respiratory rate 20, blood pressure 165/93, and oxygen saturation level of 99%.

There was no documentation Patient #1's heart rate greater than 100 was reassessed within 2 hours after the vital signs were taken at 5:10 AM or after the vital signs were taken at 8:31 AM.

There was no documentation of follow-up, assessment, examination, monitoring, or treatment related to Patient #1's pain.

Patient #1 left the Hospital ED on 9/14/2021 at 12:02 PM without being seen by a provider or receiving a MSE to determine if the patient had an emergency medical condition (7 hours and 3 minutes after arrival).

Medical record review for Patient #1 from Hospital #2 revealed Patient #1 presented to the Hospital #2 ED on 9/15/2021 at 8:49 PM with chief complaints of nausea, vomiting, and abdominal pain. Patient #1 was admitted to Hospital #2 for further evaluation and management of acute pancreatitis.

In an interview on 10/12/2021 at 10:32 AM, the ED Nursing Director stated that Patient #1 was brought into the ED via EMS to the triage room and then taken out into the waiting room where she stayed until she left the hospital. The ED Nursing Director stated that staff made rounds on patients in the waiting room depending on patient acuity. The ED Nursing Director stated that staff get vital signs on patients in the waiting room every 2-4 hours, and the patient's pain level was assessed with the vital signs. There was no documentation Patient #1's elevated heart rate was monitored every 2 hours. There was no documentation Patient #1's pain was reassessed after the initial assessment on 9/14/2021 at 5:10 AM with a pain level of 9 on a 0-10 scale.

In a phone interview on 10/13/2021 at 7:45 AM, Nurse Practitioner #1 stated the ED has been experiencing extended wait times. Nurse Practitioner #1 stated that she performed psychiatric rounds at 3:00 AM and then went to the desk at the main ED area. Nurse Practitioner #1 stated there was only one physician and herself from then until her replacement arrived at 6:00 AM to manage patient care. Nurse Practitioner #1 stated she could not specifically remember Patient #1, but she put a note in on every patient she had seen (there was no note for Patient #1). Nurse Practitioner #1 stated that if a patient was having a problem, the nurses could come to her for an order. Nurse Practitioner #1 stated she would not give any IV pain medications to a patient out in the lobby but would consider PO pain medications or Toradol (ketorolac) given intramuscularly (IM). There was no documentation Patient #1's pain was reassessed during the time in the hospital ED's waiting room while waiting to be seen by a provider.

In an interview on 10/13/2021 at 9:12 AM, the ED Medical Director stated when patients are out in the waiting room, the ED physicians have ordered Toradol to be given for patients in the waiting room who were experiencing severe pain. The ED Medical Director stated the ED tech would recheck vital signs on every patient depending on the patient acuity and would notify the triage nurse for any change or problem. There was no documentation Patient #1 received any reassessment of pain or received any medication for pain.

In a phone interview on 10/13/2021 at 9:36 AM, RN #1 stated an ED tech or nurse was assigned to the waiting room to round on patients in the waiting room. RN #1 stated the ED nurses sometimes do give oral pain medications for patients out in the waiting room, but the patients had to be seen by a provider first.

In a phone interview on 10/13/2021 at 9:45 AM, Licensed Practical Nurse (LPN) #1 stated she has been assigned to perform rounds on patients in the waiting room. LPN #1 stated she would get vital signs every 4 hours on patients who were assigned a level 3 acuity. LPN #1 stated she would report anything serious or any change in patient condition to the triage nurse.

In a phone interview on 10/13/2021 at 11:08 AM, Physician Assistant (PA) #1 stated the ED staff could not guarantee every patient would be seen by a provider within a certain time. PA #1 stated the providers would sometimes order acetaminophen or ibuprofen by mouth or Toradol IM for the patients in the waiting room who were experiencing severe pain.

In an interview on 10/13/2021 at 11:50 AM, the Patient Access Supervisor for the ED stated Patient #1 signed the consent to treat form but then told her she could not finish signing her paperwork. The Patient Access Supervisor for the ED stated she remembered Patient #1 because most patients do not stop signing paperwork in the middle and either sign all the paperwork or refuse to sign any of it. The Patient Access Supervisor for the ED stated she remembered Patient #1 was so sick and nauseated that she could not continue signing her paperwork.

The hospital failed to provide an appropriate and ongoing MSE, and failed to appropriately monitor Patient #1's nausea/vomiting and pain level before Patient #1 left the hospital on 9/14/2021 at 12:02 PM (7 hours and 3 minutes after arrival).

3. Medical record review for Patient #21 revealed the patient was a 55-year-old female and arrived at the Hospital's ED on 9/13/2021 at 4:03 PM in a private vehicle. The patient's chief complaints were nausea, headache, vomiting, and diarrhea. RN #2 also documented as a chief complaint, that Patient #21 "stated she can feel something crawling in her skin and seeds popped out of her skin."

A triage assessment performed by RN #2 began on 9/13/2021 at 4:45 PM. RN #2 assigned Patient #21 an acuity level of 3. RN #1 documented Patient #1 had gastrointestinal symptoms of diarrhea, nausea, and vomiting. Patient #2's vital signs were as follows: temperature 97.7 degrees Fahrenheit, heart rate 80, respiratory rate 17, blood pressure 191/102, and oxygen saturation level 95%. RN #2 documented Patient #21 was alert and oriented x 4 (person, place, time, and situation), but there was no documentation to address Patient #21's chief complaint that she could feel something crawling in her skin and seeds popping out of her skin.

Patient #21's vital signs were taken again on 9/13/2021 at 10:00 PM and were as follows: heart rate 72, blood pressure 173/107, and oxygen saturation level of 97%. There was no documentation provided that temperature, respiratory rate, or pain level was monitored.

There was no documentation Patient #21's vital signs were rechecked on 9/13/2021 from 4:45 PM to 10:00 PM (5 hours and 15 minutes) or were rechecked after 10:00 PM to the time she left the ED on 9/14/2021 at 4:26 AM (6 hours and 26 minutes).

There was no documentation Patient #21's abnormal blood pressure (191/102 at 4:45 PM and 173/107 at 10:00 PM) was rechecked every 2 hours or was addressed. There was no documentation Patient #21's abnormal blood pressure was communicated to the ED Provider.

There was no documentation of follow-up, assessment, examination, monitoring, or treatment related to Patient #21's diarrhea, nausea, vomiting, or mental health status.

Patient #21 left the Hospital ED on 9/14/2021 at 4:26 AM without being seen by a provider or receiving a MSE to determine if the patient had an emergency medical condition (12 hours and 23 minutes after arrival).

In an interview on 10/13/2021 at 12:20 PM, the ED Nursing Director stated the ED staff member checking vital signs out in the lobby would receive an alert in the computer if the patient's systolic blood pressure was greater than 180 or the diastolic blood pressure was greater than 100. The ED Nursing Director stated the ED staff member should notify the ED physician if a patient's blood pressure exceeded the parameters and document the notification of the physician in the medical record.

The hospital failed to provide an appropriate and ongoing MSE, and failed to appropriately monitor and address Patient #21's abnormal blood pressure, diarrhea, nausea, vomiting, and mental health status before Patient #21 left the hospital on 9/14/2021 at 4:26 AM (12 hours and 23 minutes after arrival).