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Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. Cross reference to A2404.

2. The hospital failed to ensure the nursing staff failed to perform an accurate and thorough triage assessment upon arrival to the ED for one of 20 sampled patients (Patient 1). Cross reference to A2406.

3. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for two of 20 sampled patients (Patients 1 and 14). Cross reference to A2407.

Based on interview and record review, the hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC as evidenced by:

1. The Anesthesia Call Panel did not include the individual physician's contact information.

2. The Gynecology Call Panel did not clearly identify the on-call physician by including the individual physician's name and their contact information.

These failures could result in the delay in the stabilizing treatments and substandard health outcomes to the patients.

Findings:

Review of the hospital's General Rules & Regulations of the Medical Staff, subsection of Emergency Medicine with a review date of November 2020 showed the hospital shall maintain a daily roster of the following physician specialist who must be on-call at all times and available to come into the hospital. The required Back-Up Panel coverage includes the following specialists: anesthesiologist and gynecologist.

On 10/16/24 at 1009 hours, an interview and concurrent review the General Rules & Regulations of the Medical Staff, Subsection of Emergency Medicine and the 2024 Anesthesia and Gynecology Call Panel was conducted with the Director of Medical Staff Services.

The Director of Medical Staff Services stated the ED required the back-up panel coverage included Anesthesia and Gynecology.

1. Review of the Anesthesia Call Panel showed the following:

- For May 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, 4, and 5 were not available.

- For June 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available.

- For July 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available.

- For August 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, 4, and 5 were not available.

- For September 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available.

- For October 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available.

The Director of Medical Staff Services confirmed the Anesthesia Call Panel did not include the individual physician's contact information.

2. Review of the Gynecology Call Panel showed the following:

- For May 12, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician's name and their contact information.

- For August 15, 16, and 18, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician's name and their contact information.

- For September 12, 13, 18, and 19, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician's name and their contact information.

- For October 6, 10, and 11, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician's name and their contact information.

The Director of Medical Staff Services confirmed the Gynecology Call Panel did not show there was an on-call physician for May 12; August 15, 16, and 18; September 12, 13, 18, and 19; and October 6, 10, and 11, 2024. The Gynecology Call Panel did not identify the individual physician's name and their contact information.

On 10/16/24 at 1218 hours, the CNO was interviewed about the Anesthesia and Gynecology Call Panel.

The CNO confirmed the Anesthesia Call Panel did not include the individual physician's contact information. The CNO stated the ED nurses did not have access to the direct telephone number of the physicians on the Anesthesia Call Panel and only the House Supervisor had access.

The CNO acknowledged the Gynecology Call Panel did not show there was an on-call physician for May 12; August 15, 16, and 18; September 12, 13, 18, and 19; and October 6, 10, and 11, 2024. The Gynecology Call Panel did not identify the individual physician's name and their contact information.

Based on interview and record review, the hospital failed to ensure the ED Central Log was accurately maintained for 14 of 20 sampled patients (Patients 1, 2, 3, 4, 8, 10, 11, 14, 15, 16, 17, 18, 19, and 20). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED for the treatments of their emergency medical conditions.

Findings:

Review of the hospital's P&P titled Log, Emergency Department dated June 2022 showed in part:

* Purpose: To provide method of documentation of all patients presented to the Emergency Department (ED) seeking care.

* Scope: Emergency Department Nursing Staff.

* Policy: It is the policy of this hospital that all patients that come seeking care will be documented in the ED patient log, as well as those patients that are dead on arrival shall be entered in the log, to comply with the state and county requirements.

* Procedure: An ED Central Log shall be maintained by the Emergency Department. It shall contain at least the following information on each patient who presents seeking care to the hospital ED.

- Name
- Arrival date
- Arrival time
- Means of arrival
- Age
- Sex
- Medical Record/Account number
- Nature of presenting complaint
- Disposition
- Time of departure
- Treating physician

The log will also detail whether the patient:

- Refused treatment
- Was refused treatment by the hospital
- Was transferred or stabilized and transferred
- Was admitted and treated
- Was discharged

1. On 10/14/24 at 1105 hours, an interview and concurrent review of Patient 1's medical record was conducted with the CNO.

Patient 1's medical record showed Patient 1 was brought to the ED on 9/13/24 due to a thumb fracture. On 9/14/24, Patient 1 was admitted to the Medical Surgical Unit for further treatment and discharged home later that day.

Review of the ED Central Log dated 9/13/24 did not show Patient 1's means of arrival, disposition, time of departure, and the treating physician.

The above findings were verified by the CNO.

2. On 10/14/24 at 1605 hours, an interview and concurrent review of Patient 2's medical record was conducted with the CNO.

Patient 2's medical record showed Patient 2 presented to the ED on 10/11/24 for abdominal pain, nausea and vomiting for 5 days.

Review of the ED Central Log dated 10/11/24 did not show Patient 2's means of arrival, disposition, time of departure, and the treating physician.

The above findings were verified by the CNO.

3. On 10/16/24 at 1435 hours, an interview and concurrent review of Patient 3's medical record was conducted with the House Supervisor.

Patient 3's medical record showed the patient was seen in the ED on 6/4/24, due to chest pain with shortness of breath.

Review of the ED Central Log showed Patient 3 was transferred to a higher level of care. The ED Central Log did not show the patient's arrival date, means of arrival, age, sex, time of departure, the treating physician, and if the patient was transferred or stabilized and transferred.

The above findings were verified by the House Supervisor.


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4. On 10/15/24 at 1409 hours, an interview and concurrent review of Patient 14's medical record was conducted with the CNO.

Patient 14's medical record showed Patient 14 presented to the ED on 10/14/24, for abdominal pain and left AMA.

Review of the ED Central Log dated October 2024 did not show the patient's means of arrival or time of departure.

The CNO acknowledged the above findings.

5. On 10/14/24 at 1416 hours, an interview and concurrent review of Patient 15's medical record was conducted with the CNO.

Patient 15's medical record showed Patient 15 presented to the ED on 10/13/24. The Emergency Services Pre-Screening Information form showed the reason for the visit was "Don't feel good." Patient 15's medical record showed the patient left without being seen.

Review of the ED Central Log dated October 2024 did not show the patient's date and time of arrival, means of arrival, chief complaint, and time of departure. The log showed the patient eloped.

The findings were shared with the CNO.

6. On 10/15/24 at 1353 hours, an interview and concurrent review of Patient 16's medical record was conducted with the CNO.

Patient 16's medical record showed Patient 16 presented to the ED on 6/25/24. The patient was admitted to the telemetry unit on 6/26/24.

Review of the ED Central Log dated June 2024 did not show the patient's arrival time, means of arrival, and time of departure.

The findings were shared with the CNO.

7. On 10/15/24 at 1403 hours, an interview and concurrent review of Patient 17's medical record was conducted with the CNO.

Patient 17's medical record showed Patient 17 presented to the ED on 6/18/24. The patient was discharged on 6/18/24.

Review of the ED Central Log dated June 2024 did not show the patient's departure time.

The findings were shared with the CNO.

8. On 10/15/24 at 1148 hours, an interview and concurrent review for Patient 18 'd medical records was conducted with the CNO.

Patient 18's medical record showed Patient 18 presented to the ED on 7/27/24. The patient was admitted to the telemetry unit on 7/27/24.

Review of the ED Central Log dated July 2024 did not show the patient's mode of arrival, patient's disposition, and time of departure.

The findings were shared with the CNO.

9. On 10/15/24 at 1136 hours, an interview and concurrent review for Patient 19's medical records was conducted with the CNO.

Patient 19's medical record showed Patient 19 presented to the ED on 7/26/24, and left AMA.

Review of the ED Central Log dated July 2024 did not show the patient's mode of arrival and time of departure.

The findings were shared with the CNO.

10. On 10/15/24 at 1447 hours, an interview and concurrent review for Patient 20's medical record was conducted with the CNO.

Patient 20's medical record showed Patient 20 presented to the ED on 9/23/24, and the patient left without being seen.

Review of the ED Central Log dated September 2024 did not show the patient's date and time of arrival, means of arrival, chief complaint, and time of departure. The log showed the patient eloped.

The findings were shared with the CNO.


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11. On 10/14/24, at 1545 hours, an interview and concurrent review of Patient 8's medical record was conducted with the House Supervisor.

Patient 8's medical record showed Patient 8 was brought to the ED on 8/31/24, for right leg pain and the patient was admitted on 9/1/24.

Review of the ED Central Log dated 8/21/24 did not show the patient's disposition, means of arrival, and time of departure.

The House Supervisor acknowledged the above findings.

12. On 10/15/24, at 1056 hours, an interview and concurrent review of Patient 10's medical record was conducted with the House Supervisor.

Patient 10's medical record showed Patient 10 was brought to the ED on 7/8/24, for left shoulder pain after a fall and was admitted on 7/8/24.

Review of the ED Central Log dated 7/8/24 did not show the patient's disposition, means of arrival, and time of departure.

The House Supervisor acknowledged the above findings.

13. On 10/15/24 at 1128 hours, an interview and concurrent review of Patient 4's medical record was conducted with the House Supervisor.

Patient 4's medical record showed Patient 4 was brought to the ED on 7/10/24, for an overdose and was transferred to higher level of care on 7/10/24 at 1813 hours.

Review of the ED Central Log dated 7/10/24 did not show the patient's admitting physician, transfer time, disposition, means of arrival, and time of departure.

The House Supervisor acknowledged the above findings.

14. On 10/15/24, at 1318 hours, an interview and concurrent review of Patient 11's medical record was conducted with the House Supervisor.

Patient 11's medical record showed Patient 11 was brought to the ED on 7/13/24, for failure to thrive and was admitted on 7/14/24.

Review of ED Central Log dated 7/13/24 did not show the patient's means of arrival and time of departure.

The House Supervisor acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff failed to perform an accurate and thorough triage assessment upon arrival to the ED for one of 20 sampled patients (Patient 1). This failure had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services in the hospital.

Findings:

Review of the hospital's P&P titled Triage dated June 2022 showed in part:

* Policy Purpose: To systematically and logically assign priorities of care to patients as they arrive to the Emergency Department. To ensure that every patient receives high quality, efficient and appropriate medical care based on medical need utilizing and established triage process.

* Scope: Emergency Department Registered Nurses.

* Policy: Triage will be involving a rapid, directed patient assessment, which provides an assignment of an acuity level for each patient presenting to the emergency department. The triage category is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care.

* Triage assessment and documentation: A RN will interview and assess each patient upon arrival to prioritize incoming patients and to identify those who must be seen immediately.

* Triage Procedure...The Triage Nurse and/or the Charge Nurse are responsible to see that all ambulance patients are triaged to include vital signs and have the MD assess them as quickly as possible. The Triage Nurse will be responsible to provide immediate first aid to minor injuries as necessary, e.g. splinting, cool packs, control of bleeding.

Review of the hospital's P&P titled Standard of Practice for Emergency Services dated June 2022, showed in part:

* Policy Purpose: This policy is to define the standards of practice for the Emergency Department.

* Scope: Emergency Department Nursing Staff.

* Policy: The Standards of Practice based on competent nursing care as demonstrated by the nursing process. The Standards of Practice addresses the role and boundaries of practice for acute care nursing. The professional practice of nursing is characterized by the application of relevant theories, research and evidenced based guidelines.

* Procedure:

- Standard I. Assessment: Data is collected from the patient, support person, family to develop a holistic picture of the patient's needs. Decisions are made matching knowledge with clinical findings. Relevant data is communicated to other healthcare providers.

- Standard II. Diagnosis: Diagnosis and care issues are derived from the assessment data. Diagnosis and care issues are prioritized and documented in a manner that facilitates outcomes.

- Standard III: Outcome Identification: Outcomes are derived from actual or potential diagnosis and care issues. Outcomes provide direction for continuity of care.

- Standard IV: Planning: The plan is individualized and considers patient characteristics and the situation. The plan reflects current best evidence. The plan establishes priorities of care.

- Standard V: Implementation: Interventions are delivered in a manner that minimizes complication and life-threatening situations. The implemented plan and modifications are documented. Collaboration to implement the plan occur with the patient, family, healthcare provider and the healthcare system.

- Standard VI: Evaluation: Evaluation is systemic and ongoing using evidenced based techniques and instruments. The evaluation of the effectiveness of interventions towards achieving the desired outcomes occurs. Results of the evaluation are documented.

Review of the hospital's P&P titled Assessment and Reassessment dated June 2022, showed in part:

* Policy Purpose: To establish guidelines for patient assessment and reassessment in the Emergency Department.

* Scope: Emergency Department Nursing Staff.

* Policy: It is the policy of this hospital that the Emergency Department incorporates an interdisciplinary approach to meet the physical, emotional, spiritual and health education needs of the patient and family.

* Procedure: Physical assessments are completed by a RN caring for the patient within one (1) hour or sooner of admission to the ED. Assessment includes patient's subjective statement, pertinent medical history, physical observation and/or examination to include appropriate disrobing.

On 10/14/24 at 1105 hours, a concurrent interview and review of Patient 1's medical record was conducted with the CNO.

The ED Triage documentation dated 9/13/24 at 2016, showed Patient 1 was brought in by ambulance on 9/13/24 at 1955 hours, with a chief complaint of thumb fracture.

The triage documentation did not show if the injury was on the right or left thumb. The pain assessment section showed the patient's pain was present upon triage; however, there was no documentation of the level of pain.

On 10/15/24 at 1252 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 1.

RN 1 stated RN 1 did not ask the patient about the level of pain or location of the injury when triaged. RN 1 could not recall if the EMS report included the location of patient's injury.

The findings were verified by the CNO.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for two of 20 sampled patients (Patients 1 and 14) as evidenced by:

1. The ED staff did not ensure the pain management for Patient 1 as per the hospital's P&P.

2. The P&P for leaving AMA was not implemented for Patient 14.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Pain Assessment, Intervention and Management of dated February 2022 showed in part:

* Policy Purpose: To define the process for nursing in assessing, intervening, and managing a patients concern of pain.

* Scope: Nursing

* Policy:

- The hospital strives to achieve patient pain relief in a timely manner provided by concerned and committed staff that is trained to recognize varied expression of pain.

- The goal is to control patients' pain, to provide pain relief, reassessment of pain interventions in a timely manner, to educate both patient/family and staff to effective pain management methods and refer the patient for treatment of pain when appropriate.

- The presence and absence of pain is assessed in all patients. The pain management process will be carried out by interdisciplinary team which includes the patient and representative. The process includes pain assessment, planning and intervention, reassessment of patient responses to pain management measures, education of patient and family, and documentation.

- Both pharmacologic and nonpharmocologic strategies (i.e. relaxation exercises, distraction...) will be reviewed for appropriate utilization in management of pain.

* Procedure:

- On admission and each time vital signs are taken, the patient will be asked if they are experiencing pain. If yes, they will be asked to define location and type of pain, specify their pain score utilizing the pain scale, and establish current pain goal.

- The Universal Pain Assessment Tool is a series of pain intensity rating scales used. It offers five options of describing pain including 0 to 10 scale.

- Assessment: An admission assessment for pain will be done on all patients. Elements for pain assessment may include pain intensity (utilizing the universal pain assessment tool appropriate for the patient, location (ask patient to point to the site or sites of pain), and quality and character of pain (aching, burning, throbbing or sharp)

- Reassessment: Pain will be reassessed with each set of vital signs, with the change of care giver and with each new report of pain. Consider pain level as the fifth vital sign. Reassess patient for pain at the time vital signs are taken for pain intensity, location, quality and character of pain.

- Documentation: Pain management, intervention, education may be documented in the following areas: Care and assessment tab in Electronic Medical Record (EMR) - pain management

Review of the hospital's P&P titled Triage dated June 2022 showed in part:

* Policy Purpose: To systematically and logically assign priorities of care to patients as they arrive to the Emergency Department. To ensure that every patient receives high quality, efficient and appropriate medical care based on medical need utilizing and established triage process.

* Scope: Emergency Department Registered Nurses.

* Policy: Triage will be involving a rapid, directed patient assessment, which provides an assignment of an acuity level for each patient presenting to the emergency department. The triage category is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care.

* Procedure: Triage will be completed using the Emergency Severity Index (ESI) version 4 methodology.

- ESI Level 4: Semi-Urgent: The patient presents with a condition that has a low potential for deterioration or complications. One resource is respected [SIC] to treat this patient. Vital signs will be taken at a minimum of every 2 hours until seen by the MD.

* Triage assessment and documentation: A RN will interview and assess each patient upon arrival to prioritize incoming patients and to identify those who must be seen immediately.

* Triage Procedure...The Triage Nurse and/or the Charge Nurse are responsible to see that all ambulance patients are triaged to include vital signs and have the MD assess them as quickly as possible. The Triage Nurse will be responsible to provide immediate first aid to minor injuries as necessary, e.g. splinting, cool packs, control of bleeding.

On 10/14/24 at 1105 hours, a concurrent interview and review of Patient 1's medical record was conducted with the CNO.

The ED Triage documentation dated 9/13/24 at 2016, showed the patient was brought in by ambulance on 9/13/24 at 1955 hours, with a chief complaint of thumb fracture. The ESI level was documented as level 4.

The triage documentation did not show if the injury was on the right or left thumb. The pain assessment section showed the patient's pain was present upon triage; however, there was no documentation of the level of pain, pain related interventions, and reassessment of pain of the injured hand.

The findings were verified with the CNO.

On 10/15/24 at 1252 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 1.

RN 1 stated RN 1 did not ask the patient about the level of pain or location of the injury when triaged.


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2. Review of the hospital's P&P titled Patient Detainment: Against Medical Advice (AMA) dated February 2023 showed all risks of leaving facility against medical advice shall be given to the patient and documented in the medical record.

On 10/15/24 at 1337 hours, an interview and concurrent review of Patient 14's medical record was conducted with the CNO.

Patient 14's medical record showed Patient 14 presented to the ED on 10/14/24, with a chief complaint of abdominal pain.

The ED physician documentation dated 10/14/24 at 0702 hours, showed Patient 14 had a history of Crohn's disease with one week of abdominal pain associated with nausea, vomiting and diarrhea. The patient was offered nonnarcotic pain medications, antiemetics, and diagnostic workup including CT but declined. The documentation showed patient "Will leave AMA in favor of going home and taking her own meds."

The Medical Decision-Making documentation dated 10/14/24 at 0720 hours, showed the patient "Has capacity to AMA, pt left without signing AMA form."

Review of the Nursing Narrative Note dated 10/14/24 at 0723 showed, "Left AMA refused to sign form...Ambulated out of ED."

There was no documentation to show all risks of leaving hospital AMA were given to the patient as per the hospital's P&P.

In a concurrent interview, the CNO confirmed the findings.