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Based on reviews of medical records policies and procedures and staff interviews the facility failed to ensure that a medical screening was provided for an individual that was within the capability of the hospital ' s emergency department to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed for 1 (#8)of 26 sampled patients. Refer to findings in Tag A-2406.

Based on reviews of medical records policies and procedures and staff interviews the facility failed to ensure that a medical screening was provided for an individual that was within the capability of the hospital ' s emergency department to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed for 1 (#8)of 26 sampled patients.
Findings:An interview was conducted with patient # 8, on 03/27/2014 at 9:00 AM who re-stated from the complaint that I had an accident on a job with a Table saw. I cut two fingertips off of my right hand (middle finger, and ring finger) at about 10:15 pm on 03/13/2014. I was on a job in Crystal River, and got driven to Seven Rivers Medical Center Emergency Room (ER). I arrived there about 15 minutes later at 10:30 p.m. Told the person at the desk my problem showed them my severed fingertips and they took my information, and gave me a towel. I waited for nearly 4 hours without being called in. I went back to the receptionist and asked how much longer I would have to wait and she told me at least another 2 to 4 hours. I left the Hospital and went to Name of Hospital (another acute care hospital), at which time they told me they could not reattach my fingertips due to the amount of time that has passed since the accident.
A review of patient #1 ' s medical record revealed that patient #8 presented to the emergency department on March 13, 2014 at 10:29 p.m., with " Diagnosis/sign/symptoms " Hand injury . " Further review of the medical record indicated that on 3/14/2014 at 2:26 a.m. " Normal D/C (discharge). " An attending /admitting physician name was listed. The sections of medical record titled " Diagnosis Code (Primary) " , " Complications, and " Principal Codes/Dates were all left blank. There was no documentation in the medical record to indicate that after patient #8 waited 4 hours (verified through interview and medical record review) in the emergency department with a complex hand injury that the patient was triaged (the assessment of degree of urgency to wounds and illnesses to decide order of treatment )and no medical screening examination was completed to determine whether or not an emergency medical condition existed.
The medical record from the acute care hospital where patient #8 presented to after leaving Seven Rivers Regional Medical Center was reviewed. The review of the " Emergency Documentation " form revealed that on 3/14/2014 at 5:15 a.m. patient #8 presented to the emergency department. The documentation by the nurse indicated in part, " Triage Chief complaint /Mechanism of Injury " Pt (patient) drove self to ED (emergency department) c/o (complaint /of)laceration from table saw RT (right) hand at about 10PM pt AA(awake and alert) NAD(No acute distress) able to ans (Answer) all questions Pt has a towel dsg (dressing) in place pt taken directly to ex (exam room) 7 ... Diagnoses (Active) Hand Laceration ...Classification: Emergency ...tracking acuity:3 Urgent ...Pain assessment : pain location: Hand Laterally :Right Quality: : Throbbing Primary time Pattern: Constant ...Numeric rating 6 ...Skin integrity: Not intact wound assessment: yes ...Incision Wound #1: ...comment (amputation of fingertips on 2nd (second) and 3rd (third) finger.. location ...Right hand ... description/Assessment: Edges separate.. surrounding: maceration Drainage: serous.. Comments Finger tips Gone. " The Emergency Department physician documented in part, " History of Present illness: the patient presents with right, fingertips. The onset was 8 hours ago. The course duration of symptoms is constant ... the character of symptoms is pain and bleeding ....the exacerbating factor is movement. The relieving factor is none ...Impression and plan: Diagnosis: Traumatic amputation of fingertip ...Plan: Condition: Improved: stable. "
An interview was conducted with the Director of the ER on 03/27/2014 at 10:40 AM regarding medical screening and stated that patient will not get medical screening till seen by a provider, triage is not medical screening.

An interview conducted with a Physicians Assistant assigned to the ER on 03/27/2014 at 2:50 PM stated that once triage has been completed and the patient is in the main/fast track of the ER system then a medical screening is done. Depending on the outcome of the medical screening appropriate services would then called.

Review of policies and procedures subject:

Triage: Admission to the Emergency Department, revised 03/13.
1. An RN/designee, utilizing the computer documentation system to determine the nature of their presenting complaints, their condition, there priority for receiving medical treatment shall evaluate all patients presenting for emergency treatment. The RN, prior to any registration process, will determine the patient ' s priority for treatment.
2. Patients will be treated according to severity of their condition, not order of presentation.
7. Either the Emergency Department Physician/Designee or their attending physician will medically screen all patients.

Further review of triage procedure:
1. Triage will be performed promptly to assure adequate evaluation of presenting patients in a timely manner. As the time allows and treatment areas are available, bedside registration will be imitated.

Review of policy/procedure subject: Medical Screening and Treatment/Transfer Policy/Procedure:
Basic requirements: 1. Screening Examination: Upon presentation of an individual in accordance with this policy, and as soon as reasonably possible within the capabilities of the DED, the individual will be taken to an appropriate DED examination site for an appropriate medical screening examination .
a. Triage generally is not considered to be an appropriate medical screening exam, but rather a mere determining of a priority in which multiple patients are to be seen for further examination and treatment.
2. If the hospital determines that an emergency medical condition exists, the hospital shall provide either:
a. Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the emergency medical condition or
b. For transfer of the individual to another medical facility in accordance with this policy and procedure.
The facility failed to ensure that their policies and procedure were followed as evidenced by failing to timely triage patient #8 when he presented to the emergency room with a complex hand injury. The facility also failed to ensure that on 3/13/2014 patient #8 received and an appropriate medical screening examination that was within the capability of the emergency department to include ancillary services to determine whether or not an emergency medical condition existed.