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Based on staff interviews, clinical record reviews, and facility documentation review, it was determined the facility failed provide an appropriate medical screening examination for four (4) of twenty-two (22) patients in the survey sample (Patients #10, #11, #13, & #15).

The findings included:

On 7/20/21 at 11:10 a.m. a tour of the Emergency Department (ED) was conducted with the ED Nurse Manager, Staff #20. When asked about the triage process, Staff #20 explained, when a patient is a walk-in, the RN's do the triage. If after triage, if the patient doesn't want to wait, they let us know, are explained the risks, we go over labs if applicable and document "leave without being seen." When asked how often a patient in the ED is re-evaluated, Staff #20 stated "The expectation is to be re-evaluated every 2 hours."

On 7/21/21 at 10:00 a.m. an electronic clinical record review was conducted with the Registered Nurse Informaticist (Staff #15). The review revealed Patient #10 arrived to the Emergency Department (ED) on 8/9/2020 at 6:05 p.m., triage was started at 6:04 p.m. (according to the medical record), and it was documented that the patient was dismissed at 9:58 p.m. (dismissed indicated that the patient left without being seen by a provider).

On 8/9/20 between 6:04 p.m. and 6:08 p.m., the documented nursing assessments included: ED special pathogen screening; primary assessment of airway, breathing, circulation; fall risk assessment; suicide screening; chief complaints of fever low grade, cough, weakness; allergies reviewed; and simple vital signs.

An ED note dated 8/9/20 at 6:19 p.m. read: "Pt seen wheeling another Pt to bathroom from far waiting room."

There was no time indicated that the triage was completed, nor was Patient #10 given an emergency severity index (ESI) rating. There was no documentation that Patient #10 was seen by a doctor or licensed independent practitioner (LIP).

On 7/22/21 at 11:20 a.m. an interview was conducted with the ED Nurse Manager (Staff #20). When the above information was discussed, Staff #20 reviewed the clinical record and stated "I do not see an ESI level." When asked to describe how it is determined that a patient left without being seen, Staff #20 explained the staff would call the person's name three times and if no response then it would be documented as a "left without being seen" by an LIP.

The Emergency Department Procedure No. N-3 Nursing Assessment, Re-Assessments and Vital Signs of Patients in the Emergency Department, with an effective date of February 21, 2020 read in part:
"...1. Vital Signs...iii. Vital signs will be repeated at least every 2 hours on all ED patients..."
"...3. Nursing assessments...iii. All ED patients will be re-assessed with a complete or focused nursing assessment at least every 2 hours or with change in patient condition..."

On 7/21/21 at 10:15 a.m. an electronic clinical record review was conducted with the Registered Nurse Informaticist (Staff #15). The review revealed Patient #11 arrived to the Emergency Department (ED) on 8/9/2020 at 6:11 p.m., triage was started at 6:08 p.m. (according to the medical record), triage was completed at 6:11 p.m., and it was documented that the patient was dismissed at 9:57 p.m. (dismissed indicated that the patient left without being seen by a provider).

On 8/9/20 between 6:08 p.m. and 6:15 p.m. the documented nursing assessments included: ED special pathogen screening; primary assessment of airway, breathing, circulation; fall risk assessment; suicide screening; chief complaints of diarrhea, emesis and shortness of breath; allergies reviewed; and simple vital signs.

Patient #11 was assigned an ESI rating of 3. There were no other vitals signs, re-assessments or documentation that Patient #11 was seen by a doctor or licensed independent practitioner (LIP).

On 7/21/21 at 10:30 a.m. an electronic clinical record review was conducted with the Registered Nurse Informaticist (Staff #15). The review revealed Patient #13 arrived to the Emergency Department (ED) on 8/9/2020 at 7:23 p.m., triage was started at 7:24 p.m., and it was documented that the patient was dismissed at 10:16 p.m. (dismissed indicated that the patient left without being seen by a provider).

On 8/9/20 between 7:08 p.m. and 7:15 p.m. the documented nursing assessments included: ED special pathogen screening; primary assessment of airway, breathing, circulation; fall risk assessment; suicide screening; chief complaints of diarrhea, headache, and chills; allergies reviewed; and simple vital signs.

Patient #13 was assigned an ESI rating of 3. There were no other vitals signs, re-assessments or documentation that Patient #13 was seen by a doctor or licensed independent practitioner (LIP).

On 7/21/21 at 11:00 a.m. an electronic clinical record review was conducted with the Registered Nurse Informaticist (Staff #15). The review revealed Patient #15 arrived to the Emergency Department (ED) on 8/9/2020 at 8:52 p.m., triage was started at 8:52 p.m., triage was completed at 8:54 p.m., and it was documented that the patient was dismissed at 11:15 p.m. (dismissed indicated that the patient left without being seen by a provider).

On 8/9/20 between 8:52 p.m. and 8:54 p.m. the documented nursing assessments included: ED special pathogen screening; primary assessment of airway, breathing, circulation; fall risk assessment; suicide screening; chief complaint of abdominal pain; allergies reviewed; and simple vital signs.

Patient #15 was assigned an ESI rating of 3. There were no other vitals signs, re-assessments or documentation that Patient #15 was seen by a doctor or licensed independent practitioner (LIP).

On 7/21/21 at 1:30 p.m. an interview was conducted with the interim ED Medical Director, Staff #19. when asked how often he would expect re-assessments after triage, Staff #19 stated "Would expect that the policy is followed, if it says every 15 minutes then that's what I would expect."

On 7/21/21 at 1:55 p.m. an interview was conducted with Registered Nurse, Staff #11. When asked about ESI determination and vital sign monitoring, Staff #11 stated "ESIs don't get re-evaluated," and "If a patient is in the waiting room the tech would normally check the vital signs (based on the ESI)."

On 7/22/21 at 11:20 a.m. an interview was conducted with the ED Nurse Manager, Staff #20 and the interim ED Director, Staff #21. It was discussed that the above patients did not have vital signs or re-assessments done per facility policy. Staff #20 stated she has been at the facility for approximately a month and Staff #21 stated he has been at the facility for approximately 3 months. They explained there had been changes in ED staffing and administration and that they are just starting to review policies.

A review of facility's policy states in part:

The Emergency Department Procedure No. N-3 Nursing Assessment, Re-Assessments and Vital Signs of Patients in the Emergency Department, with an effective date of February 21, 2020 read in part:
"...1. Vital Signs...iii. Vital signs will be repeated at least every 2 hours on all ED patients..."
"...3. Nursing assessments...iii. All ED patients will be re-assessed with a complete or focused nursing assessment at least every 2 hours or with change in patient condition..."