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Based on observation and interview, the facility failed to ensure that patients received care in a safe and dignified setting while in the emergency department (ED). 1) There was no mechanism in place such as call bells for hallway patients to call for assistance, and a patient was observed having a procedure done in the hallway without privacy. 2) A portable cardiac monitor used on a patient was not connected to the nurse's station.

Findings regarding #1 above include:

-- Per observation while in the ED on numerous occasions, multiple patients were noted to be on stretchers in the hallway with no call bells available.

-- Per interview of Staff M, Registered Nurse (RN) on 8/29/2024 at 1:55 pm, hallway patients have no call bells. The patients scream or grabs anyone walking by.

-- Per interview of Staff N, RN on 8/29/2024 at 1:30 pm, there are no call bells for patients in the ED hallways, they have to grab people walking by. There are no curtains for patient privacy.

-- Per interview of Staff F, RN on 9/3/2024 at 11:30 am, there are no cameras in the back hallway. Staff F relies on other staff members to notify the assigned nurse if patient needs are identified.

-- Per interview of Staff O, RN on 9/4/2024 at 9:40 am, beds in the back hall are overflow beds, there are no call bells. If the patients need help, they could flag someone down when they walk by.

-- Per interview of Patient #9, on 9/3/2024 at 11:10 am, (Patient #9 was observed in the back hallway on a stretcher against the wall with no call light or means to call for help) they stated having vital signs done this morning and seeing a physician assistant and a resident. The patient had been in the hallway since 10:00 pm on 9/1/2024 and was waiting for a computed tomography (CT) scan to be completed.

-- Per interview of Staff D, RN on 9/11/2024 at 10:15 am, patients in the hallway (near the D zone) have no call bells and would yell out to staff for help.

-- Per observation in the ED on 9/4/2024 at 9:50 am, multiple patients were in the ED hallways. Two staff members were standing next to a patient's stretcher flushing their Foley catheter to remove blood clots. The patient was yelling out in pain and had no privacy.

Findings regarding #2 include:

-- Per observation on 9/11/2024 at 11:15 am, a patient was on a stretcher in the ED hallway connected to a portable monitor. Staff P, RN acknowledged this finding at the time of observation and stated the monitor is not connected to the nurse's station in the ED. Staff P also stated if the monitor alarm came on, they would not be able to hear it.

-- During the exit conference on 9/13/2024 at 2:00 pm, Staff BB, Hospital General Director acknowledged the above findings.

Based on medical records (MR) review, facility document review and interview, it was determined that 1) the facility failed to ensure there were adequate medical and nursing staff in the emergency department (ED) to meet the written ED policies and procedures and the anticipated needs of presenting patients and 2) In 4 of 11 (Patient #1 - Patient #4) medical records reviewed of patients who presented to the emergency department (ED) via emergency medical services (EMS), the hospital failed to provide a timely medical screening exam to determine if an emergency medical condition existed.

Cross Reference:
482.55(b)(2) Qualified Emergency Services Personnel

Please see Tag 1104 and 1112.

Based on document review, medical record review, and interview, 1) In 4 of 11 (Patient #1 - Patient #4) medical records reviewed of patients who presented to the emergency department (ED) via emergency medical services (EMS), the hospital failed to provide a timely medical screening exam to determine if an emergency medical condition existed.

Findings include:

-- Review of the facility's policy and procedure titled, "Quick Check-in: Emergency Department," revised 10/2023, indicated under "Procedure: EMS patients waiting on the EMS ramp, while on Albany Med's property are considered Albany Med's patients once directed to wait on the ramp."

Findings specific to Patient #1:

-- Review of Patient #1's medical record revealed, Patient #1 (identified as Jane Doe) was a transfer from Hospital B for a higher level of care. At Hospital B Patient #1 was found to have an intracranial bleed with additional concerns for sepsis. (Patient #1 had a history of substance abuse and was found on the street unresponsive with suspected drug overdose.)

Patient #1 arrived at the facility via EMS 8/24/2024 at 5:42 pm. The patient was not triaged until 7:57 pm. The patient was given an emergency severity index (ESI) level of 2 (Level 1-life threatening, Level 5 - non-urgent). The patient was seen by a provider at 8:06 pm

Review of the EMS Patient Care Record (PCR), dated 8/24/2024, "pt arrived at hospital A, at 5:38 and transfer of care occurred at 8:05 pm.

-- Per interview of Staff A, provider on 9/4/24 at 11:35 am , Patient #1 appeared very ill and septic, with questionable endocarditis, spinal abscess, and brain bleed. The patient was clearly very sick and waited too long. Staff A stated in their opinion, the patient should have been brought in sooner. Staff A expressed concerns about the long EMS wait times.

-- Per interview of Staff B, provider on 9/4/2024 at 3:20 pm, they recalled Patient #1. Staff B wasn't aware the patient had been in the ED vestibule for 2 hours and opined that this is not appropriate.

Patient #1's medical screening exam did not start for 2.5 hours after their arrival.

Findings specific to Patient #2:

-- Review of the facility's protocol titled, "Aneurysmal Subarachnoid Hemorrhage AMC Protocol: Emergent management of a SAH," dated 1/2021, indicated the "Emergency Department provider will evaluate the patient at bedside within 10 minutes of the patient's arrival."

-- Review of Patient #2's medical record revealed, Patient #2 was a transfer from from another hospital (Hospital C). The patient had fallen from a curb, with head strike. There was no loss of consciousness and the patient was not on blood thinners. The patient had a computerized tomography (CT) at the transferring facility (Hospital C), with findings of a subarachnoid hemorrhage (brain bleed) and a skull fracture.

Patient #2 presented to the ED (from Hospital B) on 7/28/2024 at 8:07pm pm via EMS. Patient #2 remained on the ED ramp until a room became available on 7/29/2024 at 12:13 am.

12:26 am - Provider documentation indicated, "Unfortunately patient had a prolonged wait for room and EMS reports that she declined while waiting. Unclear how she has changed however family states that she appears more confused than normal. An immediate neurosurgery consult was order."

2:54 am - Computed Tomography (CT) revealed questionable thrombosis (clot) and brain contusion. Neurosurgery believes the subarachnoid (bleed) has worsened. At 2:55 am Patient admitted to the trauma team.

Patient #2's medical screening exam did not start for 4 hours after their arrival.

Findings regarding Patient #3:

-- Review of Patient #3's medical record revealed, Patient #3 presented to the ED via EMS on 8/30/2024 at 3:33 pm, with a chief complaint of right hip pain. Past medical history of bone metastasis (cancer). Patient #3 "was recently admitted to Albany Medical Center after pathological left femoral shaft fracture and underwent an open reduction and internal fixation (ORIF) on 8/18/2024 without any complications. Today at rehabilitation center while undergoing physical therapy the patient felt a snap in the right leg. Concern for right femoral shaft fracture and orthopedic surgery plans for ORIF in the morning." Patient #3 remaind on the EMS ramp until 7:20pm. (4 hours).

12:17 am - First provider evaluation done. Multiple orders written for example, CT of right leg, laboratory studies, orthopedic consult, etc.

Patient #3's medical screening exam did not start for 4 hours after their arrival.

Findings regarding Patient #4:

-- Review of Patient #4's medical record revealed, Patient #4 was a transfer from another Hospital (Hospital D). At Hospital D Patient #4 had electrocardiogram changes and chest pain.

Patient #4 presented to the ED via EMS on 8/30/2024 at 3:05 pm, (from Hospital D).

6:58 pm - First provider evaluation, indicated patient sent for further workup and possible catheterization. Patient complained of some left medial thigh discomfort that has been present for over a week following an episode of left lower leg erythema and swelling. "Patient denies hemoptysis, hematemesis, fevers/chills, nausea/vomiting, abdominal pain, numbness/tingling of unilateral swelling and erythema of extremity and increased dyspnea raises suspicion for deep vein thrombosis/possible pulmonary embolism as another potential etiology of presenting symptoms."

Per ED provider notes, dated 8/30/24 at 7:04 PM, The ED at Hospital A contacted AMC cardiology who recommended patient be transferred to AMC for acute coronary syndrome workup and possible cardiac catheterization. The patient had complaints of chest pain, shortness of breath and the transfer documents from Hospital A indicated the patient had a t-wave abnormality on EKG (abnormal t-waves may indicate the presence of cardiovascular disease). The patient was sent to the waiting room and not triaged until 6:19 PM, over three hours later.

Patient #4's medical screening exam did not start for 3 hours after their arrival.

Additional Findings:

-- Per interview of Staff C, RN on 9/4/2024 at 3:40 pm, they have concerns about EMS patients. Staff C stated "I have never seen anything like this. Emergency medical services watches the patients in the bay and on the ramp. This is a safety concern. Someone is going to get hurt."

-- Per interview of Staff D, RN on 9/3/2024 at 12:15 pm, if a patient is waiting for a room/bed, the patient is the responsibility of EMS until they give report.

-- Per interview of Staff E, RN on 9/3/2024 at 11:15 am and 9/4/2024 at 2:30 pm, in regard to the patients in the vestibule, "it is their understanding that until EMS gives report the patient is still in EMS's care. The nurse assumes care of the patient when the patient is off the EMS stretcher and the patient is in a room and report is given."

-- Per interview of Staff F, RN, on 9/3/2024 at 11:30 am and 9/5/2024 at 11:45, EMS remains responsible for the patient until they have been triaged and EMS continues to monitor and document on the patient in the patient care report (PCR).

Staff G, Director of Hospital Regulatory Affairs on 9/5/2024 at 2:42 pm, during presentation of the IJ template, acknowledged the above findings.

Based on facility document review, interview, and medical record review, the hospital failed to ensure there were adequate nursing staff in the emergency department (ED) to meet the written ED policies and procedures and the anticipated needs of presenting patients.

Findings include:

-- Review of the Clinical Staffing Plan submitted by the hospital for 2024 revealed the average ratio of patients to registered nurses (RN) is 2.58 patients on day, evening, and night shift.

-- Review of posted staffing matrix in the ED on 8/28/2024 revealed there should be 21 RNs on day shift, 24 RNs on evening shift. and 20 RNs on night shift. The daily staffing schedules showed staffing should be 20 RNs on day shift, 24 RNs on evening shift and 21 RNs on night shift.

-- Review of the hospital's policy and procedure titled, "Triage Process Guidelines" reviewed 7/2024, showed "the goal is to triage all patients within 30 minutes of arrival. If this goal cannot be met the triage nurse will communicate this to the ED triage nurse, who will then mobilize other triage staff".

-- Review of the hospital's policy and procedure titled, "Emergency Department," reviewed 4/2024, revealed under Quality Management, "Under the supervision of administration, department management is responsible for setting standards and assuring the provision of quality, safe and appropriate care within their scope of service. This is achieved by establishing regular and ongoing processes to identify and monitor at a minimum high risk and high volume activities and regulatory requirements. If this monitoring identifies an opportunity for improvement, department management is responsible for developing and implementing an action plan for goal achievement."

-- Review of the hospital's policy and procedure titled, "Quick Check-in: Emergency Department," revised 10/2023, indicated under "Procedure: EMS patients waiting on the EMS ramp, while on Albany Med's property are considered Albany Med's patients once directed to wait on the ramp."

-- Per interview of Staff N, Registered Nurse (RN), on 8/29/2024 at 1:30 pm, they feel the ED environment is unsafe and they do not really want to work in ED.

-- Per interview of Staff R, Chief Nursing Officer on 9/4/2024 at 11:05 am, the hospital has been seeing an increased number of visits to the ED and an increased number of patient boarding (awaiting admission) in the ED. There is also a 30 percent vacancy rate for RNs. A Tier Plan for the adult ED, that addresses staffing needs during times of increased volume of patients, has been developed but has not been implemented.

-- Per interview of Staff F, RN on 8/28/2024 at 9:30 am, 9/3/2024 at 11:30 am and on 9/5/2024 at 11:45 am, current staffing is as follows: 7:00 am - 3:00 pm = 20 RNs, 3:00 pm - 11:00 pm = 24 RNs, 11:00 pm - 7:00 am = 21 RNs. These are the staffing levels regardless of the number of ED patients, patient acuity and boarders. There are 55 ED beds, and 30 hallway beds. Staff F said they cannot staff intensive care unit (ICU) patients residing in the ED with 2 patients to 1 RN ratio. There is also an observation unit with 12 beds that is staffed by ED staff and float pool nurses. Staff F said ''they will get a float nurse if there is one available. There is not always one available." If an emergency medical services (EMS) patient is offloaded in the vestibule (of the ED) the flow nurse doesn't go out and get report or assess the patient unless there is a change in the patient's condition. Emergency Medical Services remains responsible for the patient until triage and they continue to document on the patient in the patient care report (PCR). Sometimes patients stay in the ambulance.

-- Per interview of Staff D, RN on 9/3/2024 at 12:15 pm, nursing assignments are 5-6 patients and not based on patient acuity. Staff D said the facility no longer goes on diversion. There are traveler nurses that are precepting new staff. Recently, for example, Staff D's assignment included a medical intensive care patient (MICU) (ICU level patient residing in the ED), a surgical intensive care unit (SICU) patient (ICU level patient residing in the ED), a patient with 1 hour neuro checks, 3 medical/surgical patients, and was involved in a code (a patient in cardiac arrest).

-- Per interview of Staff S, EMS Coordinator on 9/4/2024 at 10:00 am, regarding EMS offloading process to the ED, if a room is available the patient should go straight to the room. The flow nurse may say to hold the patient in the rig or ED vestibule, the hospital is responsible to monitor the patient, however, nursing says it's not their responsibility as they haven't taken report yet.

-- Per interview of Staff O, RN on 9/4/2024 at 9:40 am, staffing is not as good as it should be due to workload. Staff O stated having a 6:1 patient to nurse ratio that included 2 ICU (ICU level patient residing in the ED) patients and other patients with high acuity. There are lots of hall beds with the addition of new hall beds. The beds in the back hall are overflow beds, there are no call bells. If the patients need help, they could flag someone down when they walk by. Assignments make Staff O "scared and anxious."

-- Per interview of Staff C, RN on 9/4/2024 at 3:35 pm, Staff C has concerns about EMS patients. "It is a safety concern." Staff C works with the charge nurse and throughput nurse and still struggles to provide care. Staff C has never seen anything like this. Emergency medical services watches the patients in the bay and on the ramp.

-- Per interview of Staff T, Registered Nurse on 9/5/2024 at 8:30 am, sometimes patients are put in the E hall which is considered part of the waiting room. These patients can be out of vision.

-- Per interview of Staff P, RN on 9/6/2024 at 10:40 am, Staff P indicated having an assignment on that day (9/6/2024 from 7:00 am to 11:00 am) included 2 ICU patients (ICU level residing in the ED) plus 4 additional patients. Review of the medical records of the patients assigned to Staff P revealed the following:
1. Patient presented with seizures diagnosed with septic shock, admitted to MICU.
2. Patient transferred from another facility concerns for sepsis
3. Patient with left arm paralysis, stroke code called.
4. Patient with chest pain and shortness of breath
5. Patient for trauma services multiple fractures, liver and kidney lacerations from a motorcycle accident
6. Patient with flank pain and hematuria (blood in urine), kidney stones

-- Per interview of Staff V, RN on 9/9/2024 at 3:10 pm, they indicated from 7:00 am - 11:00 am being assigned 5 patients, one stepdown ICU patient (ICU level patient residing in the ED), 4 medical patients (3 patients ESI level 2 and 2 patients ESI level 3[Emergency Severity Index - five level triage algorithm that categorizes emergency department patients by evaluating both patient acuity and resource needs. ESI 1 is critical up to ESI 5 non-acute condition]). Acuity is not taken into account and staffing is usually 1:6 and can include any kind of patients including ICU patients.

-- Per interview of Staff W, RN on 9/9/2024 at 3:30 pm. Staff W indicated having 6 patients assigned until 11:00 am which included: 2 patients with ESI level 2, 3 patients with ESI level 3, and 1 which was an ICU patient (ICU level patient residing in the ED). Sometimes due to lack of staffing, Staff W doesn't feel safe.

-- Per interview of Staff X, RN on 9/4/2024 at 2:15 pm, when assigned as the flow nurse the responsibilities include moving all patient through the department. From 7:00 am - 11:00 am Staff X triages all patients who present to the ED which includes walk-ins and patients who arrive via EMS. Today a patient waited 2.5 hours before care was turned over from the EMS to the hospital

-- Per interview of Staff Y, RN on 9/4/2024 at 2:30 pm and 9/9/2024 at 10:15 am, Staff Y works as a flow nurse and nurse 1 (triage nurse) usually from 7:00 am - 11:00 am, depending on staff who call in. Staff Y also has contact with the Logistics Center and stated there is tension between staff. Medics are covering the EMS patients. Staff Y said she is concerned with the care patients are getting due to the poor staffing. Staff Y said the acuity and number of patients are difficult to manage.

-- Per observation on 9/3/2024 at 11:20 am, Patient #9, was in the back hallway (of the ED) on a stretcher against the wall with no call light or means to call for help. Per interview of Patient #9, they had their vital signs done this morning and saw a physician assistant and a resident. Patient #9 stated they had been in the hallway since 10:00 pm on 9/2/2024 and was waiting for a computed tomography (CT) scan to be completed.

-- Review of medical record revealed Patient #1 presented to the ED on 8/24/2024 at 5:42 pm via EMS as a transfer from Hospital B as a Jane Doe for a higher level of care. Transfer diagnosis was noted as intracranial bleed with additional concerns for sepsis. Patient #1 remained in the hospital's vestibule (ramp where EMS patients enter) attended by EMS personnel.

At 7:57 pm, Patient #1 was triaged by nursing staff.

Per review of the hospital's policy and procedure, titled "Triage Process Guidelines," approved 7/29/2024, "Triage level 2 is assigned to patients who are in a high risk situation/confused/lethargic/disoriented or severe pain or distress."

Per interview of Staff A, Provider, on 9/4/24 at 11:35 am, they recalled Patient #1, stated the patient appeared very ill and septic with questionable endocarditis, spinal abscess, and brain bleed. The radiologist at Hospital B suggested a brain bleed. The patient was clearly very sick and waited too long. Staff A was not aware of how long the patient had waited. Staff A stated they rarely see patients in the vestibule. If asked by EMS or the flow nurse, they will see the patient. Staff A expressed concerns about the long EMS wait times and stated in their opinion the patient should have been brought in sooner.

Per interview of Staff B, Provider, on 9/4/2024 at 3:20 pm, they recalled Patient #1. Staff B wasn't aware the patient had been in the ED vestibule for 2 hours and opined this was not appropriate.

Patient #1 was not assessed by nursing staff until 2 hours after arrival and assigned triage level 2.

-- Review of medical record revealed, Patient # 11 presented to the ED on 7/28/2024 at 11:02 pm via EMS as a transfer from Hospital C for a higher level of care. Diagnosis included MRSA (methicillin-resistant staphylococcus aureus) and bacteremia (bacteria present in the blood stream), and a change in mental status. A CT scan done at Hospital C showed a spontaneous hemorrhagic stroke. Emergency Medical Service's Patient Care Record showed Patient #11 arrived at the receiving hospital at 10:52 pm, transfer of care was on 7/29/2024 at 3:40 am.

Per review of the hospital's policy and procedure, titled "Triage Process Guidelines," approved 7/29/2024, "Triage level 2 is assigned to patients who are in a high risk situation/confused/lethargic/disoriented or severe pain or distress."

Patient # 11 was not assessed by nursing staff until 4.5 hours after arrival and assigned triage level 2. .

-- Review of medical record revealed, Patient #4, transferred via EMS on 8/30/2024 for further evaluation of 1 week of episodic chest pain and left lower extremity pain and swelling. No past medical or surgical history. Patient arrived at the ED at 3:05 pm and was placed on the EMS ramp. Transfer of care was on 8/30/2024 at 6:19 pm.

Per review of the hospital's policy and procedure titled "Triage Process Guidelines," approved 7/29/2024, "Triage level 3 is assigned to hemodynamically stable patients and in no acute distress. A patient will need two or more resources for his/her care."

Patient #4 was not assessed by nursing staff until 3 hours after arrival and assigned triage level 3.

-- Review of medical record reaveled, Patient # 3 was transported via EMS to the ED on 8/30/2024 at 3:33 pm with chief complaints of pain to the right hip. Patient # 3 was placed on the EMS ramp and monitored by EMS. Transfer of care was on 8/30/2024 at 7:20 pm.

Per review of the hospital's policy and procedure titled "Triage Process Guidelines," approved 7/29/2024, "Triage level 3 is assigned to hemodynamically stable patients and in no acute distress. A patient will need two or more resources for his/her care."

Patient #3 was not assessed by nursing staff until 4 hours after arrival and assigned triage level 3.

-- During the exit conference on 9/13/2024 at 2:00 pm, Staff BB, Hospital General Director acknowledged the above findings.