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Based on interview and record review, the facility failed to maintain a complete and accurate central log of patients admitted to their ED for 11 of 26 clinical records sampled. By not maintaining the central log, the facility would be unable to track the care provided to each patient who arrived to the hospital seeking care for an emergency medical condition.

Findings:

Clinical record review from 9/08/14 to 9/09/14 included patients who were seen in the ED from 9/03/13 through 9/03/14. The following were the 11 records found to be deficient in completeness and accuracy:

1)Patient-1: The patient was brought to the ED by the facility's security on 7/26/14 at approximately 7:30 PM for "seizures" but RN-2 did not document the patient's arrival in the log hence there was no evidence of the patient ever been registered. There was no record of the patient's triage, MSE, or discharge disposition. The patient encounter was established by interviews with staff who were witnesses or who had first hand experience with the patient on 7/26/14. RN-1 saw and heard Patient-1 in the triage area with security on 7/26/14 at
7:30 PM and according to RN-1's testimony, he heard RN-2 state to the patient, " You cannot lie down here. You have to leave.". RN-1 returned a few minutes later to the triage area but found Patient-1 was no longer there. Security
Guard-2 was one of the officers who assisted in bringing Patient-1 to the ED but only to have RN-2 instruct him to wheel the patient in the wheelchair back to the bus station across the street from the hospital. Security Guard-2 stated Patient-1 did not receive medical attention and did not see a physician.

2)Patient-2: The patient arrived in the ED by personal car on 9/01/14 at
4:27 PM for psychiatric evaluation. Triage was at 4:35 PM with an ESI 2. The MSE was at 5:20 PM. The patient's disposition did not appear in the final central log. The log should have demonstrated the patient was admitted as an inpatient. During interviews on 9/08/14 at 1:45 PM, Nurse Educator-1 and Analyst-1 stated the disposition was not populated by the new electronic medical records system, Epic.

3)Patient-3: The patient arrived in the ED by ambulance on 9/04/14 at 8:37 AM for altered mental status. Triage was at 8:39 AM with an ESI 3. The MSE was at 8:51 AM. The patient's disposition did not appear in the final central log. The log should have demonstrated the patient was discharged home. During interviews on 9/08/14 at 2:00 PM, Nurse Educator-1 and Analyst-1 stated the disposition was not populated by the new electronic medical records system, Epic.

4)Patient-5: The patient arrived in the ED by car at 9:41 AM on 8/04/14 for a headache. Triage was at 10:28 AM with an ESI 4. Patient-4 did not respond to her name when she was called three times in the waiting room at 11:25 AM, 12:00 PM, and 12:10 PM. "Home" was displayed under the nursing disposition instead of "LWBS". During interviews on 9/08/14 at 2:12 PM, Nurse Educator-1 acknowledged that "LWBS" should have been indicated under the nursing disposition.

5)Patient-6: The patient arrived in the ED by ambulance at 11:16 AM on 7/01/14 for back pain. Triage was at 11:33 AM with an ESI 4. The MSE was at 11:34 AM. The physician documented, "...Patient subsequently left the emergency department prior to disposition..., Discharge instructions given to patient. Patient and/or family expressed understanding of instructions and return precautions". But the nursing documentation indicated that discharge instructions were not given with the word, "None". The physician disposition in the log was "elopement" and the nurse disposition was "AMA". During an interview on 9/08/14 at 2:21 PM, Nurse Educator-1 stated the nurse does not have "elopement" as part of the nursing drop down menu for disposition.

6)Patient-7: The log indicated this patient arrived in the ED on 7/12/14 but there was no chief complaint, no physician disposition, no physician name, and the nursing disposition displayed, "OTHER". Upon further interview on 9/08/14 at 3:08 PM, Patient Access Supervisor-1 indicated Patient-7 was not a real patient and that "it was not mapped in". This was an error created by
Registrar-1 and Registrar-2.

7)Patient-8: The log indicated this patient had a chief complaint of "ABDOMINAL PAIN". The patient arrived at 7:50 PM on 7/26/14 and dismissed at 7:51 PM. There was no physician disposition and physician name. The nursing disposition displayed,, "LEFT WITHOUT BEING SEEN". During the interview on 9/08/14 starting at 3:08 PM, Patient Access Supervisor-1 stated this appeared to be a training session for a new employee and that the trainer (Registrar-3)used her name as the patient so there was no real patient seen.

8)Patient-12: The patient arrived in the ED by taxi at 5:58 PM on 5/07/14 for swollen tongue and jaw. The patient was roomed and had an MSE at 6:08 PM. The triage was completed at 6:09 PM with an ESI of 3. The ED log displayed, "Decision to Admit" under the physician disposition and, "Left Against Medical Advice", under the nursing disposition. Upon further record review, Patient-12 was actually admitted as an inpatient on 5/07/14 and did leave AMA from the hospital unit on 5/13/14. During an interview on 9/08/14 at 3:48 PM, Nurse Educator-1 stated Epic "pulls from the entire hospital encounter and does not populate the information". Hence, the nursing disposition should have displayed where the patient was admitted in the hospital.

9)Patient-15: The patient arrived in the ED by car at 7:07 PM on 3/08/14 for nausea and weakness. Triage was at 7:13 PM with an ESI 3. The MSE was at 7:29 PM. The log did not display a disposition by the physician. The nursing disposition displayed, "EXPIRED". Upon further record review, Patient-15 was admitted as an inpatient on 3/08/14 and later expired during the hospitalization on 3/13/14. Interview on 9/08/14 at 4:17 PM, Nurse Educator-1 stated this was another example of Epic not populating the ED information correctly into the log.

10)Patient-18: The patient arrived in the ED by car with family at 5:57 PM on 01/02/14 for suicidal ideations for three months but denied a plan to commit suicide upon arrival. Triage was at 6:15 PM with an ESI 1. The patient was roomed at 6:17 PM. Security was called to be at the bedside at 6:30 PM. The MSE was at 7:02 PM. The patient was admitted as an inpatient to the psychiatry unit at 11:32 PM. The log displayed the disposition by the MD as, "Decision to Admit", but the disposition by nursing displayed, "Home". On an interview on 9/08/14 at 10:14 AM, Nurse Educator-1 and Analyst-1 stated this was another Epic problem where the ED information was not being populated.

11)Patient -24: The patient arrived in the ED by ambulance at 5:30 PM on 11/04/13 for chest pain and shortness of breath. Triage was at 5:30 PM. The ESI was not documented by the triage RN. The MSE was at 6:21 PM. The log displayed, "AMA.... I return* " by the physician and, "Home", by the nurse. Upon further review with Nurse Educator-1 on 9/09/14 at 11 AM, Epic captured the physician's narrative documentation in the ED report about "returning" to the hospital if his symptoms recur. The disposition for nursing should have displayed, "AMA", and not "Home".

During an interview on 9/09/14 at 1 PM, Administrator-2 stated there was no policy and procedure for maintaining the ED log since Epic was instituted in November 2013 but that she would be implementing a daily verification of the ED log starting today until the problems with Epic are resolved.

Based on interview and record review, the facility failed to perform an MSE for 1 of 26 sampled patients (Patient-1). The facility's security detail brought Patient-1 to the ED to be evaluated for possible "seizures" but RN-2 did not triage the patient and subsequently instructed security to assist Patient-1 in a wheelchair through the ambulance bay to a nearby bus station to go home on her own. This deficient practice resulted in denying Patient-1 the basic right to have the required initial emergency nursing assessment which prioritizes the urgency of the patient's illness and hence an MSE by the ED physician. Consequently, Patient-1 was brought back by 911 ambulance to the facility's ED with a diagnosis of dystonia, 53 minutes after RN-2 turned the patient away from triage.

Findings:

Patient-1 was initially brought to the facility on 7/26/14 at 2:58 PM by ambulance and was treated for acute neck pain which resolved and for agitated mental status secondary to chronic schizophrenia that improved with anxiolytics. The patient was triaged at 3:09 PM with an ESI of 2 by RN-5, had an MSE by MD-1 at 3:12 PM and discharged home in stable condition at 5:25 PM.

Subsequently, on the same day at approximately 7:30 PM, almost 2 hours from her initial ED visit, Patient-1 was brought again to the emergency department but by the facility's security after they received a call from an inpatient's family member who reportedly saw Patient-1 having a "seizure" across the street from the hospital. There was no documentation from RN-2, the assigned triage nurse at the time, to confirm Patient-1's second encounter in the ED. And according to the facility's interview on 8/20/14 with Registrar-1 who stated, "(I) was not aware that the patient had come to the ED during the incident in question". The facility's interview with Registrar-1 further described the process with the following: "When the patient arrives through the ambulance bay, but not by the ambulance, the registrar should be notified by the triage RN that needs to arrive the patient. In this case, she was not notified that her assistance was needed to arrive the patient, so this action was not performed". Additionally, during an interview on 9/02/14 starting at 10:20 AM, Administrator-2 stated the security video footage in the ED showed Patient-1 being wheeled into the ED and then 10 minutes later being wheeled back out on 7/26/14 during the second encounter.

Although there was no definitive documentation of Patient-1 being registered for a second encounter other than from the security video footage and an incident report by security, the following three interviews gave additional information which established RN-2 as the triage nurse who met Patient-1 during the second visit and that the patient did in fact arrive in the ED at approximately 7:30 PM on 7/26/14 to be seen and evaluated but only to be turned away before being examined by the physician:

1) During an interview on 9/02/14 starting at 10:20 AM, RN-1 stated that RN-2 was the triage nurse with Patient-1 on 7/26/14 at approximately 7:30 PM in the triage area of the ED and that security was also present with the patient and nurse. He had recognized Patient-1 as the same patient seen earlier at 2:58 PM for neck pain and chronic schizophrenia. RN-1 heard a "raucous" in the triage area and Patient-1 talking in a loud voice, saying she wanted a soda. He resumed his nursing duties but returned a few minutes later to the triage area to look on the situation but Patient-1 was already gone. RN-1 realized that
Patient-1 was not triaged or seen by the physician. Additionally, the facility obtained an interview with RN-1 and revealed the following: "... (RN-1) heard loud talking coming from the triage area. (RN-1) looked in the direction and noted there were security personnel in the entrance to triage near the tubing station. (RN-1) observed (RN-3) and (RN-2) standing at the tube station as well as security in triage. (RN-1) heard security tell (RN-2) that they found the patient outside having what appeared to be an 'epileptic seizure'. They also stated that she had 'a PICC line still in place'... (RN-1) continued to work... when (RN-1) heard the patient talking in a loud voice, saying she wanted a soda. (RN-1) observed (RN-2) telling the patient, ' You cannot lie down in here. You have to leave'. At that time, (RN-1) approached the triage area to assess the situation. When (RN-1) got to triage.. a person (was) half lying on the exam bed in triage with her feet on the floor and the rest of her body on the stretcher. She was identified as the patient that had been seen earlier that day and discharged... (RN-1) walked back to (to resume prior duties)... At the next available moment, (RN-1) returned to triage to look in on the situation, but the patient had departed".

2) During a telephone interview on 9/02/14 starting at 3:45 PM, Security Guard-1 confirmed that he and his colleagues picked up Patient-1 in their security van and drove her to the ED for possible seizures. Security Guard-1 also confirmed it was RN-2 who was the triage nurse that met them in the ED. RN-2 stated to Security Guard-1, "(Patient-1) has been discharged already". Security Guard-1 told RN-2, "(Patient-1) needs medical attention". Security Guard-1 left the triage scene to attend another call elsewhere in the hospital.

3) During another interview on 9/08/14 starting at 2:27 PM, Security Guard-2 also confirmed he was with Security Guard-1 when they picked up Patient-1 in their security van and brought her to the ED. Security Guard-2 said they drove the van into the ambulance bay and placed her in the wheelchair. He said the triage nurse met him and the patient but she "adamantly" said, "(Patient-1) does not need to be seen". Security Guard-2 said the triage nurse "changed her tone" and said that it was OK for the patient to be seen and he wheeled the patient into the triage area. Security Guard-2 said the patient wanted a "Sprite" and a sandwich, and after she received her food, she was sent away by the triage nurse. Security Guard-2 said Patient-1 was not seen by a doctor and as instructed by the triage nurse, he wheeled Patient-1 in the wheelchair to the bus station where she stood up and walked to sit down in the bus station. Then, Security Guard-2 said he brought the wheelchair back to the ED and resumed his work day as usual. Security Guard-2 stated he believed the patient should have been seen by a physician but he wasn't medically trained and just followed instructions from the nurse. According to the facility's internal investigation report, "The patient was wheeled back out into the ambulance bay by security at 7:41 PM at the direction of the triage nurse".

Then, 53 minutes after being just turned away from triage, for the third time on 7/26/14 at 8:23 PM, Patient-1 again was brought to the facility's ED by 911 ambulance for dystonia. The patient was triaged by a different RN (RN-6) at 8:38 PM with an ESI 3, had an MSE by MD-1 at 8:24 PM, had a psychiatric evaluation by MD-2 at 9:06 PM, and was discharged in stable condition to a shelter at 11:30 PM.

Record review of the facility's incident report (INC-2014-09-00009) by Security Guard-1 documented the following: "Report Date/Time: 7/26/2014 7:10 PM, Occurred From Date/Time: 7:10 PM, Occurred To Date/Time 7:30 PM, Incident Duration: 0 Hrs. 20 Min., Summary: Security responded to calls about a person down on the sidewalk across the street from the Emergency Entrance. Security found a woman who was appeared to be having convulsions and was transported to the ER for treatment. Narrative: On the evening of July 26, 2014, approximately (7:10 PM), Security Dispatch received a transfer call from PBX from 2 visitors about a 'patient laying near on the ground about 5 cars away from the Sacramento St. bus stop'. Dispatch then called (Security Guard-1) that 'this was AMA patient who had left the hospital' although there was no report from the ER about an elopement. The visitors reporting this were never identified. (Security Guard-1, Security Guard-2, and Security Guard-3) arrived on scene at the bus stop, I was met by two women who said they were visiting a patient (from the hospital) and they were waiting for a bus and had called Security. (Security Guard-1) was unable to get any identification because they got on a Muni bus and left the area. (Security Guard-1) saw a woman was on the ground who appeared to be experiencing convulsions. At the time, (Security Guard-1) felt the woman, later identified as (Patient-1), needed to be admitted to the Emergency Department due to her medical condition. I asked Officer to get the van and meet us at the bus stop on Sacramento and Buchanan. Once (Security Guard-2) arrived we then assisted the woman into CPMC van #22 and drove her across the street into the ambulance bay where she was placed into a wheelchair and taken into the Emergency side entrance. (Security Guard-1) was asked by (RN-2) why we brought a discharged patient back. (Security Guard-1) told her that the patient was found on the ground across the street and appeared to need medical attention. She then said that the patient has been discharge 30 minutes ago and that the patient had received all discharge paperwork. (Security Guard-1) then told (RN-2) that the patient we were told... had a IV Line in her right arm which she had pulled out and dropped on the ground near where she was found. And the visitors who called us saw her remove the PICC line from her arm. (RN-2) then asked how he knew the difference between an IV and PICC line. At that moment she asked me that question (RN-3) was nearby. At that time I felt that it was so busy in the ER and the area we were in was crowded with Ambulances coming in. I then told her that this is a serious thing at this moment and we must provide aid for this patient which at the time had been discharged and allowed to leave. (RN-2) Kept going with asking the questions, so I stopped her and told her that in exact words, ' I'm not here playing EMT, but I'm here as security officer and this patient needs medical attention'. We may discuss this situation after but please lets take care of the patient's medical needs. Due to waiting security calls I had to leave the area".

MD-1's documentation of the patient's third visit showed the following: "The patient comes in with neck pain that was treated by EMS with benadryl. Differential diagnosis: dystonic reaction, muscular strain. The patient was seen and evaluated by me earlier today and was treated and released. She does have chronic schizophrenia and I evaluated her and felt that she was stable for outpatient. Because of the second visit today, psychiatry was consult and evaluated the patient at bedside. The patient became very agitated necessitating Haldol injection. The patient calmed down to the point that the psychiatry resident was able to evaluate the patient at length. She agrees that the patient has no overt psychiatry emergency requiring further evaluation".

MD-1 was off duty from the hospital for an interview by this surveyor on 9/02/14, but the facility's interview with MD-1 on 8/21/14 and 8/27/14 showed the following: "MD-1 recalls this patient, having taken care of her twice on July 26, 2014. Regarding the incident, he recalls that he was sitting in the MD office, working at the computer. He was approached by (RN-4), and asked 'if I was going to see the patient'. He states, 'I was not aware that she had left and then returned. I thought it was all the same visit. So I said that I had already seen her and that she had been discharged'. He states that he was 'not aware this was a second return' ".

RN-2 was placed on administrative leave during this investigation by this surveyor on 9/02/14 but the facility's interview with RN-2 on 8/22/14 revealed the following: " (RN-2) recalls her assignment as triage nurse. She does not recall the patient or the events that occurred that night".

The facility's policy and procedure titled, "ED Triage", Policy No. ED 100.16, effective 12/96, revised 7/13, established the following: "All patients presenting to the Emergency Department (ED) for treatment will be assessed by a Registered Nurse to determine the urgency of the patient's condition and assigned a triage/acuity level based on the Emergency Severity Index (ESI) algorithm found in Attachment A. The ESI level establishes prioritization of a medical screening exam by the ED physician. Patients awaiting a medical screening exam will be reassessed based on acuity level and the reassessment documented in the medical record... Procedure: Triage by Registered Nurse,
a) All individuals entering the Emergency Department seeking medical attention and/or treatment will be entered into the appropriate tracking system, b) The registered nurse will then perform and document an initial assessment, including a determination of triage/acuity on every patient presenting to the ED...".

In addition, the facility's policy and procedure titled, "Emergency Medical Screening and Access to Emergency Care and Treatment",
Procedure No.: CP-ED-100.05, Effective Date: 12/96, Revise 9/13, established the following: " It is the policy of California Pacific Medical Center (CPMC) to ensure that individuals coming to the hospital for emergency services receive a prompt Medical Screening Examination. Should any individual be found to have an Emergency Medical Condition, that person will receive stabilizing treatment without any delay for inquiry about insurance or payment methods. NO PATIENT WITH AN EMERGENCY MEDICAL CONDITION WILL BE REFUSED CARE DUE TO AN INABILITY TO PAY..., An initial Medical Screening Examination is to be done by the Emergency Department physician on duty..., The individual will be seen by a triage nurse to determine the order in which the individual will be seen by the Emergency Department physician on duty for a Medical Screening Examination".

During an interview on 9/02/14 starting at 10 AM, Administrator-2 stated the facility's internal investigation substantiated an EMTALA violation whereby Patient-1 was turned away from emergency treatment when RN-2 did not triage the patient and had her wheeled out of the hospital. The facility learned of the allegation on 7/30/14 and immediately launched an internal investigation. The facility self reported the violation to CDPH on 8/21/14. The facility's plan of correction included ongoing re-education and counseling of ED nurses, ED MD's, and security about EMTALA. Also, the facility was performing ED patient record audits to ensure no further violations were occurring. Additionally, Administrator-2 stated this incident will be addressed in the next Nursing Quality Assurance meeting, ED Quality Assurance, Quality Assurance & Quality Improvement, and finally to the Medical Executive Committee in November 2014.