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Based on interviews, review of Emergency Department (ED) logs, medical records, ambulance reports, and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed, within its capabilities and capacity, for one discharged patient (#21) out of 31 ED sampled cases who sought care at Mercy Springfield Medical Center ED from 02/01/22 through 08/17/22. The hospitals average monthly census in the ED over the past six months was 6,465.

Findings included:

Review of the hospital's policy titled, "Medical Screening Examinations in the Emergency Trauma Center," revised 06/16/2021 showed that any individual who came by him or herself or with another person will be provided with a Medical Screening Examination within the capability of the hospital's ED, including ancillary services available to the ED, to determine whether an EMC exists. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief medical complaint. Medical Screening Examinations were performed by individuals who were determined qualified by the hospital's medical staff bylaws and were approved by the hospital's Board of Trustees.

Review of the hospital's policy titled, "Patient Triage in the Emergency Trauma Center," revised 04/21/21 showed that patients presenting to the ED will be triaged by qualified RN personnel. Patients arriving to the ED were greeted by the primary triage RN who will obtain an initial set of vital signs (blood pressure, heart rate, respiratory rate, pulse oximetry, temperature, and weight). The primary triage nurse will assign an ESI Score, Level 1- the patient will be taken immediately to an ED treatment room. Levels 2 through 5- the patient will be taken to an ED treatment room when one became available. A secondary triage nurse will initiate a focused assessment within 30 minutes of arrival. An RN or LPN will complete a focused reassessment of patients that have been in the waiting room for a time greater than two hours: the focused reassessment will be completed in the waiting room every subsequent two hours but not to exceed every three hours of wait time, the focused reassessment will be documented in the electronic health record and will include vital signs (may be obtained by a recheck technician), pain score, and patient rounding tasks. If there was a change in patient condition it will be documented with a patient observation note and a triage nurse will be notified to assess for further intervention.

Review of the hospital's policy titled, "Tiered Trauma Response," revised 10/2016 showed to expedite the appropriate personnel response necessary to provide efficient and timely care of the injured person a three level tiered approach will be used. Trauma Activation Level Three: ED physician to evaluate patient within ten minutes of patient arrival. A Computed Tomography (CT) scan will be completed within 30 minutes of order placed.

Review of the hospital's policy titled, "Dismissal of Patients from the Emergency Trauma Center," revised 06/17/2021 showed all patients discharged have appropriate follow-up care discussed with them prior to discharge. Patients were provided with a reasonable follow-up plan, and discharge instructions. If a patient desires to leave Against Medical Advice (AMA)/LWBS Left Without Being Seen (LWBS) it was defined as: LWBS before Triage (patient leaves before nursing triage was completed), LWBS After Triage (patient leaves before medical screening examination had been conducted, but after nursing triage was completed), AMA (patient had had medical screening examination by provider and chose to leave), and Elopement (patient had had nursing triage completed and medical screening completed, but left without notifying medical staff).

Review of Patient #21's medical record showed that he was an 89 year old male who presented to the ED by ambulance on 07/03/22 at 6:51 PM with a chief complaint of a fall at home which caused a head laceration and several skin tears to his upper extremities. Patient #21 had a history of high blood pressure, heart disease, diabetes, and Alzheimer's. Patient #21 was assigned an ESI three by the primary triage nurse and asked to wait in the waiting room. On 07/03/22 at 7:45 PM Patient #21 was evaluated by the secondary triage nurse who activated the Trauma Team due to the patient's advanced age and a fall where he struck his head on concrete. The secondary triage nurse documented Patient #21 scored a Level 3 on the Trauma Scale (Trauma Scale Level 3 scoring criteria: penetrating injury, uncontrolled bleeding, bleeding in the brain, blunt abdominal injury, over 65 years old with a mechanism attributed to trauma, bleeding disorders, high speed auto crash, fall from horse, drowning, or venomous snake bite. ED physician will evaluate the patient within ten minute of patient arrival). A Computed Tomography scan (CT, is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) Head & Cervical Spine was ordered by secondary triage nurse and was completed at 7:54 PM. Vital signs were obtained in the waiting room at 10:11 AM on 07/04/22, this was the only set of vital signs documented while the patient was in the waiting room for over 18 hours. The documentation in the medical record showed there was an inappropriately long delay between the 89 year old patient's arrival in the ED at 6:51 PM on 07/03/22 and the initiation of an examination by the ED provider at 1:37 PM on 07/04/22. The evidence in the medical record indicated the patient did not receive an appropriate MSE. Prior to his arrival, the elderly patient had fallen and sustained traumatic injuries to his head and bilateral upper extremities. Documentation showed staff failed to perform a neurological examination and assess the patient's gait to ensure he was safe prior to discharge.

On 07/04/22 at 10:38 PM Patient #21 again presented to the ED by ambulance for falls at home. Patient #21 was seen by primary and secondary triage nurse and again was asked to wait in the waiting room. At 3:37 AM on 07/05/22 the patient's son arrived and took him home. Staff filled out the refusal of treatment form. After the patient was discharged home, his son took him to another ED nearby where he was admitted for a closed head injury from the first fall that happened at his home.

Review of the Medical Staff Bylaws, dated 05/21/19 showed the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available. The following individuals were authorized to conduct the initial medical screening for an emergency medical condition: Medical Staff members, Emergency Trauma Center Registered Professional Nurses, Advance Practice Nurses, and Physician Assistants. The hospital will also provide stabilizing treatment within its capacity. The following individuals were authorized to provide stabilizing treatment: Paramedics, Emergency Trauma Center Registered Professional Nurses, Physicians, Advance Practice Nurses, Physician Assistants, and the Patient's Attending Physician.

Please see A-2406 for additional information.

Based on interview, review of Emergency Department (ED) logs, medical records, record reviews, and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition within its capacity and capability for one patient (#21) out of 31 ED sampled cases from 02/01/22 through 08/08/22. This failed practice had the potential to cause harm to all patients who presented to Mercy Springfield Hospital's ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 6,465.

Findings included:

Review of the hospital's policy titled, "Medical Screening Examinations in the Emergency Trauma Center," revised 06/16/21 showed that any individual who came by him or herself or with another person will be provided with a Medical Screening Examination within the capability of the hospital's ED, including ancillary services available to the ED, to determine whether an EMC exists. It was not appropriate to merely "log in" a patient and not provide a Medical Screening Examination. Individuals coming to the ED were provided a MSE beyond initial triage. Triage was not equivalent to a MSE. Triage determines the "order" in which patients will be seen, not the presence or absence of an EMC. Mental capacity must be assessed and documented as early as possible. A MSE was the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the MSE represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. A MSE was not an isolated event. It is an on-going process. The record may reflect continued monitoring according to the patient's needs and must continue until he/she was stabilized or appropriately transferred.

Review of the hospital's policy titled, "Patient Triage in the Emergency Trauma Center," revised 04/21/21 showed that patients presenting to the ED will be triaged by qualified Registered Nurse (RN) personnel. Patients arriving to the ED were greeted by the primary triage RN who will obtain an initial set of vital signs (blood pressure, heart rate, respiratory rate, pulse oximetry, temperature, and weight). The primary triage nurse will assign an ESI Score, Level one- the patient will be taken immediately to an ED treatment room. Levels two through five- the patient will be taken to an ED treatment room when one became available. A secondary triage nurse will initiate a focused assessment within 30 minutes of arrival. An RN or LPN will complete a focused reassessment of patients that have been in the waiting room for a time greater than two hours: the focused reassessment will be completed in the waiting room every subsequent two hours but not to exceed every three hours of wait time, the focused reassessment will be documented in the electronic health record and will include vital signs (may be obtained by a recheck technician), pain score, and patient rounding tasks. If there was a change in patient condition it will be documented with a patient observation note and a triage nurse will be notified to assess for further intervention.

Review of the hospital's policy titled, "Tiered Trauma Response," revised 10/2016 showed to expedite the appropriate personnel response necessary to provide efficient and timely care of the injured person a three level tiered approach will be used. Trauma Activation Level Three: ED physician to evaluate patient within ten minutes of patient arrival. A Computed Tomography (CT) scan will be completed within 30 minutes of order placed.

Review of the hospital's policy titled, "Dismissal of Patients from the Emergency Trauma Center," revised 06/17/21 showed all patients discharged have appropriate follow-up care discussed with them prior to discharge. Patients were provided with a reasonable follow-up plan, and discharge instructions. If a patient desires to leave Against Medical Advice (AMA)/LWBS Left Without Being Seen (LWBS) it was defined as: LWBS before Triage (patient leaves before nursing triage was completed), LWBS After Triage (patient leaves before medical screening examination had been conducted, but after nursing triage was completed), AMA (patient had had medical screening examination by provider and chose to leave), and Elopement (patient had had nursing triage completed and medical screening completed, but left without notifying medical staff).

Review of the document titled, "Prehospital Care Report" dated 07/03/22, showed that at 6:03 PM an ambulance crew was dispatched to Patient #21's home residence in response to a fall. On arrival to Patient #21's home, Emergency Medical Service (EMS) found him sitting on a chair in the kitchen. EMS noted dried blood on the front step. Patient #21 stated he missed the step coming on to his porch and fell. EMS assessed him and noted a head laceration approximately one inch in length, an upper arm laceration approximately two inches in length, and a laceration on the right elbow approximately four inches in length. Wounds were bandaged, a cervical collar applied, a blood glucose was checked with a result of 209, and he walked to the ambulance stretcher. En-route to the hospital vital signs were obtained twice. At 6:36 PM vital signs were blood pressure 190/92, pulse 89, respiratory rate 15, and oxygen saturation in the blood (O2 sat) 96%. At 6:44 PM vital signs were blood pressure 182/83, pulse 86, respiratory rate 14 and O2 sat 97%. He was alert and oriented times four (A&O x 4, a person was oriented to person, place, time, and situation) during transport. On arrival to the hospital he was taken to triage and report was given to the triage nurse.

During an interview on 08/15/22 at 4:00 PM, Staff FF, Emergency Medical Technician (EMT), transported Patient #21 to the hospital on 07/03/22 at 6:37 PM. She stated that Patient #21 had fallen on his front porch and hit his head sustaining a laceration and several lacerations to his upper arms. On arrival to the hospital all of the ED treatment rooms were occupied so she took him directly to the triage nurse, helped him into a wheelchair, and gave report to the triage nurse. Staff FF stated he would need a CT quickly because he had hit his head when he fell.

Review of Patient #21's medical record, which contained both ED visits on 07/03/22 and return ED visit on 07/04/22, showed that he was an 89 year old male who presented to the ED by ambulance on 07/03/22 at 6:51 PM, and again on 07/04/22 at 10:38 PM. On 07/03/22 at 6:51 PM Patient #21 presented to the ED with a chief complaint of a fall at home which caused a head laceration and several skin tears to his upper extremities. Patient #21 had a history of high blood pressure, heart attack, diabetes, and Alzheimer's disease (a chronic brain disorder characterized by gradual loss of memory, decline in intellectual ability and deterioration in personality). Patient #21 was assigned an Emergency Severity index ESI three by the primary triage nurse and asked to wait in the waiting room. On 07/03/22 at 7:45 PM Patient #21 was evaluated by the secondary triage nurse who activated the Trauma Team with a Trauma level of three. A CT of the Head & Cervical Spine was ordered by the secondary triage nurse and was completed at 7:54 PM. Vital signs were obtained in triage and then in the waiting room at 10:11 AM on 07/04/22, this was the only set of vital signs documented while the patient was in the waiting room for over 18 hours. The docuumentation in the medical record showed there was an inappropriately long delay between the 89 year old patient's arrival in the ED at 6:51 PM on 07/03/22 and the initiation of an examination by the ED provider at 1:37 PM on 07/04/22. The evidence in the medical record indicated the patient did not receive an appropriate MSE. Prior to his arrival, the elderly patient had fallen and sustained traumatic injuries to his head and bilateral upper extremities. Documentation showed staff failed to perform a neurological examination and assess the patient's gait to ensure he was safe prior to discharge.

Review of the document titled, "Prehospital Care Report" dated 07/04/22, showed at 9:18 PM an ambulance crew was dispatched to Patient #21's home residence in response to a fall. On arrival EMS were met at the door by his family, they stated that he had fallen multiple times that day. His family reported that he suffered from a muscular atrophy disorder, dementia, and that he had been discharged from the ED earlier that day. EMS found the patient on the floor next to his bed. Patient #21 requested to be transferred back to the ED to find out why he kept falling. He had a skin tear on his left forearm approximately one inch in length. EMS assisted him to the ambulance stretcher. He was alert and oriented times three with a baseline of dementia. En-route to the hospital vital signs were obtained five times with the first set at 10:22 PM; blood pressure 143/85, pulse 98, O2 sat 92%, and blood glucose 191. On arrival to the hospital he was taken to triage and report was given to the triage nurse.

During an interview on 08/11/22 at 10:15 AM, Staff EE, EMT, stated that she transported Patient #21 to the hospital on 07/04/22 at 10:27 PM. She stated on arrival to his home he was found on the floor by his bed. He was assisted to his bed and then to the ambulance stretcher. He was alert but not fully oriented to his surroundings. Vital signs times five and blood glucose were checked en-route to the hospital. She stated on arrival to the hospital she assisted him to a wheelchair and gave report to the triage nurse.

Review of Patient #21's medical record from Hospital B (acute care hospital), dated 07/05/22, showed a past medical history that included high blood pressure, dementia, history of a heart attack, and diabetes. Patient #21 was brought in to Hospital B's ED by his son on 07/05/22 at 5:24 PM for falling at home multiple times. In the ED Patient #21 had a head CT, a chest X-Ray, UA, BMP, and EKG. He was admitted to Hospital B from the ED for treatment to stabilize his emergency medical condition.

During an interview on 08/10/22 at 1:30 PM, Staff W, ED Medical Director, stated that staffing shortages have created longer wait times in the ED. As ED Medical Director he tracked how long it took for the ED providers to make first contact with a patient once they were roomed. Tracking how long a patient waited in the waiting room was not tracked by him. He stated that not checking on a patient in the waiting room for 18 hours was unacceptable. He felt that patients in the waiting room should be checked on every two or three hours with vital signs checked every four hours. Basic laboratory values may not need to be checked on all ED patients, it would depend on the patient's chief complaint, however a patient's age and wait times in the waiting room would be a factor for possibly checking laboratory values.

During a telephone interview on 08/10/22 at 3:00 PM, Staff Y, ED RN, stated an ideal wait time for a Medical Screening Examination would be no more than two hours and if it was an extremely busy day no more than four hours wait time. Anything past five hours would be unacceptable.

During a telephone interview on 08/10/22 at 11:20 AM, Staff V, ED RN, stated a blood sugar should be checked on diabetics that had long wait times in the ED waiting room. Standard care for an elderly patient who fell multiple times should include laboratory blood values, CT, X-rays, and a neurological assessment.

During a telephone interview on 08/10/22 at 4:00 PM, Staff AA, ED RN, stated that she was on duty as the secondary triage nurse during Patient #21's 07/04/22 visit to the ED. She completed his assessment and felt he did not need any laboratory blood values rechecked because he had them checked during his first visit to the ED on 07/03/22. (There were no laboratory blood values checked during Patient #21's ED visit on 07/03/22.)

During a telephone interview on 08/10/22 at 8:30 AM, Staff K, ED RN, stated that she felt diabetic patients who had long waits in the ED should have their blood sugar checked. She felt that seven to eight hours was too long for patients to wait to be seen by the ED provider.

During an interview on 08/09/22 at 12:10 PM, Staff M, RN ED Director, stated that 18 hours was too long to wait to see an ED provider and that there were definitely opportunities for improvement in the ED. Staff should be checking on patients in the waiting room every two-three hours and checking vital signs.

During an interview on 08/11/22 at 8:40 AM, Staff BB, Physician's Assistant (PA), stated that he treated Patient #21 on 07/04/22 during the first visit in the ED. He did not order blood laboratory levels because he felt it was a mechanical fall, he just lost his balance. Staff BB stated that he did not check blood sugar levels on all diabetics that presented to the ED even if the patient had a long wait to be seen by an ED provider.

During an interview on 08/10/22 at 2:25 PM, Staff U, ED RN, stated that patients waiting in the ED waiting room should be reassessed every two-three hours.

During an interview on 08/11/22 at 9:30 AM, Staff DD, ED DO, stated he treated Patient #21 on 07/04/22 and remembered he had a head laceration from a fall and skin tears to his upper extremities. He stated the 18 hour wait time was terrible. It was not a standard to always order blood laboratory values on patients who have fallen. If a patient had multiple falls it would make sense to find out why falls were happening.

The hospital failed to provide Patient #21 with a sufficient MSE, to include a physical assessment and ancillary testing to rule out an EMC on his ED visit from 07/03/22 after sitting for over 18 hours in a wheelchair in the ED waiting room. During his ED visit on the evening of 07/04/22 he was not evaluated by an ED provider after waiting for five hours.