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Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam, resulting in unidentified patient condition and poor patient outcomes. Findings include:

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A-2406 Failure to provide a medical screening exam

Based on interview and document review the facility failed to initiate the triage process in a timely manner and/or failed to perform a timely medical screening examination to determine whether an emergency medical condition existed for 9 (P-1, 21, 22, 23, 24, 25, 26, 27, 28 ) of 28 patients reviewed who presented to the emergency department for evaluation resulting in the actual and potential poor patient outcomes up to and including death. Findings include:

On 11/20/2023 at 1030, review of the medical record for P-1, the patient of concern, revealed there was only basic registration information, consent for treatment, and medication information that had been pulled in from previous visits. The documents showed an arrival of 9/25/2023 at 2113. The complaint was listed as "Suicidal-LWBS (left without being seen)." Discharge time was listed as "2220 approx." (sic)

On 11/21/2023 at 1430, review of the facility's investigation included a statement written by Registration Clerk Staff
P on 10/2/2023 (statement was not timed). She stated that the police officer came in with P-1 and "advised that (P-1) was talking about suicide and harming herself... Around 10:25 pm (22:25) (P-1's) mother said she was missing, where did she go, call the Police. Mother left to go looking for (P-1). I said I was not aware of her leaving... (Staff L) came up front and I told her to contact (Staff N) for direction on contacting Police at 22:30. Around 22:40 someone said there was an accident on (the highway)..." Staff P was unavailable for interview.

During an interview with Staff A on 11/20/2023 at 0958, she stated the facility investigation showed P-1 had been brought in through the ED lobby by a police officer for suicidal ideation. Shortly after arrival, P-1's mother arrived. "Apparently, the patient and the mother had been fighting. The mom took a seat approximately 20 feet away from the girl in the lobby... ED was swamped. A patient with an allergic reaction and angioedema was being coded and a trach (tracheostomy-a hole placed through the neck into the trachea to help air and oxygen reach the lungs) was being placed. No call was made for nurse assessment." Staff A explained the process had been for the registration staff to call for a nurse assessment for any emergent issue such as chest pain or stroke symptoms. All other patients, the registration person would call back on a radio that a patient was in the lobby awaiting triage. "The video shows the girl look at her mom and then walk out. After about 30 seconds, the mother notices she is gone and panics, running to the door and looking for her... (P-1) deliberately stepped in front of a car. She was dead at the scene and was not brought back to the hospital (for attempted resuscitation)." Staff A further stated P-1 had a history of suicidal ideation and "this was not the first time" P-1 had stepped out into traffic.

On 11/20/2023 at 1437, review of video documentation from 9/25/2023 revealed P-1 had been sitting in the lobby waiting for triage for 70 minutes prior to leaving.

On 11/21/2023 at 1149, Staff K, the charge nurse and triage nurse from 9/25/2023, stated the ED had been extremely busy. The police officer that had brought P-1 to the hospital had informed her P-1 "had assaulted her mother. I immediately asked if she was going to be arrested. He said no. He stated he was leaving, and her mother was with her in the lobby. Nothing was ever said about her being suicidal. I never laid eyes on her...There is not a nursing presence in the lobby at all times."

On 11/21/2023 at 1430, further review of the faclity investigation interviews from 10/2/2023 revealed an untimed statement from Physician Staff Q who was also unavailable for interview. He stated there was a critical patient and he "was getting airway secured (sic). After that he was told by an RN (registered nurse) that a 16 year old was
hit on the highway and was coming in. A little later he was told that the patient was in the waiting room and then eloped and got hit." He was queried during the facility interview as to if caring for the critical patient had delayed P-1 from coming back into the ED for a medical screening exam to which he stated it did delay someone from coming back; but was unsure it would have been P-1. He further stated suicidal patients were not prioritized and he felt the ED needed a dedicated triage nurse as well as a dedicated social worker for psychiatric consults/assessments.

When interviewed on 11/20/2023 at 1308, Risk Manager Staff C stated she was called by VP Nursing Staff A within one hour of the event. "I knew right away we would need an RCA for this critical incident." Staff C stated there were multiple "opportunities" identified for the facility to improve upon. "First, the patient was not triaged. This is the root of the situation. Had she been triaged correctly this could have potentially been avoided... There was a drift from normal practice. It is not the role of non-clinical people to determine acuity... There is not a good process in place for behavioral health patients. Somewhere, they forgot about being able to use sitters for behavioral health patients... While it was busy and a lot was going on, it doesn ' t absolve us of our responsibility. Hospital work demands assessment of priorities. Suicidal ideation is a priority. There was no suicide screening being done.

Review of the Action Plan on 11/21/2023 at 1030 revealed 14 of 20 items listed were still in progress or their stage had not been identified on the provided documentation as follows:

3. Send policy to QPCC (Quality Patient Care Committee) In progress.
4. Audit compliance - number of CSSRS vs number of patients with chief complaint of behavioral health concern. Audit weekly for 90 days. After first week, evaluate need for additional education. In progress.
5. Triage Update/Nurse Assessment - Nurse Assessment must be called on EVERY patient. In progress.
6. Find location for triage at the front desk. In progress.
9. Reiterate patients are 1:1 only if they are a high risk from CSSRS. In progress.
11. Update Elopement policy. Stage process is in is unidentified.
12. Educate staff on what to do when a patient elopes. In progress.
14. Evaluate security. In progress.
15. Track door to triage time. In progress.
16. Evaluate length of stay. Stage process is in is unidentified.
17. Re-educate on Policy Stat. Stage process is in is unidentified.
18. Send CBL (computer-based learning) for staff to complete? Update as needed. In progress.
19. Train team lead to complete Safe-T tool. In progress.
20. Re-educate staff on elopement policy. Stage process is in is unidentified.

On 11/20/2023 at 1129, a targeted review of the 24-hour census from 9/25/2023 revealed other patients also left without being seen (LWBS) as follows:

-P-21 An 8-year-old male who presented to the ED at 0847 for an upper extremity injury. Triage 0945. LWBS 1035.
-P-22 A 7-year-old female who presented to the ED at 0914 for a cough. Triage 0950. LWBS 1250.
-P-23 A 59-year-old male who presented to the ED at 0919 for a laceration. Traige 0955. LWBS 1236.
-P-24 A 36-year-old male who presented to the ED at 0929 for abdominal pain. Triage 1000. LWBS 1302.
-P-25 A 24-year-old female who presented to the ED at 1143 for a sore throat. Triage not done. LWBS 1250.
-P-26 A 27-year-old male who presented to the ED at 1615 for generalized weakness. Triage not done. LWBS 1711.
-P-27 A 19-year-old female who presented to the ED at 2015 for an upper extremity injury. Triage not done. LWBS 2300.

Review of facility policy #9076427 titled "Triage" last revised 4/2015 states, "All patients who present to the Emergency Department will be classified by an RN. 1. The most important key factors required to determine a patients' (sic) disposition are: a. Chief complaint and signs/symptoms associated with complaint b. General appearance c. Vital signs d. Allergies (for patient safety) e. Patient history including medication, (prescription, non-prescription and supplements. The above information will be required on all patients in Triage and may be collected in a room prior to entering ED or at the bedside." The policy fails to include the triage process, such as timelines, how patients in the lobby are monitored, and what to do if a nurse is not present at the time the patient presents to the facility to be seen.

Review of the facility "Medical Staff Bylaws" last revised 1/31/2019 failed to identify who could conduct a medical screening exam. Request was made for the medical staff "Rules and Regulations" but was not provided prior to end of survey.