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Based on record reviews and staff interviews, it was determined the hospital did not reassess two (2) out of 20 patients (Patient #1 and #14) who presented to the ED per the hospital's policies and procedures, that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases. This deficient practice poses a risk to the health and safety of patients if the patient's condition starts to deteriorate and goes unnoticed while waiting for care in the ED.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: " ...Procedure ...A. Registration and Triage ...HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care. All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing an medical emergency, must receive a medical screening examination ....Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination described in (B), below ....Triage does not satisfy the requirements for a medical screening examination as defined below in Section (B). B. Medical Screening Examination. HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services (or when such a request is made on their behalf), regardless of their ability to pay. The purpose of the medical screening examination is to determine whether the person has an emergency medical condition ....If the Person is determined not to have an emergency medical condition, the qualified medical personnel who performed the medical screening examination will document this fact in the person's medical record. C. Stabilizing Treatment. If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment within its capabilities, unless the person requests transfer to another facility ....The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person's emergency medical condition has been stabilized ...."

Hospital policy titled, "Network Emergency Department Operating Policy", revealed: " ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity ....Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient ...."

Hospital document titled, "HonorHealth Emergency Department Reassessment Guidelines", revealed: " ...Purpose: Reassessment guidelines promote rapid identification of changes or deterioration in patient's conditions and are determined by evidence-based practice and clinical expertise ....Guideline/Parameters ...ESI Level ...Should be reassessed (after initial assessment) ...2 ...No less frequently than every hour for the first four hours, then every two hours if clinically stable ...3 No less frequently than every four hours if vital signs are within normal limits and no less frequently than every two hours for the first four hours if vital signs are abnormal then every four hours if clinically stable ....Situations Requiring Special Considerations ...Patients remaining in the waiting room for an extended period. Reassessment frequency, including vital signs, should occur at a minimum of every two hours until brought into the department ...."

Patient #1's medical record dated 07/26/2024 identified an ED care timeline, and it revealed: " ...7/26/2024 ...23:54 ...Patient arrived in ED ...23:55 ...Arrival Complaint ...Asthma ...23:57 ...Vital Signs ...Heart Rate: 140 ...Resp: 22 ...BP: 148/87 ...7/27/2024 ...00:00 ...Patient Acuity: 2 ...00:00 ...Chief Complaints Updated ...Asthma (Pt reports increased SOB and cough x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working) ...01:26 ...ED Prolonged Wait Patient Message ...02:54 ...Vital Reassessment ...04:14 ...Patient roomed in ED ...to room 17 ...04:14 ...Assign Physician ...04:26 ...Patient Care Initiated ....04:48 ...Medication Given ...ipratropium-albuterol (DUONEB) 0.5 mg-2.5 mg/3mL nebulizer solution 3mL ...04:48 ...RT Therapies ...RT Assessment ...Respiratory Pattern: Dyspnea at rest (SOB), Right Upper Lobe Auscultation: Crackles, Right Middle Lobe Auscultation: Crackles, Right Lower Lobe Auscultation: Crackles, Left Upper Lobe Auscultation: Crackles, Left Lower Lobe Auscultation: Crackles ...."

Patient #14's medical record dated 07/26/2024 identified an ED care timeline, and it revealed: " ...23:58 ...Patient arrived in ED ...00:00 ...Vital Signs ...Heart Rate: 125 ...BP: 160/104 ...00:01 ...Chief Complaints Updated ...Leg Swelling (Pt reports L leg swelling x3 days with warmth and throbbing pain. Pt reports L hip replacement 7/15/24) ...00:02 ...Patient Acuity: 2 ...01:28 ...ED Prolonged Wait Patient Message ....02:30 ...Patient dismissed ...."

Review of Patient #14's medical record revealed a document titled, "Refusal of Screening Examination and Treatment", and Patient #14 was called with no answer at 04:33, 04:48, and 05:03. Further review of Patient #14's medical record revealed no reassessment between triage at 00:01 ESI of 2 and Patient #14's LWBS at 04:33, with four hours and 32 minutes elapsed.

Employee #4 and Employee #6 confirmed during an interview conducted on 10/22/2024 that Patient #1 and Patient #14 did not have documented reassessment or vital signs retaken for changes of condition per the facility's policies and procedures and guidelines.

Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for three (3) out of 20 patients (Patients #1, #10, and #14), who presented to the ED seeking medical treatment. Failure to provide timely medical screening examination and treatment poses a potential risk that the patient's condition deteriorates and they do not receive life saving medical treatment

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: " ...Procedure ...A. Registration and Triage ...HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care. All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing an medical emergency, must receive a medical screening examination ....Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination described in (B), below ....Triage does not satisfy the requirements for a medical screening examination as defined below in Section (B). B. Medical Screening Examination. HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services (or when such a request is made on their behalf), regardless of their ability to pay. The purpose of the medical screening examination is to determine whether the person has an emergency medical condition ....If the Person is determined not to have an emergency medical condition, the qualified medical personnel who performed the medical screening examination will document this fact in the person's medical record. C. Stabilizing Treatment. If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment within its capabilities, unless the person requests transfer to another facility ....The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person's emergency medical condition has been stabilized ...."

Hospital policy titled, "Network Emergency Department Operating Policy", revealed: " ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity ....Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient ....VI. Staffing: ...The Emergency Department is staffed with professional and non-professional staff members to provide the required hours of nursing care for its daily census ...Staffing will be flexed and managed by Nursing Supervisors to account for changes in acuity ...."

Hospital document titled, "End of Shift Report 07/26/2024", revealed: " ...Time: 1800-0600 ...Volume: 56 ...Barriers & Safety: ...Closed main assignment 17-20 at midnight due to staffing ...5 in the lobby at 0220 ...CN covering assignment while nurse took patient to MRI and take patients left in assignment 3-6 allowing the 3am nurse to leave on time. CN unable to go into the count, helping RNs with task trying to get everyone caught up. CN called reports, discharged patients, and landed patients from triage and ambulances. Short staffed with high acuity patients. Patient on split flow need a consult from plastics due to a dog bite to the face, (Provider #3) refused to come see the patient. NP treated the patient. (Patient #21) ...."

The end of shift report for the morning shift of 07/26/2024 was requested. None was provided.

Review of hospital ED log for July 2024 revealed from 07/26/2024 18:00 through 07/27/2024 06:00 there were 12 patients that left without being seen (LWBS).

Review of Patient #1's medical record dated 07/26/2024 identified an ED care timeline, and it revealed: " ...7/26/2024 ...23:54 ...Patient arrived in ED ...23:55 ...Arrival Complaint ...Asthma ...23:57 ...Vital Signs ...Heart Rate: 140 ...Resp: 22 ...BP: 148/87 ...7/27/2024 ...00:00 ...Patient Acuity: 2 ...00:00 ...Chief Complaints Updated ...Asthma (Pt reports increased SOB and cough x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working) ...01:26 ...ED Prolonged Wait Patient Message ...02:54 ...Vital Reassessment ...04:14 ...Patient roomed in ED ...to room 17 ...04:14 ...Assign Physician ...04:26 ...Patient Care Initiated ....04:48 ...Medication Given ...ipratropium-albuterol (DUONEB) 0.5 mg-2.5 mg/3mL nebulizer solution 3mL ...04:48 ...RT Therapies ...RT Assessment ...Respiratory Pattern: Dyspnea at rest (SOB), Right Upper Lobe Auscultation: Crackles, Right Middle Lobe Auscultation: Crackles, Right Lower Lobe Auscultation: Crackles, Left Upper Lobe Auscultation: Crackles, Left Lower Lobe Auscultation: Crackles ...."

Review of Patient #1's medical record dated 07/27/2024 identified an ED provider note, and it revealed: " ...Time Seen: 4:26 AM ...Chief Complaint ...Asthma Pt reports increased SOB and coughing x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working ...presents to the emergency department for evaluation of cough an {sic}(and) asthma exacerbation. Patient reports history of asthma, and recent diagnosis of bronchitis that (Patient #1) reports triggered (Patient #1) asthma ....reports both a dry and productive cough of clear mucus. (Patient #1) reports that (Patient #1) was cough so hard (Patient #1) experienced post-tussive emesis and shortness of breath earlier ...Radiology Studies: XR Chest ...Impression: No acute findings ....Patient will be given Solu-Medro, IV fluids, DuoNeb, promethazine with codeine ...Patient reassessed at bedside, resting comfortably, still with cough, however has improved from prior. Discussed the patient is on all appropriate therapies ....instructed to follow up with pulmonology, to use a humidifier while at home, and to continue compliance with all...medications. Updated on results. Discussed plan for discharge including indications to return to ER. Instructed to follow up with PCP/other specialist. Patient agrees with plan ...."

Review of Patient #1's medical record revealed they remained in the waiting area after triage at 00:00, and no laboratory or diagnostic imaging were ordered, and no interventions and treatment were initiated until after medical screening examination at 04:26.

Review of additional 19 randomly selected ED medical records revealed two (2) patients had a delay in examination or treatment:

1. Patient #10, arrived 07/14/2024 21:55 for chest pain, triaged 22:00 with ESI 3, EKG 22:07 with no documentation reviewed by a qualified medical provider, no MSE, LWBS 23:46, time elapsed from arrival: one hour and 51 minutes;
2. Patient #14, arrived 07/26/2024 23:58 for leg swelling, triaged 07/27/2024 00:01 with ESI 2, no MSE, patient called but no answer 04:33, 04:48, and 05:03, time elapsed from arrival: four hours and 35 minutes

Employee #4 and Employee #6 confirmed during an interview conducted on 10/22/2024 that Patient #1 presented to the ED with asthma exacerbation, and was triaged an acuity of two. Employee #4 and Employee #6 also confirmed Patient #1 did not receive a medical screening examination until four hours and 32 minutes after arrival. Employee #4 confirmed Patient #1 did not receive breathing treatment for their asthma exacerbation until four hours and 51 minutes after arrival.