HospitalInspections.org

Based on a review of the medical records of 44 patients, interviews with administrative staff, tours of the emergency departments of two campuses, a review of facility policies and procedures, and a review of related documentation, it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice.

Findings include:

1. The facility failed to ensure that policies and procedures governing medical care in the emergency department were implemented (Refer to Tag A1104).

A. Based on a review of an emergency department policy and procedure, review of the medical records of 4 of 4 patients (#S5, #S10, #S11, #S20) documented as having been discharged from the Union SED (Satellite Emergency Department), and interview with administrative staff, it was determined that a policy regarding discharge from the emergency department was not implemented.

Findings include:

Reference: Policy and procedure titled, "Discharge Instructions and Discharge Process from the Emergency Department" states:
".....
PROCEDURE
.....
C. The nurse caring for the patient will verify the discharge order .....
....."

1. The EMERGENCY COURSE AND TREATMENT section in the medical record of Patient #S5 for an Emergency Department (ED) visit on 1/29/21 stated:
".....
Patient was discharged ambulatory and with steady gait.
.....
CONDITION OF DISCHARGE: Stable
....." The entry was electronically signed by a physician. There was no order to discharge the patient in the medical record.

2. The EMERGENCY COURSE AND TREATMENT section in the medical record of Patient #S10 for an ED visit on 2/2/21 stated:
".....
On discharge, patient is resting comfortably in no acute distress. .....
.....
Discharge instructions discussed with patient. Patient is amenable.
CONDITION ON DISCHARGE: Stable
PLAN: The patient remained hemodynamically stable, awake, and ambulatory and will be discharged. .....
....." The entry was electronically signed by a physician assistant and a physician. There was no order to discharge the patient in the medical record.

3. The EMERGENCY COURSE AND TREATMENT section in the medical record of Patient #S11 for an ED visit on 2/4/21 stated:
".....
Fourth re-evaluation, patient now more awake and alert. Seen ambulating with a steady and unassisted gait. Patient appears clinically sober at present time.
Based on the patient's reassessment and response to treatment [sic] arrangements made for discharge.
Patient has improved upon re-evaluation and requires no further treatment or management in the Emergency Department. At this time, the patient is medically stable for discharge.
.....
CONDITION ON DISCHARGE: Stable
....." The entry was electronically signed by a physician. There was no order to discharge the patient in the medical record.

4. The EMERGENCY COURSE AND TREATMENT section in the medical record of Patient #S20 for an ED visit on 1/31/21 stated:
".....
On subsequent re-evaluation, patient is now awake, alert, oriented (x3), in not acute distress. Seen resting comfortably on stretcher, in no acute distress. Patient answering questions. Speaking in clear sentences. (-) slurred speech. No focal deficits noted. Seen ambulating in a steady and unassisted gait.
Patient has improved upon re-evaluation and requires no further treatment or management in the Emergency Department. At this time, the patient is medically stable for discharge to Serenity.
Patient states he fully agrees with and understands discharge instructions. States that he agrees with the plan and disposition. I have given the patient the opportunity to ask additional questions.
.....
CONDITION ON DISCHARGE: Stable
....." The entry was electronically signed by a physician assistant and a physician. There was no order to discharge the patient in the medical record.

5. Administrator #30 agreed with the findings.

B. Based on a review of an emergency department policy and procedure, review of the medical record of one of two patients (#S1) who presented to the Satellite Emergency Department (SED) with a chief complaint of alcohol ingestion, and interview with administrative staff, it was determined that the hospital has a policy for the management of intoxicated patients that was not implemented.

Findings include:

Reference: Policy and procedure titled, "BEHAVIORAL HEALTH, MANAGEMENT OF THE PATIENT IN THE EMERGENCY DEPARTMENT (ED) Protocol" states: ".....
II. CONTENT
A. Triage
1. The triage nurse will assess the patient upon presentation to the Emergency Department (ED). Any patient assessed to be "at risk" will be placed on observation pending physician evaluation and physician order for observation. The patient assessed "at-risk" will be assigned the appropriate level of observation in the ED by the ED physician. .....
2. "At-risk" will be defined as suspected or known: .....
c) in imminent danger of harm to self, others, or property, or "at-risk" with potential for elopement; ..... . Patients with any one of the above will be considered at-risk. .....
.....
4. Precautions will be initiated by the nursing staff for all patients assessed to be at-risk:
a. Patient is under observation at all times. Physician order must clearly document 1:1 or video-enhanced, shared or continuous observation.
.....
B. Levels of Observation
1. 1:1 Observation
.....
e. Agitated and/or uncooperative behavior
.....
2. Video-enhanced, shared, continuous observation
.....
d. Intoxicated with risk of falls or elopement
.....
D. Medical Evaluation of Behavioral Health Patients
.....
2. Medical Evaluation of Behavioral Health (BH) Patients
Patients who present to the Emergency Department with behavioral health complaints are evaluated by an emergency physician.
....."

1. Review of the medical record of Patient #S1 revealed that he/she arrived to the SED by ambulance on 12/31/20 at 9:15pm with an "ED Complaint" of "Etoh (ethyl alcohol), foot pain" as documented by a registrar. The "Admission Type" subsection of the "Visit Information" section stated: "Emergent." There was no evidence in the medical record that the patient documented with a chief complaint of "Etoh" was assessed by nursing staff and placed on an increased level of observation.

C. Based on a review of the rules and regulations of the medical staff and the medical records 3 of 9 patients (#S4, #S18, #S20), it was determined that a policy and procedure governing documentation of medical care provided in the Emergency Department (ED) was not adhered to.

Findings include:

Reference: Policy and procedure titled, "Medical Record Content, Compilation and Use" states:
".....
Procedure:
.....
III. Content of Medical Records for Emergency Department Patients .... :
J. Physician Assessment .....
.....
M. Treatment rendered ..... (signed by person who rendered the treatment);
.....
P. Final Disposition;
....."

1. Review of the medical record of Patient #S4, a 7 year-old, revealed that the patient presented to the Satellite Emergency Department (SED) on 11/3/20 at 3:28pm with a complaint of "Fever, headache, vomiting." A note entered by a registrar at 3:37pm stated: "Patient dismissed." Administrator #30 agreed that "Patient dismissed" was not an accepted disposition.

2. Review of the medical record of Patient #S18 revealed that the patient presented to the SED on 11/10/20 at 6:17pm with an "Arrival Complaint" of "Throat pain, Nosal [sic] Coingestion [sic], Stomach pain." A note entered by a registrar at 6:30pm stated: "Patient dismissed." The "Discharge Disposition" section of the medical record contained the entry at 10:55pm: "Lwbs (Left without being seen) After Triage." There was no documentation in the medical record indicating that a triage assessment or medical screening exam were started. Administrator #30 agreed that "Patient dismissed" was not an accepted disposition and that the medical record did not support the entry that the patient left without being seen after triage.

3. Review of the medical record of Patient #S20 who presented to the SED on 1/30/21 at 2:02pm revealed:

a. An OBSERVATION FLOWSHEET, dated 1/30/21, included entries indicating that the patient was in 4-point restraints and sleeping at 3:00pm, 3:15pm, and 3:30pm; and in 2-point restraints and sleeping at 3:45pm, 4:00pm, 4:15pm, and 4:30pm.

b. A ED Care Timeline dated 1/31/21 included the entry at 3:42pm:
"Violent or Self-Destructive Restraints
End Violent Restraint Alerts
End Violent Restraint Alerts: Yes
Assessment
Less Restrictive Alternative: 1:1 patient care
.....
Education
Discontinuation Criteria: No longer Combative; No longer threat to others; No longer threat to self; Cooperation with treatment (sleeping well at this time, right wrist restraint and left ankle restraint removed at this time)
Criteria explained: Yes
Patient's Response to Intervention: Sleeping
....."

The nurse documented that he/she educated a sleeping patient regarding the discontinuation criteria for restraint usage and that the patient's response was that he/she was asleep. Education cannot be provided to a sleeping patient.

D. Based on review of the medical record of one patient (#S20) who was physically restrained for behavior management, review of policy and procedure, and interview with administrative staff, it was determined that a policy and procedure governing the use of physical restraints in the ED was not implemented.

Findings include:

Reference: Policy and procedure titled, "Restraints and Seclusion" states:
"Purpose:
The purpose of this policy is to establish a process for the appropriate use of restraints and seclusion in accordance with CMS (Centers for Medicare & Medicaid Services), NJDOH (New Jersey Department of Health) and Joint Commission standards and to ensure that the use of restraints and seclusion is limited to clinically appropriate and adequately justified situations.
Policy Statement:
.....
Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
.....
Procedures:
.....
6. Discontinuation of restraint and seclusion/removal of restraint/seclusion
1. Restraint or seclusion is discontinued as soon as it is safely possible, and the patient meets the behavioral criteria established by the ordering Physician, or ordering nurse practitioner/clinical nurse specialist, licensed physician assistant, or resident physician authorized to write the order.
2. A Practitioner or a registered nurse can remove the restraint or the patient from seclusion.
....."

1. Review of the medical record of Patient #S20 who presented to the Satellite Emergency Department (SED) on 1/30/21 at 2:02pm revealed:

a. The "Criteria for Discontinuation" section of a 4-point restraint order for violent or self-destructive behavior order electronically signed by an APN (Advance Practice Nurse) at 2:08pm on 1/30/21 stated:
"No longer combative
No longer threat to self
No longer threat to others
Cooperation with treatment."

b. An OBSERVATION FLOWSHEET dated 1/30/21 included entries indicating that the patient was in 4-point restraints and sleeping at 3:00pm, 3:15pm, and 3:30pm; and in 2-point restraints and sleeping at 3:45pm, 4:00pm, 4:15pm, and 4:30pm.

c. An ED Care Timeline dated 1/31/21 included the entries by the same RN:
"1542 (3:42pm) Violent or Self-Destructive Restraints
End Violent Restraint Alerts
End Violent Restraint Alerts: Yes
Assessment
Less Restrictive Alternative: 1:1 patient care
.....
Education
Discontinuation Criteria: No longer Combative; No longer threat to others; No longer threat to self; Cooperation with treatment (sleeping well at this time, right wrist restraint and left ankle restraint removed at this time)
Criteria explained: Yes
Patient's Response to Intervention: Sleeping
.....
15:42 Violent or Self-Destructive Restraints
Restraint Monitoring Every 30 Minutes
Patient Assessment/Response to Intervention: Sleeping
Criteria met for discontinuation of restraints: Yes
Continuous observation: Yes (2 restraints still on left wrist restraint [sic] and in [sic] right ankle [sic] restraints still on)
1542 Restraint Summary
Other flowsheet entries
BH (Behavioral Health) Restraint Status: CONTINUED .....
....."

Although the patient was documented by a 1:1 sitter to have been asleep while in restraints from 3:00pm until 4:30pm and an RN to have met the criteria for discontinuation of restraints at 3:42pm, the RN continued the use of restraints until at least 4:30pm. Administrator #30 agreed with the findings.

E. Based on review of policy and procedure, review of the medical record of 1 of 2 patients (#S5) who were placed on a 1:1 (one-to-one) level of supervision, and interview with administrative staff, it was determined that a policy and procedure governing patient safety observation in the Emergency Department (ED) was not implemented.

Findings include:

Reference: Policy and procedure titled, "Patient Safety Observation Policy (Sitter Policy)
.....
Purpose: The purpose of this policy is to ensure a safe and therapeutic environment for all patients, including an increased level of observation, when indicated and clinically appropriate, for those who are at risk for self-harm, suicide, falls, or other safety events.
.....
Procedure:
.....
Indications:
.....
* 1:1 Sitter for Safety and/or Spotter: a patient a [sic] risk for safety or other approved criteria
.....
Roles and Responsibilities of Patient Safety Technician (PST) and Patient Care Technician (PCT)/Nursing Assistant (NA):
* General Responsibilities:
.....
° Documents on Observation Flowsheet
....."

1. Review of the Satellite Emergency Department (SED) medical record of Patient #S5 revealed:

a. A physician order dated 1/29/21 at 12:49am stating: "Restraints violent or self-destructive behavior adult (age 18 and older) ....."

b. A physician order dated 1/29/21 at 12:51am stating: "Patient Observation Status: 1:1 Eye Contact ....."

c. An ED Care Timeline included the entry dated 1/29/21 at 2:38am: "Orders Discontinued Patient Observation Status: 1:1 Eye Contact (01/29/21 0052)"

d. There was no evidence in the medical record of an Observation Flowsheet for the 1 hour and 46 minutes that the patient was ordered to be on a 1:1 level of observation.

2. Administrator #2 agreed with the findings.

F. Based on a review of an Emergency Department (ED) policy and procedure, review of the medical records of 4 of 9 patients (#S1, #S4, #S18, #S19) who presented to the Union Satellite Emergency Department (SED), and interview with administrative staff, it was determined that not every patient who presented to the SED was triaged.

Findings include:

Reference: Policy titled, "Emergency Department Triage" states: ".....
Policy Statement:
It is the policy of Atlantic Health System that all patients presenting to the Emergency Department will be triaged by a registered nurse. .....
.....
Definitions:
Emergency Department Triage: is a process of sorting and prioritizing injured and or sick patients according to their severity of illness and care and care needs. .....
.....
Triage is a two-step process, "Quick Triage" and "Full Triage." The quick and full triage will be based completed based on chief complaint, clinical history and physical assessment. The triage assessment shall include rapid, systemic collection of data related to the patient's chief complaint. Patients will receive a triage evaluation to determine the nature, seriousness, and level of acuity of their complaint.
Procedure:
1. Quick Triage: The quick triage process can be initiated by the charge nurse based on the department needs. Patients receive a Quick triage evaluation to determine the nature and seriousness of their chief complaint and to determine their acuity/ESI level. .....
a. Components of quick triage include:
i. Chief Complaint
ii. Vital Signs/Pain
* Vital Signs to include: Pulse, pulse oximetry and respirations. (Additional vital signs
may be obtained based on clinical assessment)
* Age appropriate Pain scale is utilized
iii. Acuity/ESI Level assignment:
.....
....."

1. Review of the medical record of Patient #S1 revealed that he/she arrived to the SED by ambulance on 12/31/20 at 9:15pm with an "ED Complaint" of "Etoh (ethyl alcohol), foot pain" as documented by a registrar. The "Admission Type" subsection of the "Visit Information" section stated: "Emergent." A "CoVID-19 Exposure Screening" was documented as having been done. There no no evidence in the medical record that the patient was triaged.

2. Review of the medical record of Patient #S4 revealed that the patient arrived to the SED on 11/3/20 at 3:28pm. A registrar documented the "ED Complaint" as "Fever, headache, vomiting." The "Admission Type" subsection of the "Visit Information" section stated: "Emergent." There no no evidence in the medical record that the patient was triaged.

3. Review of the medical record of Patient #S18 revealed that the patient arrived to the SED on 11/10/20 at 6:17pm. A registrar documented the "ED Complaint" as "Throat pain, nosal coing." [sic] The "Admission Type" subsection of the "Visit Information" section stated: "Emergent." There was no evidence in the medical record that the patient was triaged. A registrar entry at 6:30pm stated: "Patient dismissed."

4. Review of the medical record of Patient #S19 revealed that the patient arrived to the SED on 11/27/20 at 7:59pm. A registrar documented the "ED Complaint" as "Covid ruleout." [sic] The "Admission Type" subsection of the "Visit Information" section stated: "Emergent." There no no evidence in the medical record that the patient was triaged. An RN entry at 10:54pm stated:
"Patient roomed in ED
To room HALL A."
A registration entry at 10:55pm stated: "Patient discharged and an RN entry at 10:55:32pm stated: "ED disposition set to Left Without Being Seen."



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G. Based on review of one (1) of one (1) medical record (#O9), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that patients presenting to the Emergency Department (ED) with signs and symptoms related to COVID-19 are triaged according to facility protocol.

Findings include:

Reference: Facility document, New ED Entrance, Quick Triage, Quick Registration and Direct Bedding, states, "... If the patient has had recent COVID-19 exposure and reports s/s (signs/symptoms) related to COVID-19: 1. Contact Charge Nurse for immediate bed placement ... Escort patient to assigned ED exam room through the ambulance entrance ..."

1. Review of Medical Record #O9 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 11/17/20 at 1:53 AM with complaints of shortness of breath, chest pain, cough, and dizziness.

b. The ED Note at 2:00 AM by the RN (Registered Nurse) states, "Pt (patient) outside waiting because he reports experiencing cough, sob (shortness of breath), dizziness. Pt asking nurse "what's the deal?" Pt informed that because he is having COVID symptoms he needs to wait outside ..."

c. The charge nurse was not contacted for immediate bed placement.

d. The patient was not escorted to an assigned ED exam room.

2. The above findings were confirmed with Staff #17.

H. Based on review of eleven (11) of twenty-four (24) medical records (#O3, #O6, #O9, #O10, #O18, #O21, #O23, #S2, #S8, #S12 and #S13), staff interviews, and review of facility policies and procedures, it was determined that the facility failed to ensure that a complete assessment of vital signs and a pain assessment/management, is provided to each patient during the triage process.

Findings include:

Reference #1: Facility policy, "Emergency Department Triage" states, "... Patients receive a Quick triage evaluation to determine the nature and seriousness of their chief complaint and to determine their acuity/ESI level. ... a. Components of quick triage include ... ii. Vital Signs/Pain... Vital Signs to include: Pulse, pulse oximetry and respirations. (Additional vital signs may be obtained based on clinical assessment). ... b. If the quick triage process cannot be completed: The chief complaint and quick assessment will be documented, and the patient will be escorted to a room for ESI determination and Full Triage. ... ."

Reference #2: Facility policy titled, "Pain Assessment/Management" states, "...Procedure: 1. Emergency Department (ED) Pain Assessment a. Personnel: The ED nurses will work in conjunction with the practitioners to evaluate a patient's level of pain and implement non-pharmacological as well as pharmacological treatments to alleviate or lessen the pain. ...c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record. ...d. if pain is present, assessment may include but is not limited to: location, rating, description, pain indicators, scale used, and interventions implemented, as appropriate for the patient. ...e....iii. MAUPG (Mutually Agreed Upon Pain Goal). Establish the MAUPG for acute pain patients to achieve a level of functioning where they are able to participate in daily activities.

1. Review of Medical Record #O9 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 11/17/20 at 1:53 AM with complaints of shortness of breath, chest pain, cough, and dizziness. The patient received a quick triage at 1:55 AM, where he/she was assigned an acuity level of 2.

(i) At 1:54 AM, under the section marked "Vital Signs," the patient's temperature was assessed.

b. There was no evidence that the patient's pulse, pulse oximetry, or respirations were assessed during triage.

c. There was no evidence that the patient's pain was assessed during triage.

2. Review of Medical Record #O23 on 4/8/21 revealed the following:

a. The patient arrived to the ED on 12/28/20 at 10:31 AM with complaints wanting to speak to a social worker. The patient received a quick triage at 10:32 AM, where he/she was assigned an acuity level of 3.

b. There was no evidence that the patient's pulse, pulse oximetry, or respirations were assessed during triage.

c. There was no evidence that the patient's pain was assessed during triage.

3. The above findings were confirmed with Staff #17.


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4. Review of Medical Record #O3 on 4/6/21 revealed the following:

a. The patient arrived to the ED on 10/23/20 at 5:13 PM with complaints of a low hemoglobin. The patient received a quick triage at 5:18 PM and a full triage at 5:36 PM, where he/she was assigned an acuity level of 2.

(i) At 5:32 PM, under the section marked "Vital Signs," the patient's temperature was assessed.

b. There was no evidence that the patient's pulse, pulse oximetry, or respirations were assessed during triage.

c. There was no evidence that the patient's pain was assessed during triage.

5. Review of Medical Record #O6 on 4/6/21 revealed the following:

a. The patient arrived to the ED on 11/22/20 at 10:05 PM with complaints of "not feeling well" and "requesting an evaluation." The patient was triaged at 10:07 PM and assigned an acuity level of 4.

b. There was no evidence that vital signs that include the patient's pulse, pulse oximetry, or respirations, were assessed during triage.

c. There was no evidence that the patient's pain was assessed during triage.

6. Review of Medical Record #O10 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 10/23/20 at 4:41 PM with complaints of hallucinations and suicidal ideation. The patient received a quick triage at 4:45 PM and a full triage at 4:51 PM, where he/she was assigned an acuity level of 2.

b. There was no evidence that the patient's pain was assessed during triage.

7. Review of Medical Record #O18 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 11/22/20 at 11:43 PM with complaints of hearing voices. The patient received a quick triage at 11:47 PM and a full triage at 11:56 PM.

b. There was no evidence that the patient's pain was assessed during triage.

c. ED provider notes dated 11/23/20 at 1:42 AM state, "Reports bilateral foot pain."

8. Review of Medical Record #O21 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 11/16/20 at 10:23 PM with complaints of foot pain and hearing voices. The patient received a quick triage at 10:26 PM and a full triage on 11/17/20 at 12:44 AM.

b. There was no evidence that the patient's pain was assessed during triage.

9. Staff #1, Staff #2, and Staff #3 confirmed the above findings on 4/7/21 at 2:50 PM.

10. Review of Medical Record #S2 on 4/6/21 revealed the following:

a. Patient #S2 presented to the ED on 11/16/20 at 4:29 PM with complaints of "foreign body in throat."

b. There was no evidence that a pain assessment was completed.

11. Review of Medical Record #S8 on 4/6/21 revealed the following:

a. Patient #S8 presented to the ED on 2/19/21 at 2:23 PM with complaints of "knee pain."

b. There was no evidence that a pain assessment was completed.

12. Review of Medical Record #S12 on 4/7/21 revealed the following:

a. Patient #S12 presented to the ED on 1/10/21 at 7:31 PM with complaints of "hand injury." On the "Patient Care Timeline" at 7:45 PM, under Vital Signs, it states "Pain Score: 7 - Severe pain."

b. There was no evidence that a MAUPG was established.

c. There was no evidence that interventions were implemented to reduce the pain score.

13. Review of Medical Record #S13 on 4/6/21 revealed the following:

a. Patient #S13 presented to the ED on 3/3/21 at 8:32 PM for complaints of "Alcohol Intoxication."

b. There was no evidence that a pain assessment was completed.

14. The above findings were confirmed with Staff #4.

I. Based on review of six (6) of seventeen (17) medical records (#O3, #O6, #S2, #S3, #S6A, #S14), review of policy and procedure, and interviews with administrative staff it was determined that the facility failed to ensure that staff notifications and attempts to locate patients who leave the Emergency Department (ED) without being seen, are documented.

Findings include:

Reference: Facility policy, "Left Without Being Seen" states, "... 1. The staff member discovering the patient's absence will notify the physician, the Charge Nurse, and the Clinical Nursing Coordinator, where applicable. 2. The staff member discovering the patient's absence will enter the time of discovery, make three attempts to locate the patient, including immediate premise, and document their efforts in the patient's electronic medical record (EMR). ... 5. Documentation will be made in the patient's EMR of the date, time, who notified, and outcome of the attempts of notification. ... ."

1. Review of Medical Record #O3 on 4/6/21 revealed the following:

a. The patient arrived to the ED on 10/23/20 at 5:13 PM with complaints of a low hemoglobin. The patient was triaged at 5:36 PM and assigned an acuity level of 2. Documentation in the medical record indicated that the patient left the ED without being seen at 7:20 PM.

(i) There was no evidence in the medical record that the staff member who discovered the patient notified the Physician, Charge Nurse, and Clinical Nursing Coordinator of the patient's absence.

(ii) There was no evidence in the medical record that three (3) attempts to locate the patient were made.

2. Review of Medical Record #O6 on 4/6/21 revealed the following:

a. The patient arrived to the ED on 11/22/20 at 10:05 PM with complaints of "not feeling well" and "requesting an evaluation." The patient was triaged at 10:07 PM and assigned an acuity level of 4. Documentation in the medical record indicated that the patient left the ED without being seen at 10:27 PM.

(i) There was no evidence in the medical record that the staff member who discovered the patient notified the Physician, Charge Nurse, and Clinical Nursing Coordinator of the patient's absence.

(ii) There was no evidence in the medical record that three (3) attempts to locate the patient were made.

3. Staff #1, Staff #2, and Staff #3 confirmed the above findings on 4/7/21 at 2:50 PM.

4. Review of Medical Record #S2, on 4/6/21 revealed the following:

a. Patient #S2 presented to the ED on 11/16/20 at 4:29 PM with complaints of "foreign body in throat." Patient #S2 was triaged at 4:29 PM and assigned an acuity level of 3. On the ED log, the disposition states, "Left Without Being Seen."

b Following Patient #S2's departure from the ED, there was no evidence that any attempts were made to locate the patient.

5. Review of Medical Record #S3 on 4/6/21 revealed the following:

a. Patient #S3 presented to the ED on 11/30/20 at 9:50 PM with complaint of "emesis during pregnancy." Patient #S3 was triaged at 10:31 PM and assigned an acuity level of 3. On the ED log, the disposition states, "Left Without Being Seen."

b. Following Patient #S3's departure from the ED, there was no evidence that any attempts were made to locate the patient.

6. Review of Medical Record #S6A (Medical records reviewed for the survey included two SED visits for Patient S6. Medical Record S6A refers to the first visit on 4/6/21) revealed the following:

a. Patient #S6A presented to the ED on 11/10/20 at 7:13 AM with complaints of "crisis." The ED documentation states, "Discharge Date/Time 11/10/20 0730 Discharge Disposition lwbs (left without being seen) before Triage."

b. Following Patient #S6A's departure from the ED, there was no evidence that any attempts were made to locate the patient.

7. Review of Medical Record #S14 on 4/7/21 revealed the following:

a. Patient #S14 presented to the ED on 3/4/21 at 11:46 PM with complaints of "animal bite." Patient #S14 was triaged at 11:54 PM and assigned an acuity level of 4. On the ED log, the disposition states, "Left without being seen."

b. Following Patient #S14's departure from the ED, there was no evidence that any attempts were made to contact the patient.

8. Staff #4 confirmed the above findings

J. Based on six (6) of twenty-nine (29) medical records (#O4, #O5, #O6, #O10, #O15 and #S6), staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that patients who present to the Emergency Department (ED) are screened for suicide using the Columbia Suicide Severity Rating Scale (CSSRS) upon triage.

Findings include:

Reference: Facility policy titled, "Care of the Patient Assessed to be at Risk for Suicide" states, " ... Policy Statement: It is the policy of ... to provide screening of all patients in order to determine risk for suicide ... Procedure: 1. All adult inpatients/observation patients and Emergency Department patients will be screened for suicide upon admission or presentation using the Columbia Suicide Severity Rating Scale (CSSRS-Quick). ..."

1. Upon interview on 4/6/21 at 11:50 AM, Staff #17 stated, "A full Columbia assessment is done during full triage for all patients, not just patients with SI (suicidal ideation) or HI (homicidal ideation)."

2. Review of Medical Record #O4 on 4/6/21 revealed the following:

a. The patient presented to the ED on 2/28/2021 at 3:37 PM with complaints of dark colored cloudy urine.

b. The patient was triaged at 3:40 PM and assigned an acuity level of 3. The patient subsequently left without being seen at 9:23 PM

c. There was no evidence that the patient received a CSSRS suicide assessment during triage.

3. Review of Medical Record #O5 on 4/6/21 revealed the following:

a. The patient presented to the ED on 12/26/2020 at 7:51 PM with complaints of chest pain.

b. The patient was triaged at 7:55 PM and assigned an acuity level of 2. The patient subsequently left without being seen at 8:05 PM.

c. There was no evidence that the patient received a CSSRS suicide assessment during triage.

4. Review of Medical Record #O6 on 4/7/21 revealed the following:

a. The patient arrived to the ED via ambulance on 11/22/20 at 10:05 PM with complaints of "not feeling well" and "requesting an evaluation."

b. The ambulance record dated 11/22/20 states, "... History of Present Illness ... found on [name of street] with [name of city] Police Officers ... complaining of feet pain. Patient also states [he/she] is hearing voices. ... ."

c. The patient was triaged at 10:07 PM and assigned an acuity level of 4. The patient subsequently left without being seen at 10:27 PM.

d. There was no evidence that the patient received a CSSRS suicide assessment during triage.

5. Review of Medical Record #O10 on 4/7/21 revealed the following:

a. The patient arrived to the ED on 10/23/20 at 4:41 PM with complaints of hallucinations and suicidal ideation. The patient received a quick triage at 4:45 PM and a full triage at 4:51 PM, where he/she was assigned an acuity level of 2.

b. There was no evidence that the patient received a CSSRS suicide assessment during triage.

6. Review of Medical Record #O15 on 4/7/21 revealed the following:

a. The patient presented to the ED on 1/14/2021 at 6:51 PM with complaints of ch