HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse (RN) was readily available to triage patients arriving to the emergency department (ED) with an emergency condition for 9 of 30 medical records (MR) reviewed (Patients #20, 21, 22, 23, 24, 26, 27, 28 and 29).

Findings include:

1. Review of the policy/procedure Emergency Services 678-02 (approved 2-21) indicated the following: "The Emergency Services providers perform examination and/or treatment without delay and without regard to the patient's insurance, payment status, or any other discriminatory factors."

2. Review of the policy/procedure Triage 678-304 (approved 2-21) indicated the following: "The triage responsibilities will include the following ...Perform a focused assessment for all presenting with a medical condition/complaint ...Determine an acuity level for all assessed patients and assign to the appropriate care area ...Patients with acuity level 1 or 2 will be taken to an empty bed immediately..."

3. Review of the MR for Patient #26 indicated the patient presented to the ED on 9-29-21 at 1849 hours with a chief complaint of fever, sore throat, left sided dental pain and nausea and no triage assessment was performed prior to 2148 hours when the patient was not found in the ED waiting room and classified as LWBS.

4. Review of the MR for Patient #27 indicated the patient presented to the ED on 9-29-21 at 2002 hours with a chief complaint of abdominal pain into their back and no triage assessment was performed prior to 2319 hours when the patient was not found in the ED waiting room and classified as LWBS.

5. Review of the MR for Patient #28 indicated the patient presented to the ED on 9-29-21 at 2137 hours with a chief complaint of lower abdominal pain for six hours and no triage assessment was performed prior to 9-30-21 at 0057 hours when the patient was not found in the ED waiting room and classified as LWBS.

6. Review of the MR for Patient #29 indicated the patient presented to the ED on 9-29-21 at 2211 hours with a chief complaint of right sided pain and no triage assessment was performed prior to 9-30-21 at 0350 hours when the patient was not found in the ED waiting room and classified as LWBS.

7. Review of the MR for Patient #20 indicated the patient presented to the ED on 9-30-21 at 0135 hours with a chief complaint of indigestion and trouble breathing and no triage assessment was performed prior to 0557 hours when the patient was not found in the ED waiting room and classified as LWBS.

8. Review of the MR for Patient #21 indicated the patient presented to the ED on 9-30-21 at 1550 hours with a chief complaint of 15 weeks pregnant and witness to an accident and no triage assessment was performed prior to 1706 hours when the patient was not found in the ED waiting room and classified as LWBS.

9. Review of the MR for Patient #25 indicated the patient presented to the ED on 9-30-21 at 1551 hours with a chief complaint of pain from their back down their legs and no triage assessment was performed prior to 1914 hours when the patient was not found in the ED waiting room and classified as LWBS.

10. Review of the MR for Patient #22 indicated the patient presented to the ED on 9-30-21 at 1559 hours with a chief complaint of feels like passing out and no triage assessment was performed prior to 1803 hours when the patient was not found in the ED waiting room and classified as LWBS.

11. Review of the MR for Patient #23 indicated the patient presented to the ED on 9-30-21 at 1658 hours with a chief complaint of abdominal pain for a week and no triage assessment was performed prior to 1758 hours when the patient was not found in the ED waiting room and classified as LWBS.

12. Review of the MR for Patient #24 indicated the patient presented to the ED on 9-30-21 at 1835 hours with a chief complaint of needing stitches removed and no triage assessment was performed prior to 1937 hours when the patient was not found in the ED waiting room and classified as LWBS.

13. On 10-26-21 at 1220, 1225 and 1240 hours, staff A4 confirmed the MRs for Patients #20, 21, 22, 23 and 24 lacked documentation as seen above.

14. On 10-26-21 at 1310 hours, staff A4 confirmed the MRs for Patients #26, 27, 28 and 29 lacked documentation as seen above.

15. On 10-26-21 at 1615 and 1620 hours, the Regional Director of ED Services A3 confirmed the ED did not staff a dedicated triage nurse and the triage nurse also provided direct care for ED patients and confirmed no ED staffing policy, staffing matrix or staffing grid was available.

Based on document review and interview, the facility failed to ensure documentation indicating an MSE (Medical Screening Exam) was performed (see tag A2406).

Findings include:

1. See findings cited at 489.24(1) Medical Screening Exam A2406.

Based on document review, observation and interview, the facility failed to maintain a central log of each individual that comes to the ED (Emergency Department) seeking assistance and medical care including information whether the patient refused treatment, or was refused treatment, or was transferred, or treated and discharged, or admitted and treated, or stabilized and transferred for 1 of 30 medical records (MR) reviewed (Patient #30).

Findings include:

1. Review of the policy/procedure Emergency Services 678-02 (approved 2-21) indicated the following: "All persons seeking emergency care will be recorded into an electronic tracking board which serves as the Central Log."

2. Review of facility 078 administrative documentation titled ED Log Report lacked documentation indicating a patient in need of a mental health assessment (Patient #30) was registered on 10-8-21 around 1940 hours after being transported to the ED by law enforcement officers.

3. Review of the MR obtained from facility 100 for Patient #30 indicated on 10-8-21 at 1956 hours the patient was transported to the ED by law enforcement officers after first arriving (and departing) from facility 078.

4. On 10-25-21 at 1230 hours, the Quality Manager A4 confirmed the ED log lacked documentation indicating on 10-8-21 around 1940 hours a patient (Patient #30) in need of a mental health assessment was registered after arriving to the ED in the company of law enforcement officers.

Based on document review, observation and interview, the facility failed to ensure a MSE (medical screening exam) by a physician or other QMP (qualified medical provider) was provided for 1 of 30 medical records (MR) reviewed (Patient #30).

Findings include:

1. Review of the policy/procedure Emergency Services 678-02 (approved 2-21) indicated the following: "The Emergency Services provider will provide an appropriate medical screening exam, stabilizing treatment for emergency medical conditions and labor, and arrange for transfer or further treatment as indicated."

2. Review of administrative documentation provided by the Regional Director of ED Services A3 titled RCA Notes dated 10-15-21 indicated on 10-8-21 at 2000 hours a patient in need of a mental health assessment was transported by law enforcement officers from the ED of facility 078 to the ED of facility 100 for evaluation.

3. Review of administrative documentation titled ED Log Report failed to indicate a patient in need of a mental health assessment (Patient #30) was registered on 10-8-21 around 1940 hours after being transported to the ED by law enforcement officers.

4. On 10-25-21 at 1230 hours, the Quality Manager A4 confirmed the above and confirmed no MR documentation indicating a MSE was provided on 10-8-21 around 1940 hours to a patient in need of a mental health assessment (Patient #30) was available.