HospitalInspections.org

Based on review of policies and procedures, hosptial documents, medical records, observations, and staff interviews, it was determined the Hospital failed to follow policies and procedures when a patient (Patient #1) presented to the Emergency Department for a medical screening and treatment for a possible emergency medical condition.

Findings include:

A request was made for the hospital's Left Without Being Seen or Left Without Being Treated policy; however, none was provided.

Hospital policy titled, "Emergency Department Nursing Triage", revealed: "...1. All patients receive a rapid triage assessment including: a. Chief complaint; b. Allergies; c. Vital signs, including temperature, pulse, respirations, blood pressure and paint intensity; d. Other information, if appropriate, may include oxygen saturation, last menstrual period, past medical history, and weight...2. Whenever possible patients are immediately place into open treatment spaces and triage is performed at the bedside...3. First aid measures including but not limited to, applying dressings, ice packs, splinting and elevation are initiated...4. The registered nurse my approach a designated LIP (licensed independent practitioner) regarding orders for any patient requiring urgent medications...5. Patients are triaged into one of the five Emergency Severity Index (ESI) levels (below) and Triage Algorithm (Attachment 1)...Level 1: Patients who require immediate evaluation and treatment with the use of many resources; Level 2: Patients who require evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources; Level 3: Stable patients who could wait for evaluation and treatment requiring multiple diagnostic and therapeutic resources; Level 4: Stable patients who could wait for evaluation and treatment and require minimal or no resources; Level 5: Stable patient who could wait for evaluation and treatment and require minimal or no resources...6. If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified ...Attachment 1: Emergency Severity Conceptual Algorithm: A. Requires immediate life-saving intervention? Yes > Level 1; No> B: high risk situation? Or confused/lethargic/disoriented? Or severe pain/distress? Yes> Level 2; C. how many different resources are needed? None> Level 5; One> Level4; Many> Danger zone vitals? age 8 years or older= SatO2 less than 92%; RR (respiratory rate) over 20, HR (heart rate) over 100 Yes> Level 2; No> Level 3...."

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...Every patient, regardless of ability to pay, who (1) presents to the Hospital's Dedicated Emergency Department or on Hospital Property and (ii) requests an examination or treatment of a potential Emergency Medical Condition ("EMC") shall receive an appropriate Medical Screening Examination ("MSE") to determine whether the patient is experiencing an EMC. If it is determined that the patient is experiencing an EMC, the Hospital shall either stabilize the EMC within the capacity of the Hospital or transfer the patient to another medical facility in accordance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) and this policy ...1. Medical Screening Examination Requirements: All patients who present to the Hospital's DED (dedicated emergency department) or on Hospital Property and request examination or treatment of a potential EMC (emergency medical condition), shall receive and appropriate MSE (medical screening examination)...Scope of the MSE: 1. A physician or QMP (qualified medical professional) must perform the MSE to determine if an EMC exists. The MSE must be appropriate to the patient's presenting complaint and symptoms, and the medical history of the patient...2. The MSE may range from a simple process involving only a brief history and physical examination to a more complex process involving ancillary studies routinely available to the emergency department, such as laboratory and x-ray testing, CAT scans, MRIs, other diagnostic tests/procedures or specialty consultation until the physician or QMP has reasonably determined whether an EMC exist...Treatment of Patients with EMCs: A. Stabilizing Treatment Requirement: 1. If a patient is determined to have an EMC, the Hospital must provide the patient with further medical examination and treatment, within the capabilities of its staff and facilities, to resolve or stabilize the medical condition, or undertake an " appropriate " Transfer of the patient...Transfers of unstabilized patients are allowed only at the patient's request and after the patient has been informed to the Hospital's EMTALA obligations and the risks of Transfer, or when a physician or QMP, in consultation with a physician, certifies that the medical benefits reasonably expected as a result of Transfer outweigh the risks to the patient from being transferred...2. If a patient has an EMC that has been Stabilized, as defined above, and if, within reasonable clinical confidence, a physician or QMP determines that the patient has reached the point where his or her continued care, including diagnostic work-up and/or treatment, can be reasonably performed as an outpatient or later as an outpatient or later as an inpatient, the Hospital may discharge the patient...The Hospital shall provide Stabilized patients who are being discharged with discharge instructions, including a plan for appropriate follow-up care, and will, within reason, assist/provide discharged patients the necessary information to secure the necessary follow-up care to prevent relapse or worsening of the medical condition following release from the Hospital...Documentation of Unannounced Leave: 1. If a patient leaves the Hospital without notifying a Hospital staff member, this must be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises. Triage notes, registration documentation and /or additional records must be retained. If the patient leaves prior to triage, but after registration, the information shall be documented on the triage documentation form...."

Hospital policy titled, "Patient Elopement and Leaving Against Medical Advice", revealed: "...Definitions: ...Elopement: The act, by a patient, of leaving the Hospital, after evaluation by a medical or allied health professional staff member but prior to the completion of treatment without informing a member of the healthcare staff...Left Before Medical Screening Examination: To leave the Hospital's Emergency Department (ED) before examination by an ED physician or Qualified Medical Personnel (QMP)... Emergency Department-General Considerations Regarding a Person's Right to Discontinue Medical Treatment...An Adult or Emancipated Minor patient with Medical Decision-Making Capacity who expresses or demonstrates a wish to leave the ED before completing an MSE and/or being cleared by an ED physician or QMP should be encouraged to remain in the ED until he/she can speak with the ED physician or QMP. If the patient is not willing to wait for the ED physician or QMP, or still demonstrates a wish to leave the Hospital after speaking to the ED physician or QMP about the risks associated with leaving the ED, the ED staff should initiate the Leaving Against Medical Advice (AMA) discharge process...Any patient who desires to leave the ED AMA (or before Medical Screening or stabilizing treatment has been initiated) shall be advised (when possible) by the attending physician. WQMP, or designed of: the right to refuse treatment; and the potential risks associated with leaving the ED prior to the completion of assessment and/or treatment...If the patient decides to leave before the medical screening examination has been completed OR after stabilizing treatment has been completed, ED staff shall make reasonable attempts to have the patient's decision documented. The patient shall be asked to sign the Hospital's Refusal of Medical Screening Exam or AMA statement form before leaving the Hospital, with a member of the nursing staff witnessing the signature. If the patient refuses to sign the Refusal of Medical Screening Exam or MAA statement, the refusal, including the patient's responses to discussion concerning the right to refuse treatment and the risks of leaving the ED, shall be carefully document in the patient's medical record...Patient Elopement from Emergency Department: When it is first notices that an ED patient has eloped, search of the ED shall be conducted immediately by the nursing and/or the ED's security staff...Documentation of the elopement in the medical record should include: Condition of the patient at the time of elopement...Date and time of patient reported missing/eloped; and notification of primary care physician and family if indicated...."

A review of Patient #1 medical record for Hospital #1 dated 02/06/2023 revealed the following:

An attestation Statement dated 02/06/2023 revealed: "...Reg Date/ Time: 02/06/2023 13:11...Discharge Date/Time: 02/06/2023 14:24...Discharge Disposition: Left without being seen...Diagnosis Data: 03/06/2023 ...Procedure and treatment not carried out due to patient leaving prior to being seen by a health care provider ...."

An Emergency Department Timeline dated 02/06/2023 revealed: " ...ED Triage Assessment 02/06/2023 13:12 ....:
An ED Interventions/Assessments/Treatments Flowsheet dated 02/06/2023 revealed: " ...COVID initial assessment start 02/06/2023 13:12 ...ED Paramedic Triage start 02/06/2023 13:12 ...ED Triage Assessment start 02/06/2023 13:12 .... "

ED Triage Assessment dated 02/06/2023 at 13:12 revealed: " ...Mode of Arrival: Walk-in ...ED Triage Note: pt {sic} states [he] has a blood clot in R (right) lower leg. Pt {sic} states [he] is not currently under treatment for a blood clot. Pt {sic} seems mildly confused and hard of hearing ...Temperature 36.6 ...Pulse rate 65 ...Respiratory rate 18 ...Pulse oximetry 95 Room air ...Blood Pressure 143/72 ...Pain score 5 ...Pain location R lower leg ...ESI Level 3 ...Fall Risk Score 5 .... " The review of the document titled, "Emergency Department Nursing Triage," showed the hospital did not follow its own triage policy and procedure for assigning an ESI score of 3 to Patient #1 who was "mildly confused", which based on the hospital triage policy, should have been assigned an ESI of 2. Further, the hospital policy stated that, "...6. If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified...." However, further review of Patient #1's medical record revealed, ED Disposition Documentation dated 02/06/2023 14:15 revealed: " ...Patient disposition: Left Without Being Seen .... "

A random sample of 19 additional ED patient records were reviewed. There was documentation in all records that triage, medical screening examinations and stabilizing treatment were provided, when applicable, prior to discharge, inpatient admission or transfer to another facility. Further review of the ED patient records revealed documentation was present for all patients that were coded as LWBS (left without being seen), eloped, left Against Medical Advice (AMA) and left before triage. Review of the ED logs revealed that all patient information was present on the ED logs.

Employee #1 confirmed on 03/14/2023 the abbreviation LWBS is equal to left before the MSE. Employee #1 confirmed that the documentation of LWBS indicates that the patient was discovered to be not present in the ED and was not seen before leaving. Employee #1 confirmed that an elopement event is when the patient is already in the back of the ED being treated and left without telling anyone. Employee #1 confirmed that if a patient wants to leave AMA, staff would attempt to get patient to stay and if not triaged, would attempt to get triage and get MSE done. Employee #1 confirmed that if the patient continues to want to leave AMA, then the patient would be asked to sign AMA papers and if the patient refused to sign, staff would document the AMA events in the medical record including that the patient refused to sign the AMA paperwork. However, the hospital policy does not describe a specific differentiation to the terms of "elopement" and "left without being seen."

Employee #9 confirmed that when a patient comes into the ED, the patient is triaged and an MSE performed. Employee #8 confirmed that once the MSE is completed, the patient receives treatment and when stable will be discharged to home, admitted, or transferred to another facility for higher level of care, if indicated.

Per hospital policy all patients who present to the Hospital's DED (dedicated emergency department) or on Hospital Property and request examination or treatment of a potential EMC (emergency medical condition), shall receive and appropriate MSE (medical screening examination). Patient #1 did not receive a MSE before leaving the ED. Further there was no documentation present in the medical record for Patient #1 that hospital staff looked for the Patient or called out for the patient multiple times before documenting the patient had left without treatment.

Based on review of policies and procedures, hospital documents, medical records, observations and staff interviews it was determined the Hospital failed to provide a medical screening examination to a patient (Patient #1) in a timely manner.

Findings include:

Patient #1 presented to the hospital ' s dedicated Emergency Department on 02/06/2023 at 13:11 complaining of right leg swelling and possible blood clot. Patient #1 was triaged at 13:12 with an ESI (emergency severity index) of 3. Patient #1 was placed back in the ED lobby to await an ED room to become available. Patient #1 was found to have left the ED when patient was called to be roomed. Patient #1 had left the ED for treatment at another facility.

Hospital policy titled, "Emergency Department Nursing Triage", revealed: "...1. All patients receive a rapid triage assessment including: a. Chief complaint; b. Allergies; c. Vital signs, including temperature, pulse, respirations, blood pressure and paint intensity; d. Other information, if appropriate, may include oxygen saturation, last menstrual period, past medical history, and weight...2. Whenever possible patients are immediately place into open treatment spaces and triage is performed at the bedside...3. First aid measures including but not limited to, applying dressings, ice packs, splinting and elevation are initiated...4. The registered nurse my approach a designated LIP (licensed independent practitioner) regarding orders for any patient requiring urgent medications...5. Patients are triaged into one of the five Emergency Severity Index (ESI) levels (below) and Triage Algorithm (Attachment 1)...Level 1: Patients who require immediate evaluation and treatment with the use of many resources; Level 2: Patients who require evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources; Level 3: Stable patients who could wait for evaluation and treatment requiring multiple diagnostic and therapeutic resources; Level 4: Stable patients who could wait for evaluation and treatment and require minimal or no resources; Level 5: Stable patient who could wait for evaluation and treatment and require minimal or no resources...6. If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified...Attachment 1: Emergency Severity Conceptual Algorithm: A. Requires immediate life-saving intervention? Yes > Level 1; No> B: high risk situation? Or confused/lethargic/disoriented? Or severe pain/distress? Yes> Level 2; C. how many different resources are needed? None> Level 5; One> Level4; Many> Danger zone vitals? age 8 years or older= SatO2 less than 92%; RR (respiratory rate) over 20, HR (heart rate) over 100 Yes> Level 2; No> Level 3...."

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...Every patient, regardless of ability to pay, who (1) presents to the Hospital's Dedicated Emergency Department or on Hospital Property and (ii) requests an examination or treatment of a potential Emergency Medical Condition ("EMC") shall receive an appropriate Medical Screening Examination ("MSE") to determine whether the patient is experiencing an EMC. If it is determined that the patient is experiencing an EMC, the Hospital shall either stabilize the EMC within the capacity of the Hospital or transfer the patient to another medical facility in accordance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) and this policy ...1. Medical Screening Examination Requirements: All patients who present to the Hospital ' s DED (dedicated emergency department) or on Hospital Property and request examination or treatment of a potential EMC (emergency medical condition), shall receive and appropriate MSE (medical screening examination) ...Scope of the MSE: 1. A physician or QMP (qualified medical professional) must perform the MSE to determine if an EMC exists. The MSE must be appropriate to the patient ' s presenting complaint and symptoms, and the medical history of the patient...2. The MSE may range from a simple process involving only a brief history and physical examination to a more complex process involving ancillary studies routinely available to the emergency department, such as laboratory and x-ray testing, CAT scans, MRIs, other diagnostic tests/procedures or specialty consultation until the physician or QMP has reasonably determined whether an EMC exist...Documentation of Unannounced Leave: 1. If a patient leaves the Hospital without notifying a Hospital staff member, this must be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises. Triage notes, registration documentation and /or additional records must be retained. If the patient leaves prior to triage, but after registration, the information shall be documented on the triage documentation form...."

A review of Patient #1 medical record for Hospital #1 dated 02/06/2023 revealed the following:

An attestation Statement dated 02/06/2023 revealed: "...Reg Date/ Time: 02/06/2023 13:11...Discharge Date/Time: 02/06/2023 14:24...Discharge Disposition: Left without being seen...Diagnosis Data: 03/06/2023 ...Procedure and treatment not carried out due to patient leaving prior to being seen by a health care provider ...."

An Emergency Department Timeline dated 02/06/2023 revealed: " ...ED Triage Assessment 02/06/2023 13:12 ....:
An ED Interventions/Assessments/Treatments Flowsheet dated 02/06/2023 revealed: " ...COVID initial assessment start 02/06/2023 13:12 ...ED Paramedic Triage start 02/06/2023 13:12 ...ED Triage Assessment start 02/06/2023 13:12 .... "

ED Triage Assessment dated 02/06/2023 at 13:12 revealed: " ...Mode of Arrival: Walk-in ...ED Triage Note: pt {sic} states [he] has a blood clot in R (right) lower leg. Pt {sic} states [he] is not currently under treatment for a blood clot. Pt {sic} seems mildly confused and hard of hearing ...Temperature 36.6 ...Pulse rate 65 ...Respiratory rate 18 ...Pulse oximetry 95 Room air ...Blood Pressure 143/72 ...Pain score 5 ...Pain location R lower leg ...ESI Level 3 ...Fall Risk Score 5 .... " The review of the document titled, "Emergency Department Nursing Triage," showed the hospital did not follow its own triage policy and procedure for assigning an ESI score of 3 to Patient #1 who was "mildly confused", which based on the hospital triage policy, should have been assigned an ESI of 2. Further, the hospital policy stated that, "...6. If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified...." However, further review of Patient #1's medical record revealed, ED Disposition Documentation dated 02/06/2023 14:15 revealed: " ...Patient disposition: Left Without Being Seen .... "

Further review of the medical record for Patient #1 revealed no documentation why Patient #1 was assigned an ESI of 3 instead of the ESI algorithm indication of confused, lethargic, disoriented, or severe pain/distress is an ESI 2. Further review of the medical record for Patient #1 revealed no evidence of a medical screening examination being performed for Patient #1 before the patient left the ED.

A review of Patient #1 medical record for Hospital #2 dated 02/06/2023 through 02/08/2023 revealed the following:
An ED Triage note dated 02/06/2023 revealed: "...ED Triage Performed 15:20...Chief complaint: c/o RLE (right lower extremity) ache and swelling onset last night denies long travel or injury...Temperature: 36.6 ...Blood pressure 135/74...Respiratory rate 18...SpO2 (oxygen saturation) 98% room air...Tracking Acuity: 3...Pain assessment: Right leg: 5 = Moderate pain...." However, further review of Patient #1's medical record failed to reveal a documentation of a Medical Screening Examination (MSE) performed by a physician or QMP.

An ED Provider note dated 02/06/2023 revealed: "...Provider care initiated: 02/06/2023 15:33...complaining of swelling to the right leg for the past few days...denies significant pain...has chronic neuropathy...has venous stasis discoloration of the lower legs which is chronic and unchanged...denies any trauma or injury...ED Course: Patient evaluated for swelling to the right lower leg. We did an ultrasound to rule out DVT and it was positive. There is an occlusive clot from the popliteal vein distally. Patient does have good circulation. No clinical signs of compartment syndrome or infection. I started the patient on Xarelto, first dose given. Ultrasound also showed an enlarged lymph node in the groin, advised patient to discuss this with [his] primary care doctor. Blood work does not show any emergent issues. Stressed that the patient needs to follow-up with either primary care or vascular for further treatment of [his] DVT...During my evaluation and work-up I have determined that patient will be: discharged...."

Further review of Patient #1 ED record from Hospital #2 revealed Patient #1 was discharged to home on 02/06/2023 at 17:59.

A total of 19 additional ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. There was no documentation that there were any delays in assessments and/or treatments based on each patient's ability to pay for medical services.

A tour of the hospital ED was conducted on 03/14/2023. Observation while on tour revealed a patient being called from the lobby by a triage nurse and the patient was taken back to the triage room. After patient was triaged, the patient was escorted to the lobby and told by triage nurse that the patient would be called back shortly.

Employee #9 confirmed on 03/14/2023 that the admission/triage process for patients coming into lobby is: patient goes to desk and completes the intake form with patient information and reason for visit. Employee #9 confirmed that if an ED room is available the patient is roomed and triage will be done there and if there is no room available the patient is then triaged in triage room. Employee #9 confirmed that the triage process consists of reviewing the reason for visit, obtaining vitals, medication reconciliation, medical history review, and ESI is done at this time. Employee #9 stated that once triage is completed, the triage nurse will contact the charge nurse to see if there is a bed available in back and if so the patient will be roomed. Employee #9 stated that if there is not a room available, then the triage nurse will do any pertinent initial labs or EKG and then place patient in lobby to await room placement. Employee #9 confirmed that the MSE is done in the room once the patient is roomed. Employee #9 confirmed that if a patient comes in complaining of an ailment that needs immediate care such as chest pain, possible stroke serious injury will perform EKG and labs in triage and notify the charge nurse and medical provider.

Employee #9 confirmed that when patients are found to have left the ED, such as left without being seen (LWBS), the triage nurse will ask the registration clerk if they saw patient leave or know where patient is. Employee #9 stated staff will attempt to call for patient 3 times in case patient was in bathroom or outside to make sure the patient is gone and then will notify charge nurse to document the patient LWBS. Employee #9 stated that the triage nurse will document as well what time patient was identified as missing. Employee #9 stated that if a patient is seen attempting to leave, staff will attempt to stop the patient and will get a provider to come to the triage room to do the MSE. Employee #9 stated that if a patient leaves before triage, it is coded as left before triage and the charge nurse is notified, and a note is placed on the triage assessment form.

Employee #9 confirmed that if a patient comes in with a complaint of leg swelling, the nurse will get a health history, check the patient's vitals, ask the patient if they have a history of blood clots and if they are taking any anticoagulants. Employee #9 confirmed that if the patient appears stable they would most likely be an ESI of 3 and placed in room if available or in lobby if no room. Employee #9 confirmed that waiting an hour for MSE after triage is not unusual or considered a long time.