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Based on observation, interview, and record review, the facility failed to:

1. Timely triage (assign an urgency-score to patients arriving for emergency medical care) patients arriving to the emergency department (ED) by ambulance;
2. Reassess walk-in patients who had been triaged but awaited room placement in the ED;
3. Provide sufficient staffing in the ED to ensure timely triage and emergency medical screening.

These failure did not comply with facility policy, delayed medical screening examination (MSE), and had the potential to cause patients' emergency medical conditions to worsen without monitoring or detection. These failures also delayed the community's emergency medical response services as ambulance crews could not leave ambulance patients alone an unattended while awaiting ED triage, MSE and room placement.

Findings:

1. On 9/27/21 the Department received a complaint from Confidential Complainant (CC) that indicated on 9/23/21 at approximately 2 p.m., two ambulances arrived at the facility. One ambulance had a patient with a complaint of a seizure, the other ambulance had a patient who had a fall. Both ambulance crews waited inside the hospital with the patients on gurneys for over an hour. One crew waited one hour and eight minutes, the other waited one hour and 26 minutes. CC was told the delay was due to waiting on a new shift to come on so that they may open beds. At no time was a medical screening completed to determine whether an emergency medical condition existed or any type of treatment took place.

During an interview on 11/9/21 at 2:20 p.m., CC confirmed the patients transported to the ED on 9/23/21 at approximately 2 p.m. were Patient 100 and Patient 101. CC stated he felt hospitals were taking advantage of ambulance crews in general. He stated ED staff rely on ambulance crews to "be the eyes and ears for the patients," and confirmed ED staff expect the ambulance crew to watch out for the patient while they wait. CC stated "it's terrible". He stated he not only sympathized with the patients, but also the ambulance crews because they are standing the whole time they have to wait, and they cannot take a break when they are left waiting for long periods.

During a record review on 11/9/21 at 4:30 p.m., Patient 100's document titled "Patient Care Report," provided by CC, indicated that on 9/23/21 Patient 100 was taken by ambulance to the facility ED for a seizure. The document indicated the ambulance arrived at the facility at 1:59 p.m., and EMS (emergency medical services) Staff H and EMS Staff I were the ambulance crew. The document further indicated the ambulance crew transferred care to the ED staff at 3:20 p.m. Patient 101's document titled "Patient Care Report" indicated that on 9/23/21 Patient 101 was taken to the facility ED for an unwitnessed fall. The document indicated Patient 101 had a hematoma (pooled blood under the skin) developing on the back of the head. The document indicated the ambulance arrived at the facility at 2:39 p.m., and EMS Staff J and EMS Staff K were the ambulance crew. The document further indicated the ambulance crew transferred care to the ED staff at 3:45 p.m..

During an observation and interview on 11/15/21 at 11:28 a.m., at the facility ED ambulance bay, Administrative Staff A stated that patients who arrived by ambulance typically were taken from the ambulance bay down to the registration clerk at the nurses' station. Administrative Staff A pointed to the A pod nurses' station straight ahead of the ambulance bay.

During an observation on 11/15/21 at 11:35 a.m., an ambulance crew unloaded a patient onto a gurney, and rolled the gurney up to the A pod nurses' station. A registration clerk behind a plexiglass partition spoke with the ambulance crew, and then gave the patient an armband. One of the ambulance crew members walked behind the nurses' station and spoke with the assistant nurse manager.

During an interview on 11/15/21 at 2:08 p.m., EMS Staff H stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff H stated the patient had stopped seizing and became more alert as they got to the hospital. EMS Staff H stated the ED staff told the crew member with him, EMS Staff I, that they were not ready for the patient, so they moved against the wall across from the A pod nurses' station. EMS Staff H stated that at one point while they waited, he had to get a urinal for the patient, and then rolled the patient around the corner of the hallway that was more private so the patient could urinate. EMS Staff H stated that while he was waiting, he saw other ambulances "stacking up behind us" and felt "antsy", he was asking himself, "Why are we still here?" EMS Staff H stated there was no interaction between the patient and the ED nursing staff while they waited for the patient to get a room. EMS Staff H stated he felt that he was sometimes being relied on (by ED staff) to monitor the patients when the EMS staff have to wait in the ED for the patient to get a room. When queried, EMS Staff H stated the impact of a long wait in the ED was an increased response time for an ambulance in the community. EMS Staff H stated they already had staffing issues, so when the EMS staff have to wait in the ED, the community was having to wait for an ambulance.

During an interview on 11/15/21 at 2:29 p.m., EMS Staff I stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff I stated they were transporting a patient who had a seizure. EMS Staff I stated they waited with the patient in the facility's ED due to a lack of available beds. EMS Staff I stated no nurse came over to interact with the patient. EMS Staff I stated the nurse behind the counter received report (communication of information about a patient between caregivers for continuity of care), but had no contact with the patient. EMS Staff I stated he generally had to wait over 20 minutes, once a week, for the facility's ED to receive the patient for triage and MSE. EMS Staff I stated two weeks ago he had to wait over an hour when he had a young man with a gun shot wound to his finger. EMS Staff I stated it was embarrassing because the patient felt like [their condition] was not that serious, so they had to wait. EMS Staff I stated he did not know why the patient with the gun shot wound had to wait. EMS Staff I stated he kept his patients on the monitor (to take vital signs and monitor heart rhythm) while they waited and he has seen the ED staff taking down the vital signs off of his monitor. When asked if this made him feel like he was being used as ED staff, EMS Staff I confirmed that it did. EMS Staff I stated the long waits in the ED resulted in delayed ambulance response times for incoming calls from the community.

During an interview on 11/15/21 at 3:13 p.m., EMS Staff J stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff J stated he pulled the patient into the ED (on a gurney), went up to the registration desk and gave the clerk patient information for registration, and then they were queued and "waiting on the wall." EMS Staff J stated there was another ambulance crew behind them and the ED was busy. EMS Staff J stated the charge nurse told him it would be a while, that there were no beds. EMS Staff J stated while they were waiting against the wall, he checked the patient's vital signs every 15 minutes. EMS Staff J stated no other care was provided to the patient while they waited, and did not recall any nurse interacting with the patient while they waited. When queried, EMS Staff J stated waiting for that length of time used a lot of resources and a lot of time. When queried, EMS Staff J stated the ED staff were relying on the ambulance crew to monitor the patient, the ED did not have the staff to monitor her. EMS Staff J stated, "They absolutely use us as additional workers." EMS Staff J stated his concern with with long waits in the ED was that he could not respond to the next 911 call. EMS Staff J stated, "Heart attacks, car accidents, pediatric respiratory attacks. Patients have to wait that much longer for us to get to [them]." EMS Staff J stated it made him feel "very disheartened, . . . waiting on a wall, I don't get to do what I meant to do with my life." EMS Staff J stated the ambulance company had to "up staff" (schedule additional staff to work) because the facility could not put a patient in a bed.

During an interview on 11/15/21 at 3:31 p.m., EMS Staff K stated on 9/23/21 at 2 p.m., he parked the ambulance, and walked into the ED with the patient. EMS Staff K stated they saw an ambulance crew at the desk who told them they had been waiting a while, and that the facility did not have enough nurses in the ED. EMS Staff K stated they waited another 20 to 30 minutes after the other crew left before they were able to leave. EMS Staff K stated the ED staff told him the facility's ED did not have enough nurses. EMS Staff K stated the patient was uncomfortable waiting on the gurney. EMS Staff K stated he did not remember a nurse approaching the patient while they waited. EMS Staff K confirmed the ED staff relied on him to be responsible for patient care. When queried, EMS Staff K stated, "That's an hour we're out of service. It could have been busy, they might have needed us to respond to a patient that needed emergency medical attention."

[Definitions: The Emergency Severity Index (ESI) is a five-level triage system indicating the patient acuity level. ESI priority 1 concerns the highest acuity patient, with a life- or limb-threatening illness or injury requiring immediate emergency interventions. ESI priority 2 is a patient with an illness or injuries that place them at high risk, or present with unstable vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and require prompt attention. ESI priority 3 is a patient with illnesses or injury that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. ESI priority 4 is a patient who has no medical emergency and has an illness or injury that requires one resource. ESI priority 5 is a patient who has no medical emergency and requires no resources, such as seeking care for a chronic or routine problem.]

During a record review on 11/16/21 at 12:30 p.m., the ED records of sampled patients were reviewed. Patient 100 arrived by ambulance on 9/23/21 at 2:03 p.m. with seizures. Patient 100 was given a room at 3:17 p.m. and seen by the physician at 3:20 p.m. Patient 100 was given an ESI priority of 3 at 3:29 p.m. Patient 101 arrived by ambulance on 9/23/21 at 2:42 p.m. after having a mechanical fall. Patient 101 was given a room at 3:45 p.m., and was assigned an ESI priority of 2 (requires prompt attention) at 3:54 p.m., one hour and 12 minutes after arrival. Patient 102 arrived by ambulance on 9/23/21 at 2:38 p.m. with a complaint of chest pain, relieved by nitroglycerin (a medication that can dilate blood vessels, improving blood flow to the heart muscle). Patient 102 was given a room at 3:43 p.m. and triaged at 4:05 p.m. Patient 102's ESI priority was 3. Patient 103 arrived by ambulance on 9/23/21 at 2:22 p.m. after she was found lethargic and hard to wake up. Patient 103 was given a room at 3:33 p.m. and assigned an ESI priority of 2 at 3:41 p.m., one hour and 19 minutes after arrival.

During an interview on 11/16/21 at 2:55 p.m., Licensed Nurse L stated that when patients come into the ED through the lobby, the patient was first registered in front, then the ED technician brought the patient back to the triage room and got the patient's vital signs while she interviewed the patient. Licensed Nurse L stated if patients had a long wait, she would call for the back up triage nurse, or the rapid care nurse could come help her out. Licensed Nurse L stated if a patient was critical, there were chairs in the hall outside the triage room where she could keep an eye on them after they were triaged. Licensed Nurse L stated if a patient had vital signs that were concerning she would put a comment into the computer for the assistant nurse manager to place the patient in a room first. When asked how often patients were assessed after they had been triaged, if no rooms were available and the patients had to go back to the lobby to wait, Licensed Nurse L stated she checked on patients every two hours, including vital signs, depending on the situation.

During an observation and concurrent interview on 11/16/21 at 3:05 p.m., the A pod area of the ED was crowded with staff and patients. Staff were walking around quickly and the ED was noisy. An ambulance crew was standing by the A pod nurses' station with a patient on a gurney against the wall. EMS Staff P stated he had just gotten there with the patient. When asked if patients were ever triaged in the hall, EMS Staff P stated, "Sometimes, depending on the urgency of the patient."

During an interview on 11/17/21 at 10 a.m., Licensed Nurse M stated she had worked in the ED for 19 years. Licensed Nurse M stated patients who came in by ambulance would come in through the ambulance bay and into the A pod hallway. Licensed Nurse M stated the patients were registered at the registration desk with the clerk, the assistant nurse manager asked any follow up questions and then the patient would be taken to their assigned bed. Licensed Nurse M stated if there were no beds available, the patient would go to triage where the triage nurse would assign them a priority level. Licensed Nurse M stated if triage was full, the patient would stay in the hallway by the assistant nurse manager. Licensed Nurse M stated the patient would have been transferred to an ED gurney at this point. Licensed Nurse M stated the ED has had staffing issues. Licensed Nurse M stated when she has the role of triage nurse for her shift, she was supposed to reassess patients in the lobby every two hours. Licensed Nurse M stated being short staffed affected her ability to timely reassess patients.

During an interview on 11/17/21 at 10:20 a.m., Licensed Nurse N stated she had worked in the ED for 10 years. Licensed Nurse N stated patients who came into the ED by ambulance came in through the ambulance bay, then stopped by the A pod desk and were assigned a room, then were taken to the room where the EMS crew gave report to the nurse, and then a nurse commenced care of the patient. Licensed Nurse N stated rooms were assigned by the triage nurse based on who was highest acuity. Licensed Nurse N confirmed she worked in the role of triage nurse sometimes. Licensed Nurse N stated patients who were waiting for a room were to be reassessed every two hours, with vital signs, to make sure nothing has changed during their wait.

During an interview on 11/17/21 at 10:37 a.m., Assistant Nurse Manager O stated patients who come in by ambulance come to the A pod clerk to verify their information. Assistant Nurse Manager O stated that if the rooms and hallway beds were full, then the patient may have to stay with EMS. Assistant Nurse Manager O stated they could usually get to them in at least 20 minutes, and if there were any "outliers" (instances where patients waited longer) he was not aware. Assistant Nurse Manager O stated, "We would certainly expect that EMS staff to be watching that patient while they're under their care."

During a record review on 11/17/21 at 11:15 a.m., Patient 104's document titled "Patient Care Report," provided by CC, indicated that on 10/13/21 Patient 104 was taken by ambulance to the facility ED for a gunshot wound to the left thumb. The document indicated the ambulance arrived at the facility at 6:34 p.m., and EMS Staff I was a member of the ambulance crew. The document further indicated the ambulance crew transferred care of Patient 104 to the ED staff at 7:28 p.m.

During a review of Patient 104's ED record from the facility, the ED record indicated Patient 104 arrived to the facility by ambulance on 10/13/21, at 7:27 p.m., with gunshot wound to the left thumb. Patient 104 was given a room and triaged at 7:31 p.m., and given an ESI priority of 3. The record did not indicate Patient 104's ambulance had originally arrived to the facility at 6:34 p.m., as per the ambulance report.

During a concurrent interview and record review on 11/17/21, at 12:44 p.m., Management Staff E and Management Staff F reviewed a sampling of medical records. Patient 10 came in by ambulance on 10/13/21 at 7:57 p.m. with a complaint of dizziness. Patient 10 was triaged at 8:06 p.m. and given an ESI priority of 3. Patient 10's blood pressure was rechecked at 10:29 p.m., and then was not assessed again until 1:30 a.m., roughly 3 hours.

During concurrent interviews on 11/17/21 at 3:16 p.m., Administrative Staff D, Management Staff F, and Physician G were present. When asked about the documented time of arrival for Patient 104, Administrative Staff D stated that as soon as an ambulance crew reached the desk, the patient was logged as arrived, so the discrepancy could be due to a long line of ambulances all arrived at once, or a surge. When asked about Patients 100, 101, 102, 103 waiting an hour or more before triage, Management Staff F stated the paramedic was responsible for the patient until they transferred the care to the room nurse. Management Staff F stated the EMS company was having a staffing issue too. When Physician G was asked if he was aware of the RN shortages in the ED, he stated, "In general, yes." When asked about the outcome to the community when ambulance crews are delayed, Physician G stated the outcome was people would have to wait for an ambulance, there was a longer response time. When asked about the potential outcome to the patient if they are not reassessed for several hours, Physician G stated the staff could potentially miss a change in status for the patient.

Review of the facility policy "Patient Flow in the Emergency Department," last revised 6/2018, indicated, "An RN or physician will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity. . . . During times of surge or when patient volume exceeds rooming capacity, triage will be performed by a nurse who has been assigned a "triage" nurse or by a physician utilizing the 5 level Emergency Severity Index (ESI). Timely triaging of patients provides: Appropriate priority setting . . . . Any significant symptoms will be reassessed for change and the acuity category increased if necessary. Triage is a dynamic process; a patient's condition may improve or deteriorate during the wait for the entry to the treatment area."

Review of the facility policy "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)," last reviewed 2/2019, indicated "Triage" was not the equivalent of a medical screening examination and [did] not determine the presence or absence of an emergency medical condition. The policy indicated a patient's triage should identify the type and level of emergency care to be received patient received, and the MSE would determine if an emergency medical condition existed. The policy indicated that after the MSE, "when it is determined that the individual has an [emergency medical condition], the hospital will ... provide further medical examination and treatment," for stabilization.

Review of the facility policy "ED Assessment and Reassessment," last revised 6/2018, indicated, "Nursing reassessments and vital signs are documented as defined by the priority level, patient vital signs, symptoms, treatments, response to treatments and per physician request or at a minimum once per shift. The general guideline is: ESI Level 1 and 2: Reassess at least every hour, including a set of vital signs or more frequently as needed per patient condition. ESI Level 3: Reassess at least every two hours, including a set of vital signs or more frequently as needed per patient condition."


2. During an interview on 11/16/21 at 2:55 p.m., Licensed Nurse L stated that when patients come into the ED through the lobby, the patient was first registered in front, then the ED technician brought the patient back to the triage room and got the patient's vital signs while she interviewed the patient. Licensed Nurse L stated if patients had a long wait, she would call for the back up triage nurse, or the rapid care nurse could come help her out. Licensed Nurse L stated if a patient was critical, there were chairs in the hall outside the triage room where she could keep an eye on them after they were triaged. Licensed Nurse L stated if a patient had vital signs that were concerning she would put a comment into the computer for the assistant nurse manager to place the patient in a room first. When asked how often patients were assessed after they had been triaged, if no rooms were available and the patients had to go back to the lobby to wait, Licensed Nurse L stated she checked on patients every two hours, including vital signs, depending on the situation.

During an interview on 11/17/21 at 10 a.m., Licensed Nurse M stated she had worked in the ED for 19 years. Licensed Nurse M stated when she was assigned the role of triage nurse for her shift. Licensed Staff M stated in that role she had to reassess patients in the lobby every two hours. Licensed Nurse M stated being short staffed affected her ability to timely reassess patients.

During an interview on 11/17/21 at 10:20 a.m., Licensed Nurse N stated she had worked in the ED for 10 years. Licensed Nurse N stated patients who were waiting for a room were to be reassessed every two hours, with vital signs, to make sure nothing has changed during their wait.

During a concurrent interview and record review on 11/17/21, at 12:44 p.m., Management Staff E and Management Staff F reviewed a sampling of medical records. The records indicated Patient 19 walked into the ED on 10/28/21 at 8:44 p.m. with a complaint of shortness of breath and a cough, COVID-positive on 10/24/21. Patient 19 was triaged at 8:58 p.m. and given an ESI priority of 3. Patient 19 was given a room at 1:01 a.m. on 10/29/21, then at 1:06 a.m. was seen by the physician, and at 5:37 a.m. was admitted to the hospital. When asked if Patient 19 was reassessed while waiting for a room, Management Staff E stated the records indicated Patient 19's vital signs were reassessed at 12:00 a.m. Management Staff E confirmed the patient was not reassessed between the time of triage and 12 a.m. Management Staff F stated facility staff should have reassessed Patient 19 before 12 a.m. Management Staff F stated her expectation was for staff to reassess patients every two hours.

Continuing the record review of the expanded sample, Patient 21 walked into the ED on 10/28/21 at 7:20 p.m. with a complaint of abdominal pain. Patient 21 was triaged at 7:38 p.m. and given an ESI priority of 3. Patient 21 was given a room at 12:48 a.m., on 10/29/21, and then was seen by the physician. When asked if Patient 21 was reassessed while waiting for a room, Management Staff E found no documentation that Patient 21 was reassessed. Management Staff E confirmed the patient was not reassessed between the time of triage the time Patient 21 was roomed, roughly 5 hours.

Patient 22 walked into the ED on 10/28/21 at 4:20 p.m. with complaints of chest pain for four days. Patient 22 was triaged at 4:27 p.m. and given an ESI priority of 3. Patient 22 was given a room at 8:30 p.m. and was seen by the physician. When queried, Management Staff E confirmed she found no documentation that Patient 22 was reassessed or had vital signs taken between triage and the time Patient 22 was roomed, roughly 4 hours.

Patient 7 walked into the ED on 8/4/21, at 4:16 p.m. with complaints of chest pain. Patient 7 was triaged at 4:25 p.m. and given an ESI priority of 3. During a review of Patient 7's medical record, the document titled "Emergency Department (ED) Leaving Before Medical Evaluation/Treatment" indicated Patient 7 had eloped from the facility. The record indicated ED staff called Patient 7 twice on 8/4/21, at 7:43 p.m. and 8 p.m. but Patient 7 did not answer. Management Staff E confirmed the medical record did not indicate facility staff reassessed Patient 7 between the time of triage and the time ED staff called Patient 7. Management Staff E stated that if an attempt was made to reassess a patient, she would expect staff to document that attempt.

Review of facility policy "Patient Flow in the Emergency Department," last revised 6/2018, indicated, "An RN or physician will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity. . . . During times of surge or when patient volume exceeds rooming capacity, triage will be performed by a nurse who has been assigned a "triage" nurse or by a physician utilizing the 5 level Emergency Severity Index (ESI). Timely triaging of patients provides: Appropriate priority setting . . . . Any significant symptoms will be reassessed for change and the acuity category increased if necessary. Triage is a dynamic process; a patient's condition may improve or deteriorate during the wait for the entry to the treatment area."

Review of facility policy "ED Assessment and Reassessment," last revised 6/2018, indicated, "Nursing reassessments and vital signs are documented as defined by the priority level, patient vital signs, symptoms, treatments, response to treatments and per physician request or at a minimum once per shift. The general guideline is: ESI Level 1 and 2: Reassess at least every hour, including a set of vital signs or more frequently as needed per patient condition. ESI Level 3: Reassess at least every two hours, including a set of vital signs or more frequently as needed per patient condition."



3. During an interview on 11/9/21 at 2:20 p.m., CC confirmed the patients transported to the ED on 9/23/21 at approximately 2 p.m. were Patient 100 and Patient 101. CC stated he felt hospitals were taking advantage of ambulance crews in general. He stated ED staff rely on ambulance crews to "be the eyes and ears for the patients," and confirmed ED staff expect the ambulance crew to watch out for the patient while they wait. CC stated "it's terrible". He stated he not only sympathized with the patients, but also the ambulance crews because they are standing the whole time they have to wait, and they cannot take a break when they are left waiting for long periods.

During an interview on 11/15/21 at 2:08 p.m., EMS Staff H stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff H stated the patient had stopped seizing and became more alert as they got to the hospital. EMS Staff H stated the ED staff told the crew member with him, EMS Staff I, that they were not ready for the patient, so they moved against the wall across from the A pod nurses' station. EMS Staff H stated that at one point while they waited, he had to get a urinal for the patient, and then rolled the patient around the corner of the hallway that was more private so the patient could urinate. EMS Staff H stated that while he was waiting, he saw other ambulances "stacking up behind us" and felt "antsy", he was asking himself, "Why are we still here?" EMS Staff H stated there was no interaction between the patient and the ED nursing staff while they waited for the patient to get a room. EMS Staff H stated he felt that he was sometimes being relied on (by ED staff) to monitor the patients when the EMS staff have to wait in the ED for the patient to get a room. When queried, EMS Staff H stated the impact of a long wait in the ED was an increased response time for an ambulance in the community. EMS Staff H stated they already had staffing issues, so when the EMS staff have to wait in the ED, the community was having to wait for an ambulance.

During an interview on 11/15/21 at 2:29 p.m., EMS Staff I stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff I stated they were transporting a patient who had a seizure. EMS Staff I stated they waited at the counter for a while and the reason they were given (for the wait) was a lack of beds. EMS Staff I stated no nurse came over to interact with the patient. EMS Staff I stated the nurse behind the counter received report (communication of information about a patient between caregivers for continuity of care), but had no contact with the patient. EMS Staff I stated he generally had to wait over 20 minutes at the ED to release a patient once a week. EMS Staff I stated two weeks ago he had to wait over an hour when he had a young man with a gun shot wound to his finger. EMS Staff I stated it was embarrassing because the patient felt like [their condition] was not that serious, so they had to wait. EMS Staff I stated he did not know why the patient with the gun shot wound had to wait. EMS Staff I stated he kept his patients on the monitor (to take vital signs and monitor heart rhythm) while they waited and he has seen the ED staff taking down the vital signs off of his monitor. When asked if this made him feel like he was being used as ED staff, EMS Staff I confirmed that it did. EMS Staff I stated the long waits in the ED resulted in delayed ambulance response times for incoming calls from the community.

During an interview on 11/15/21 at 3:13 p.m., EMS Staff J stated he remembered the events of 9/23/21 at 2 p.m. EMS Staff J stated he pulled the patient into the ED (on a gurney), went up to the registration desk and gave the clerk their information, the patient was registered, and then they were "waiting on the wall." EMS Staff J stated there was another ambulance crew behind them and the ED was busy. EMS Staff J stated the charge nurse told him it would be a while, that there were no beds. EMS Staff J stated while they were waiting against the wall, he checked the patient's vital signs every 15 minutes. EMS Staff J stated no other care was provided to the patient while they waited, and did not recall any nurse interacting with the patient while they waited. When queried, EMS Staff J stated waiting for that length of time used a lot of resources and a lot of time. When queried, EMS Staff J stated the ED staff were relying on the ambulance crew to monitor the patient, the ED did not have the staff to monitor her. EMS Staff J stated, "They absolutely use us as additional workers." EMS Staff J stated his concern with with long waits in the ED was that he could not respond to the next 911 call. EMS Staff J stated, "Heart attacks, car accidents, pediatric respiratory attacks. Patients have to wait that much longer for us to get to [them]." EMS Staff J stated it made him feel "very disheartened, . . . waiting on a wall, I don't get to do what I meant to do with my life." EMS Staff J stated the ambulance company had to "up staff" (schedule additional staff to work) because the facility could not put a patient in a bed.

During an interview on 11/15/21 at 3:31 p.m., EMS Staff K stated on 9/23/21 at 2 p.m., he parked the ambulance, and walked into the ED with the patient. EMS Staff K stated they saw an ambulance crew at the desk who told them they had been waiting a while, and that the facility did not have enough nurses in the ED. EMS Staff K stated they waited another 20 to 30 minutes after the other crew left before they were able to leave. EMS Staff K stated the ED staff told him the facility's ED did not have enough nurses. EMS Staff K stated the patient was uncomfortable waiting on the gurney. EMS Staff K stated he did not remember a nurse approaching the patient while they waited. EMS Staff K confirmed the ED staff relied on him to be responsible for patient care. When queried, EMS Staff K stated, "That's an hour we're out of service. It could have been busy, they might have needed us to respond to a patient that needed emergency medical attention."

During an interview on 11/17/21 at 10 a.m., Licensed Nurse M stated she had worked in the ED for 19 years. Licensed Nurse M stated when she was assigned the role of triage nurse for her shift. Licensed Staff M stated in that role she had to reassess patients in the lobby every two hours. Licensed Nurse M stated the facility had been short staffed and this did not allow facility staff to timely reassess patients awaiting emergency medical care.

During an interview on 11/17/21 at 1:37 p.m., M