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Based on interview and record review, the facility failed to prevent a delay in care for one of 20 sampled patients (Patient 16) when:

1. A medical screen exam (MSE - medical screening, examination, and evaluation by a physician to determine if an emergency medical condition exists) was not completed in a timely manner.
2. Registered Nurses (RN) did not use the emergency standardized procedures (SP) prior to the MSE.
3. Patient 16 did not have vital signs (VS - heart rate [HR], respiratory rate [RR], oxygen saturation [Sat- a measure of how much hemoglobin is currently bound to oxygen], blood pressure [BP], temperature [temp] and pain level) completed as required.

These failures resulted in Patient 16 waiting in the Emergency Department (ED) for 7 hours and leaving without being seen (LWBS - no MSE).

Findings:

1. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RN Informatics (RNI), Patient 16's medical record (MR) was reviewed. The MR indicated the following:
RN 1 documented on 1/7/25 at 9:54 p.m. "ED Triage Chief Complaint: PT [Patient 16] C/O [complain of] ABD [abdominal] PAIN AND VOMITING X [times] 3 DAYS. . . Triage Pain Assessment. . . Numeric Rating Pain Scale: 3 (0-3 mild pain). . . Numeric Pain Acceptable Intensity Scale: 0 = No pain. . . Recommended ESI [Emergency Severity Index - a number that indicates how urgent a patient's condition is and how many resources they need] Level: 3 [an urgent triage level for patients who need immediate attention but can wait up to 30 minutes for treatment]."
MD 1 and MD 2 documented on 1/8/25 at 5:29 a.m. "Attempt made to medically evaluate patient however patient left prior to being seen by provider. Unable to render care."
MD 3 documented on 1/11/25 at 1:02 a.m. "Unspecified abdominal pain (Final). . . Vomiting, unspecified (Final)-Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider (Final)-Discharge Disposition: Left Prior to MSE by Provider (LWBS)."
RN 2 documented on 1/8/25 at 5:05 a.m. "Supervised Shelter. . . Wait too long. . . Refusal of Treatment Form: Form not read, patient left."
RNI stated she is not sure why Patient 16 waited 7 hours without an MSE. RNI stated there was no other physician documentation.

During an interview on 1/28/25 at 11:13 a.m. with Chief of Emergency Medicine (COEM), COEM stated it is not ideal or appropriate for Patient 16 to wait 7 hours to have an MSE completed.

During a review of the facility's policy and procedure (P&P) titled, "COBRA/EMTALA Compliance," dated September 2022, the P&P indicated, "III. POLICY STATEMENT: It is the policy of [Facility 1] to meet its statutory duty to provide a medical screening examination and emergency care, as required by the patient's condition after triage. . .V. PROCEDURE: A. 1. If an individual comes to the ED, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's ED, including all ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists."

2. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RNI, Patient 16's MR was reviewed. MR indicated, "Pain History Grid. . . Pain Site #1. . . Location: Abdominal lower. . . Quality: Aching." RNI stated the MR does not indicate diagnostic studies, medications, or other treatments were ordered.

During an interview on 1/28/25 at 11:13 a.m. with COEM, COEM stated he is surprised that the RNs did not initiate the SP during the 7 hours Patient 16 waited for a MSE to help alleviate some of Patient 16's concerns/symptoms.

During a review of the facility's P&P titled, "Standardized Procedures, Unit-Specific, Emergency Department," dated August 2023, the P&P indicated, "I. PURPOSE: Emergency standardized procedures (SP) provide a means for nursing staff to implement orders approved by the medical staff of the Emergency Department (ED). The Registered Nurse (RN) can initiate/implement standardized procedures to provide care for patients with presenting symptoms and complaints. By providing diagnostic studies and offering defined medications prior to the medical screening examination (MSE), the wait time now becomes productive. . . V. PROCEDURE: A. Triage - SP are chief complaint driven. . .3. Emergency SP are enacted upon and are carried out by the ED RN. . . Associated Form A. . . APPROVED ED STANDARDIZED PROCEDURES. . . NOTE: If no provider in triage, the ED RN may initiate the following Standardized Procedures based on the patient's Chief Complaint. . . ED NUR [Nursing] Lower Abdominal Pain. . .CBC w/diff [blood test that measures complete blood count], BMP [basic metabolic panel - blood test that measures various substances in the blood] and UA [urinalysis - urine test to assess various substances and conditions]."

3. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RNI, Patient 16's MR was reviewed, the MR indicated:
1/7/25 at 9:54 p.m. BP: 144/87; HR 93; RR: 18; Sat: 97%; Temp: 36.7 C; Pain level: 3
1/8/25 at 2:21 a.m. BP 129/76; HR 101; RR: 18; Sat: 97%; Temp: 37.2 C; pain level: (missing).
RNI stated Patient 16 had an ESI level of 3 and VS and reassessments should be done every 2 hours and it was not completed as per documentation.

During a review of the facility's P&P titled, "Triage Process in the Emergency Department," dated September 2024, the P&P indicated, "III. POLICY STATEMENT: It is the policy of [Facility 1] that all patients presenting at the ED will be triaged to determine the type and urgency of their condition. . . V. PROCEDURE: A. Triage Acuity Process. . .c) Level Three - Urgent . . . 1) Patient requiring two (2) or more resources with stable vital signs. . .5. After triage, reassessments occur based on the following guidelines. . .c) ESI Level III - Reassessments approximately every two (2) hours. . . VIII. DOCUMENTATION. . . D. Vital signs and documentation of patient's condition/status during reassessment."

Based on interview and record review, the facility failed to ensure four of 12 sampled transferred patients (Patient 2, Patient 6, Patient 12 and Patient 20) transfer consent was complete prior to transfer to another Facility. This failure had the potential to result in Patient 2, Patient 6, Patient 12 and Patient 20 not understanding the transfer process to make an informed decision before consenting to the transfer.

Findings:

During a review of Patient 2's medical record (MR), dated 11/5/24, the MR indicated Patient 2 was a 16-year-old female who arrived via ambulance on 11/5/24 at 12:29 a.m. with chief complaint of intentional overdose and suicide attempt. Patient 1 ingested 100 325 mg (milligram) aspirin tablets. Patient 1's family member (FM) found the empty bottle at home and called Emergency Medical Services (EMS). Patient 1 was assigned an Emergency Severity Index (ESI) score of 2 (emergent - needing prompt care). Patient 2 was alert and oriented and the FM was at the bedside. Facility 1 transferred Patient 2 to Facility 3 on 11/5/24 at 4:17 a.m. via ALS (Advance Life Support) Ambulance with a Registered Nurse (RN) for "HLOC (higher level of care)."

During a concurrent interview and record review on 1/27/25 at 1:05 p.m., with RN 3, Patient 2's "IMPORTANT LEGAL NOTICE" (ILN), dated 11/5/24, was reviewed. The ILN indicated there was no signature by Patient 2 or Patient 2's FM consenting to the transfer. RN 3 stated the ILN should have been signed by Patient 1's FM.

During a review of Patient 6's MR, dated 10/2/24, the MR indicated Patient 6 was an 86-year-old female arrived at the emergency department (ED) on 10/2/24 at 8:53 a.m. Patient 6 was referred to the ED because Patient 6's outpatient ultrasound (US- an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside the body) showed the kidneys were swollen due to a buildup of urine. Patient 6 had a history of chronic kidney issues. Patient 6 was assigned an ESI level 3 (urgent but non-life-threatening emergency). Patient 6 was alert and oriented. After a MSE, it was determined Patient 6 needed to be admitted for further care. Facility 1 transferred Patient 6 to Facility 4 on 10/2/24 at 8:24 p.m. via basic life support (BLS) ambulance for insurance reasons.

During a concurrent interview and record review on 1/28/25 at 9 a.m. with RN 4, Patient 6's ILN, dated 10/2/24, was reviewed. The ILN indicated the statement "Based on my examination of the patient and the information available to me at the time of transfer, I certify that the risks of transfer are outweighed by the benefits reasonably anticipated from proper care at the receiving facility," was not checked. The ILN indicated Patient 6 did not indicate the understanding of the risks and benefits of the transfer, and did not indicate if Patient 6 consented to or refused the transfer. The ILS indicated the time Patient 6 signed the consent was not documented, and the employee who witnessed Patient 6's signature did not date or time their signature. RN 4 stated the form was not complete and should be completed.


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During a review of Patient 12's MR, dated 9/21/24, the MR indicated Patient 12 was a 35-year-old male who presented to the ED on 9/21/24 at 4 a.m. via ambulance, with chief complaint of "shot in the left eye with a pepper gun." Patient 12 was alert and oriented. The ED assigned Patient 12 an ESI score of 2. Facility 1 transferred Patient 12 to Facility 2 via ALS ambulance on 9/21/24 at 7:54 a.m. for, "Requires specialty care."

During a concurrent interview and record review on 1/27/25 at 1:56 p.m. with RN Informatics (RNI), Patient 12's ILN, dated 9/21/24, was reviewed. RNI stated Patient 12's signature including date/time was missing. RNI stated Medical Doctor's (MD unidentified) signature was missing the date/time.

During a review of Patient 20's MR, dated 8/12/24, the MR indicated Patient 20 was a 55-year-old male who presented to the ED on 8/12/24 at 10:35 a.m. via ambulance, with chief complaint of left lower extremity pain, swelling, and wound. Patient 20 was alert and oriented. The ED assigned Patient 20 an ESI score of 3. Facility 1 transferred Patient 20 to Facility 3 via BLS ambulance on 8/12/24 at 9:55 p.m. for insurance reason.

During a concurrent interview and record review on 1/27/25 at 3:20 p.m. with RNI, Patient 20's ILN, dated 8/12/24, was reviewed. RNI stated Patient 20's signature including date/time was missing. RNI stated the RN's (unidentified) signature was missing the date/time.

During an interview on 1/28/25 at 1:40 p.m. with MD 4, MD 4 stated transfer forms need to be complete before transferring the patient to another facility.

During a review of the facility's policy and procedure (P&P) titled, "COBRA/EMTALA Compliance," dated September 2022, the P&P indicated, "C. Transfer of Patient Without Emergency Medical Condition. . . e) Transfer Summary. . . (n) Declaration of the person signing the he/she is assured, within reasonable medical probability, that the transfer creates no medical hazard to the patient. . . D. Transfer of Patient with Emergency Medical Condition. . . 2. Transfer Request or Physician Certification. . . d) Criteria for Appropriate Transfer. . . (c) In which the transferring Facility sends to the receiving facility copies of all available medical records related to the patient's emergency condition that are available at the time of transfer, including . . . the written informed consent."

During a review of the facility's P&P titled, "Transfers to Another Facility," effective date 9/2024, the P&P indicated, "Physician Responsibilities. . . d) Discuss with the patient/consent giver the risks, benefits, alternatives and consent for the treatment and for the transfer. . . Nursing Responsibilities a) Validate the patient's consent for transfer to and treatment at another facility by reviewing the physician's documentation and verifying the patient's understanding of the risks, benefits and alternatives to the transfer. . .d) Complete and/or review the following documents (as applicable) for completion prior to transfer of patient: 1) Transfer Form, mandatory."