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A. Based on review of three (3) of five (5) medical records (#3, #16, and #18) of patients who eloped from the Emergency Department (ED), review of facility documents, and staff interviews, it was determined the facility failed to ensure implementation of the facility's policy and procedure for elopement.

Findings include:

Reference: Facility policy titled, "Management of Elopement" states, " ... Policy/Procedure 1. When a patient is found to have eloped from the patient unit, the assigned nurse shall immediately activate the emergency response system ... and have the operator announce: ''CODE GREY-FLIGHT" (ALONG WITH LOCATION) 2. The assigned nurse shall then immediately notify: a. Security Staff ... i. Provide patients name, age, sex, race, and brief description ii. Areas/location last seen iii. Clothes worn (if known) iv. Specific instructions for interventions to be taken b. House Staff Physician c. Nursing supervisor d. Attending Physician 3. The nurse shall document the following information in the nursing note. a. Time of occurrence. b. Patient's behavior c. Condition and mental status prior to elopement d. Measures that are taken to find the patient e. Persons notified regarding the situation 4. Security officers shall immediately implement lockdown procedures until a quick facility search can be conducted. All visitors will remain at entry locations until further notice. 5. The Security Supervisor will ensure the patient description is provided to all security and establish search teams to quickly search all areas of the premises (to the edge of hospital property.) Findings will be reported back to Nursing and the Security Control Center. 6. The nurse manager or nursing supervisor will call the phone numbers on record (patient/emergent contact) at fifteen-minute intervals for a maximum of three times. 7. If all efforts have been made and [facility name] has been unsuccessful in contacting the patient or family, REMS... and the police department ... shall be notified in special circumstances. The special circumstances include but are not limited to: a. Intravenous access in place b. Patient deemed incompetent c. Patient suicidal 8. If the patient cannot be found within the hour, the Nurse Supervisor should direct the operator to call: "Code Grey- Flight (Location) - All Clear" 9. The above efforts and all supporting documentation shall be documented in the medical record, and in a Verge report..."

1. On 12/10/21 at 10:23 AM, a review of Medical Record #3 revealed the following:

a. Patient #3 arrived in the ED on 11/15/21 at 2:09 PM, with a complaint of "left side rib pain."

(i) At 2:52 PM, Patient #3 eloped from the facility.

(ii) Upon request from the surveyor, Staff #1 was unable to provide the required documentation concerning the elopement.

b. During interview with Staff #6 on 12/10/21 at 11:28 AM, he/she confirmed there were no nursing notes documented for this event and that a code grey was not called.

2. On 12/13/21 at 10:13 AM, a review of Medical Record #18 revealed the following:

a. Patient #18 arrived in the ED on 8/25/21 at 4:50 PM, with complaints of "shortness of breath."

(i) At 6:30 PM, Patient #18 eloped from the facility.

(ii) At 7:04 PM, the ED Providers Note stated, "Patient walked out of the emergency room."

b. Upon request by the surveyor for documentation regarding the elopement, Staff #1 was unable to provide required documentation concerning the elopement.

3. On 12/13/21 at 11:32 AM, during a review of Medical Record #16, the following was revealed:

a. Patient #16 arrived in the ED on 9/13/21 at 11:26 PM, via EMS for evaluation of drug abuse.

b. On 9/14/21 at 12:30 AM, the ED Notes stated, "patient asked to use bathroom ... Upon checking on patient in the bathroom patient was gone, gown was on the floor and patient belongings were gone ..."

c. The patient's discharge status was "eloped."

4. On 12/13/21 at 12:15 PM, Staff #1 confirmed there was no documentation from security or the nursing supervisor concerning the above eloped patients.

B. Based on review of two (2) of ten (10) medical records (#5 and #16), staff interviews, and review of facility documents, it was determined the facility failed to ensure a Columbia-Suicide Severity Rating Scale (C-SSRS) is performed on all Emergency Department (ED) patients.

Findings include:

Reference: Facility policy titled, "Suicide Risk Assessment/Suicide Precautions" states, "POLICY 1. [Facility name] will properly conduct a risk screen and assessment that identifies specific characteristics of the individual and environmental features that may increase or decrease the risk for suicide ... 3. The Columbia-Suicide Severity Rating Scales (C-SSRS) tool will be used for screening and risk assessments ... All ED patients and inpatients shall be asked: ..."

1. On 12/10/21 at 2:30 PM, a review of Medical Record #5 revealed the patient arrived in the ED with complaints of anxiety/depression.

a. A proper C-SSRS screening was not documented in the medical record.

b. Patient #5 was discharged at 1:04 PM. The patient's discharge disposition was "left without being seen after triage."

c. Review of the Physician Assistant's note stated, "Left without being seen ... Reason for LWBS: Tells [Name], RN that [he/she] just 'wants a phone number to a hotline' and does not want to be seen."

d. This finding was confirmed with Staff #6.

2. On 12/13/21 at 11:32 AM, a review of Medical Record #16 revealed the patient arrived in the ED on 9/13/21 at 11:26 PM, via EMS for evaluation of drug abuse.

a. A C-SSRS screening was not documented in the medical record.

b. At 12:30 AM, the patient eloped from the ED.

c. This finding was confirmed with Staff #3.

C. Based on review of eight (8) of twenty-one (21) medical records (#3, #4, #7, #10, #11, #14, #15, and #18), staff interviews, and review of facility documents, it was determined the facility failed to ensure consent for treatment is obtained for all patients for each date of service.

Findings include:

Reference: Facility policy titled, "Consent for Treatment; General" states, "... general patient Consent Forms be obtained for all patients being treated or admitted prior to the initiation of any services, except in the case of emergent or urgent situations ..."

1. On 12/10/21, a review of Medical Records #3, #4, #7, #10, and #11 revealed the following:

a. At 10:23 AM, review of Medical Record #3 revealed the patient arrived at the ED on 11/5/21 at 2:09 PM.

(i). The general consent for treatment in the "Conditions of Admission" Form was signed on 7/9/21 at 1:10 PM.

(ii) There was no consent for treatment signed on the day of service.

b. At 10:48 AM, a review of Medical Record #10 revealed the patient arrived at the ED on 12/4/21 at 9:07 PM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 2/4/21 at 9:40 AM.

(ii) There was no consent for treatment signed on the day of service.

c. At 11:10 AM, a review of Medical Record #11 revealed the patient arrived at the ED on 12/4/21 at 9:27 PM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 10/7/21 at 9:30 AM.

(ii) There was no consent for treatment signed on the day of service.

d. At 1:41 PM, a review of Medical Record #7 revealed the patient arrived at the ED on 11/25/21 at 6:19 PM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 9/11/21 at 7:50 PM.

(ii) There was no consent for treatment signed on the day of service.

e. At 2:18 PM, a review of Medical Record #4 revealed the patient arrived at the ED on 11/26/21 at 12:41 PM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 1/31/21 at 4:29 PM.

(ii) There was no consent for treatment signed on the day of service.

2. On 12/13/21, a review of Medical Record #14, #15, and #18 revealed the following:

a. At 10:13 AM, a review of Medical Record #18 revealed that the patient arrived at the ED on 8/25/21 at 4:50 PM.

(i) The general consent for treatment on the "Conditions of Admission" Form was signed on 8/14/21, and no time was indicated.

(ii) There was no consent for treatment signed on the day of service.

b. At 10:48 AM, a review of Medical Record #15, revealed the patient arrived at the ED on 9/21/21 at 5:14 AM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 2/11/21 at 1:56 PM.

(ii) There was no consent for treatment signed on the day of service.

c. At 10:53 AM, a review of Medical Record #14 revealed the patient arrived at the ED on 9/21/21 at 4:35 PM.

(i) The general consent for treatment in the "Conditions of Admission" Form was signed on 8/22/21 at 8:46 PM.

(ii) There was no consent for treatment signed on the day of service.

3. During an interview conducted on 12/10/21 at 11:16 AM, Staff #19 stated the facility document, "Conditions of Admission," which includes the consent to Medical and Surgical Procedures, are valid for one (1) or two (2) years (Staff #19 was unsure of the timeframe) and was not signed on each emergency room visit.

4. This was confirmed with Staff #1, Staff #2, Staff #3, and Staff #21 during the exit conference.


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D. Based on review of two (2) of three (3) medical records (#8 and #9) of patients discharged home, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure the condition of the patient is assessed and documented prior to discharge.

Findings include:

Reference: Facility policy titled, "Patient Rights Under EMTALA" states, "...3. A MSE (medical screening exam) is an ongoing process, not an isolated event. The patient's record shall reflect continued monitoring in accordance with the patients needs and must continue until the patient is stabilized or appropriately transferred or discharged. There should be evidence of this evaluation in the medical record prior to discharge or transfer."

1. On 12/10/21, a review of Medical Record #8 and Medical Record #9 revealed there was no documentation of the patient's condition prior to discharge.

2. During an interview with Staff #6 on 12/10/21 at 2:51 PM, he/she confirmed the condition of Patient #8 and Patient #9 was not documented upon discharge.

Based on a random review of four (4) of four (4) medical records (#1, #15, #17, and #21) of patients with discharge dispositions left blank in the ED log, and staff interviews, it was determined the facility failed to ensure a complete and accurate ED central log is developed and maintained.

1. On 12/9/21 at 10:00 AM, upon request for the ED Central Log, Staff #1 stated the facility does not have an ED Central Log. Information needed is pulled from the EPIC system and a log is created for the survey.

a. Upon interview, Staff #6 confirmed an ED Central Log is not maintained in the ED.

b. An ED log was created for the survey after surveyors provided Staff #1 with the required ED log items.

2. Review of the printed ED Log for Medical Record #1, #15, #17, and #21 revealed there were no entry (left blank) under the ED discharge disposition.

a. Upon review of Medical Record #1, an ED visit dated 10/14/21, revealed the patient was "dismissed" at 6:38 AM.

b. Upon review of Medical Record #15, an ED visit dated 9/21/21, revealed the patient was discharged home.

c. Upon review of Medical Record #17, an ED visit dated 7/5/21, revealed the patient eloped.

c. Upon review of Medical Record #21, an ED visit dated 7/4/21, revealed the patient was "dismissed" at 7:59 PM.

2. On 12/10/21 at 12:30 PM, the facility policy for "dismissed" status was requested from Staff #6. Staff #1 stated that there was no policy concerning "dismissed" patients in the ED.

3. These findings were confirmed with Staff #1, Staff #2, Staff #3, Staff #10, and Staff #21, during the exit conference.

Based on a random review of three (3) of four (4) medical records (#1 and #21) of patients without a discharge disposition in the ED Log, staff interviews, and review of facility documents, it was determined the facility failed to ensure appropriate medical screening is provided to identify whether an Emergency Medical Condition (EMC) exists.

Findings include:

1. On 12/10/21 at 12:16 PM, during review of Medical Record #1, the following was revealed:

a. The patient was a 13-month-old female who arrived at the ED, on 10/14/21 at 6:31 AM, with complaints of Allergic Reaction.

b. The ED Patient Care Timeline indicated that at 6:37 AM, the patient was "dismissed."

(i) The ED Dismiss tab in the electronic medical record contained documentation that stated, "Parents looking for pediatrician specifically."

c. The patient was not provided an appropriate medical screening to identify whether an EMC exists.

2. On 12/13/21 at 2:44 PM, during review of Medical Record #21, the following was revealed:

a. The patient arrived at the ED on 7/4/21 at 7:45 PM, with complaints of "pregnant, abdominal pain."

b. At 7:57 PM, ED Notes stated, "Pt [patient] requesting to be seen by OB-GYN, denies vaginal bleeding. Pt will go to the nearest hospital with OBGYN."

c. The ED Patient Care Timeline indicated that at 7:59 PM, the patient was "dismissed."

d. The patient was not provided an appropriate medical screening to identify whether an EMC existed.

3. Upon request, Staff #1 was unable to provide a policy on "dismissed" patients in the ED.

4. These findings were confirmed with Staff #1 and Staff #6.

A. Based on review of one (1) of four (4) medical records (#4) of transferred patients, it was determined the facility failed to ensure a signed consent for transfer, is obtained for all patients transferred to another Acute Care Facility.

Findings include:

Reference: Facility policy titled, "Transfer from the Emergency Department to Another Facility" states, "... 6. It is the responsibility of the ED provider to explain the rationale for transfer to another facility and the risk/benefits of such transfer to the patient or patient representative. ... 7. The ED provider will complete section 1 of the EMTALA Transfer Form in EPIC, print the document and have the patient/representative sign the form. ..."

1. On 12/10/21 at 2:18 PM, during review of Medical Record #4, it was indicated the patient was transferred to another Acute Care Facility. Upon review of the EMTALA transfer documentation, it was revealed the patient's signed consent was not obtained before the patient was transferred.

2. This finding was confirmed with Staff #6.


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B. Based on review of two (2) of ten (10) medical records (#2 and #8), staff interview, and review of facility documents, it was determined the facility failed to ensure a reasonable registration process for patients seeking treatment that will unduly discourage individuals from remaining for further evaluation.

Findings include:

Reference: Facility policy titled, "Patient Rights Under EMTALA" states, "... Procedures/Guidelines...5. [Facility Name] shall not delay providing an appropriate MSE (medical screening exam) or further medical examination and stabilizing treatment to inquire about an individuals method of payment or insurance status or to request reauthorization from a managed care plan. However, the Hospital can request information about insurance in accordance with its normal registration process..."

1. Review of Medical Records #2 and #8 on 12/10/21, indicated full registration was completed prior to triage.

a. Patient #2 arrived at the ED on 11/5/21 at 3:51 AM, with complaints of nasal congestion.

(i) Registration was completed at 3:56 AM.

(ii) At 4:48 AM, Triage was documented. Then at 4:50 AM, the patient was "dismissed."

(iii) At 4:50 AM, the ED Provider note stated, "We did not see or evaluate this patient. As per RN (registered nurse) [name], pt (patient) Left the ED before triage."

(iv) A full triage and Medical Screening Exam (MSE) was not completed.

b. Patient #8 arrived at the ED on 11/25/21 at 11:27 PM, with complaints of chest pain.

(i) Registration was completed at 11:32 PM.

(ii) Triage was started at 11:35 PM.

(iii) The Medical Screening Exam (MSE) was completed at 11:39 PM.

2. On 12/9/21 at 11:10 AM, upon interview, Staff #13 stated patients receive a quick registration on arrival to the ED, and the full registration, which includes asking for insurance information, does not occur until after the patient is seen by the nurse.

3. The above findings were confirmed with Staff #19 on 12/10/21 at 11:16 AM.