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Based on record reviews, policy review, and interviews, the hospital failed to ensure a central log was maintained on each patient who comes to the emergency department (ED) seeking assistance and whether the patient refused treatment; admitted and treated, stabilized and transferred to another hospital; or discharged. The hospital failed to include the patient disposition on the ED log for 217 patients and had 14 patients with a line marked through the name with no explanation why the patient was removed from the log from 01/01/20 through 10/31/20. Four patients from a total of 23 sampled patients' record reviewed were either omitted from the ED log (Patient 1), had an incorrect chief complaint documented (Patient 12) or were lined through with no documentation why the patient was removed from the log (Patient 22 and Patient 23). This failure had the potential to prevent the hospital from tracking the care provided to each future individual who comes to the hospital seeking care for an emergency medical condition.


Findings Include:


1. Review of the ED log from 01/01/20 through 10/31/20 showed 217 patients were listed without a disposition that showed whether the patient refused treatment, was refused treatment, or whether the patient was admitted and treated, stabilized and transferred, or discharged. There were 14 patients during this time period that had a line drawn through the patient's name on the ED log with no documentation of the reason the line was drawn through the patient's name.

Review of the ED log on 12/03/20 showed under the column titled "Disposition" that either "HOM," "AIP," "XACUTE," "LWBS," or "NH" was documented. There was no documentation that showed whether the patient refused treatment, was refused treatment, or whether the patient was admitted and treated, stabilized and transferred, or discharged.

During an interview on 12/08/20 at 11:30 AM, Staff F, Emergency Department Registered Nurse (EDRN) stated the computer system went live on 12/01/20, and one of the things that changed was the ED record and log. She stated the ED discharge record still shows screened/treated, discharged, and such like the "old one did." She stated she "assumes "HOM" means home, "AMA" means against medical advice, "ADM" was for admission, "XACUTE" I would have to go into a record to tell you what it means, "NH" I don't know and again we can look into the chart and it would be there, "LWBS" means left without being seen, "XPSY" I don't know." Staff B, Director of Performance Improvement/Risk Management (DPI/RM), who sat in during the interview, stated that the ED log isn't giving the information required by the regulations about the patient's disposition and treatment, such as screened, treated, and released, left against medical advice, left without being seen, admitted, or transferred. She stated it's "not an upgrade but a new platform" (regarding the computer system). When asked what a line struck through means, Staff F, EDRN stated, "it usually means an account was created with either a misspelling of a name or the patient was supposed to be admitted as a direct admit and not to be an ED patient."

During an interview on 12/10/20 at 7:37 AM, Staff L, Emergency Department Nurse Manager (EDNM) with Staff B, DPI/RM present, stated information technology created a report that pulls in the necessary information from the patient's ED medical record, and it's set to print around 8:00 AM each morning. She stated the ED staff reviews it for missing information (from the day before), and they pass on to whoever needs to correct it, or they can correct it themselves. She stated the report is based off the nurses' documentation, and it can pull the room number, the time the patient arrived and left, and their disposition. She stated the first step is the admission clerk enters the patient's account into the system, and that information gets pulled into the report. When the surveyor told Staff L, EDNM the number of incomplete/inaccurate entries found during review of the ED log, she stated they normally mark through if an entry is a duplicate, or if it was an outpatient who initially came into the ED and were taken to another section of the hospital.

2. Review of the ED log for 11/27/20 showed no documented evidence that Patient 1 was listed as having presented to the ED seeking assistance. A request was made on 12/09/20 at 8:30 AM for a copy of the ED log for 11/27/20. A copy of this ED log was not received as of the time of exit on 12/10/20 at 4:15 PM.

During an interview on 12/08/20 at 11:05 AM, Staff B, DPI/RM stated that Patient 1 had presented to the ED with his mother and his approximate five-year old sibling on 11/27/20. Patient 1's mother was informed by Staff J, Screener that she could not allow the sibling in the ED because the hospital did not allow anyone under 18 years of age to enter the hospital. The mother left with Patient 1 and did not return. It appeared that Patient 1 was turned away without receiving a medical screening exam (MSE) and Staff B was concerned about whether the child got to the other hospital once she left here. Staff B, DPI/RM further stated that the ED log did not include Patient 1 as being refused treatment, but his name and disposition should have been listed on the 11/27/20 log.

3. Review of the ED log for 11/12/20 showed Patient 12 was listed with the "Diagnosis/Visit Reason" of "Labor abnormality."

Review of Patient 12's ED medical record showed he presented to the ED on 11/12/20 at 3:07 PM with chief complaint of "General." Review of the "Triage Assessment" documented on 11/12/20 at 3:24 PM showed the stated complaint included "Pt [patient] presented to ER [emergency room] stating he needed to be checked out. States he had a routine check up and had lab work done 1 week ago. Today a nurse told him his potassium was 7.8 and he needed to go to the ER. . ."

During an interview on 12/09/20 at 1:45 PM, Staff G, Emergency Department Physician (EDP) reviewed the documentation of Staff Q, EDP (who was not available to be interviewed) in Patient 12's ED medical record. He stated the chief complaint of "labor abnormality," which was listed on the ED log and in the medical record was not correct. He stated he viewed nothing in the ED record that could be assessed as "Labor abnormality."


4. Review of the ED log for 11/29/20 showed Patient 22 and Patient 23 were listed as arriving at 11:53 AM and 11:55 AM respectively, both with "Diagnosis/Visit Reason" of "Possible Jaundice" with no documented disposition. Further review showed both patients' names were lined through with no documentation of the reason they were lined through.

Based on record reviews, policy reviews, document review, and interviews, the hospital failed to ensure an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ED), including ancillary services routinely available to the emergency department, was provided to each patient presenting to the ED to determine whether or not an emergency medical condition (EMC) exists for two (Patient 1 and Patient 17) of 23 sampled patients. This failed practice had the potential to affect all future patients seeking assistance in the ED who may have an emergency medical condition that could result in deterioration in their condition, including serious complications or even death.


Findings Include:


1. Review of Patient 1's ED medical record from Hospital A (acute care hospital ~ 1.25 hours away) showed he presented to the ED on 11/27/20 at 5:05 PM with a chief complaint of "Well Child." His "Visit Diagnoses" included "Weight loss (primary), Nasal congestion, Infant fussiness, Anemia of neonatal prematurity, Poor feeding, Premature infant of 30 weeks gestation, Viral illness." Patient 1 had a COVID-19 and Influenza panel lab test done on 11/27/20 at 5:42 PM.

Further review of Patient 1's ED Medical Record titled, "ED Triage Notes Addendum," dated 11/27/20, completed by Hospital A Staff Z, RN at 5:22 PM showed, "Pediatrician from Liberal, Staff K, planned to admit infant to liberal hospital for unknown reason. Mother states she was refused entry into hospital due to having too many COVID pt. Pediatrician asked mother to bring infant to Hospital A."

Review of Patient 1's "Pediatric Discharge Summary" from Hospital A showed ". . . Admission Date: 11/27/20 Discharge Date: 11/28/20 . . . Assessment & Plan 11/28/20: Afebrile overnight. Nasal congestion treated with suctioning. . . Discharge today. 11/27/20: CBC [complete blood count] and pt [patient] hx c/w [history with] viral illness upon admission. Will treat as such with IV [intravenous] hydration, addition of Pedialyte with feedings, addition of Tylenol for pain or fever prn (not scheduled). COVID, RSV [Respiratory Syncytial Virus], Influenza swab sent in ER prior to admission and was negative. Respiratory panel sent and pending. Assessment & Plan 11/27/20: Noted anemia on CBC c/w [with] anemia of prematurity. Recommend PCP [primary care physician] place infant on iron supplementation when over this viral illness. . ."

During an interview on 12/08/20 at 11:05 AM, Staff B, DPI/RM stated that she was notified on Friday evening (11/27/20) that Patient 1 had arrived at the hospital with his mother and a toddler sibling, and Staff J, Screener wouldn't allow Patient 1 and his mother into the hospital because no one under 18 years of age was allowed in the hospital. When Staff B came in on Monday morning (11/30/20), she stated that she contacted Staff I, Staff Development Coordinator (SDC), who is over the screening department and that she called Hospital A's Risk Manager and given her Patient 1's name to see if the child had been seen in the emergency department (ED) or had been admitted to their facility. Staff B stated that she also called Staff K, Pediatrician (PED), who had sent the child from the pediatrician's office to be seen at this hospital. She stated that Staff K related that Patient 1 was seen in the ED at Hospital A and was admitted as an observation patient.

During an interview on 12/08/20 at 11:30 AM, Staff F, Emergency Department Registered Nurse (EDRN), stated she was working the day Patient 1 came to the hospital. She stated that they were expecting him because Staff H, House Coordinator (HC), called one of the other nursing staff to let them know that Patient 1 was on his way in and would be seen in the ED and evaluated. She stated that Patient 1 never appeared in the ED that day.

During an interview on 12/08/20 at 1:30 PM, Staff H stated she was working on 11/27/20, the day of the incident involving Patient 1. She stated Staff K, PED, called her and told her she was sending a two-month old to the ED to be triaged. She stated that she was told the baby "was dehydrated and having respiratory distress because the baby kept coughing." Staff H stated that she called the ED to let them know that the baby was coming and to please let me know if the patient was admitted. She stated that she wasn't told the name of the patient. About an hour later, Staff H looked at the ED tracker and didn't see an infant on the list. Staff H stated that she called Staff F, EDRN who told her no baby had checked in. She stated that she then called Staff K, PED to notify her that an infant had not been brought to the ED. She stated that Staff K, PED, sounded upset and told Staff H that the hospital wouldn't let the baby in. She stated that she asked Staff J, Screener if a baby had checked in, and Staff J, Screener, stated that there was a mom with a baby and a child who looked like a five-year old with her. Staff H said, "Staff J, Screener, told her about the visiting policy that no children are allowed."

During an interview on 12/08/20 at 2:00 PM, Staff J, Screener, Staff I, SDC, and Staff B, (DPI/RM), present, Staff J, Screener stated that on a Friday (11/27/20) in the evening Patient 1, a sibling, and Patient 1's mother appeared at the screening desk outside the emergency department (ED). She stated that she asked Patient 1's mother what they were here for, and Patient 1's mother said they "were sent over." Staff J, Screener stated Patient 1's mother didn't say who sent them or for what reason they were sent. She asked the screening questions: "if she was experiencing any symptoms of cough, fever, nausea; if she was COVID positive or had been exposed to anyone who was; who the patient was today, and she [Patient 1's mother] gestured to the child who was in the car seat carrier. Staff J, Screener, stated that she told Patient 1's mother she wasn't supposed to allow anyone under 18 in the hospital unless they were a patient, and Patient 1's mother stated that she didn't have anyone to take care of the sibling, and Staff J, Screener, stated that she told Patient 1's mother "they would have to reschedule or talk to whoever sent her." She stated Patient 1's mother left and was seen talking on her phone. Staff J, Screener, stated that she assumed she was trying to get someone to take care of the five-year old. She stated Patient 1's mother "left and never came back."

During an interview on 12/09/20 at 9:10 AM, Staff K, PED, stated that she saw Patient 1 in the clinic with a cold. She stated that the Patient 1 returned to urgent care on 11/27/20 and "was not getting better, not eating, crying, no wet diaper, but no fever." She stated she told Patient 1's mother that she would "admit him and investigate." Staff K, PED, stated that she spoke with an ED nurse and told her Patient 1 would come to the ED. She stated she told Patient 1's mother to go to the ED. She stated Patient 1's mother called her at urgent care to tell her they would not let her and Patient 1 in the hospital. When the surveyor asked Staff K, PED, what the risk was for Patient 1 having to travel by personal vehicle with his parents to go to Hospital A, Staff K, PED, stated the "baby was not eating, was dehydrated, and irritable." When asked by the surveyor if there could have been a negative outcome for Patient 1, she stated it was "difficult to say." When asked by the surveyor if there was a possibility of Patient 1 going into respiratory distress or stopping breathing during transport to Hospital A, Staff K, PED, stated, "it could have happened, because the baby was crying a lot and not feeding, and dehydrated."


2. Review of Patient 17's ED medical record showed he presented to the ED on 11/08/20 at 1:40 PM complaining of a cough and muscle aches, and that the patient had "Questionable, Suspected, or Confirmed COVID." Further documentation showed patient 17 had a low grade temperature of 99.6 (normal temperature 98.6), an elevated heart rate 98 (normal adult heart rate at rest 70s - 80s), an elevated blood pressure 149/101 (normal BP range 120/80-140/90), an elevated respiratory rate 20 (normal at rest rate 16-18) and a decreased oxygen saturation 96% (normal is 100-98%). At 3:46 PM Staff P, RN documented the patient did not have any needs but did not document an assessment of the patient's vital signs. At 5:20 PM a licensed practical nurse (LNP) documented the patient did not have any needs but did not document an assessment of the patient's vital signs. At 6:00 PM Staff P, RN documented patient 17's oxygen saturation level had decreased to 93% and that [staff name] "from admissions called and stated that the patient has walked to admissions and is stating he is leaving." The medical record did not contain evidence that staff tried to get the patient to stay or explained the medical risks of leaving before receiving a medical screening examination (MSE) during his 4 hour and 20-minute stay in the ED.

During an interview on 12/09/20 at 4:10 PM, Staff U, Clinical Care Coordinator (CCC), stated Patient 17 arrived at the emergency department (ED) at 1:40 PM on 11/08/20 and triaged at 1:44 PM. She stated Patient 17 was moved to an ED room at 3:44 PM and left without notice at 6:00 PM. Staff U, CCC, confirmed that Patient 17 did not receive a MSE.

During an interview on 12/10 at 10:00 AM with Staff B, DPI/RM, and Staff L, EDNM, present, Staff L, EDNM, presented information regarding follow-up on Patient 17 related to the failure to provide an MSE. She stated Patient 17 arrived on 11/08/20 at 1:40 PM, was triaged at 1:44 PM with an ESI level three, and seen by a nurse at 3:46 PM, 5:30 PM, and he left at 6:00 PM. Staff L EDNM, stated vital signs were not assessed every hour in accordance with ED policy. She confirmed Patient 17 did not have an MSE during his 4 hour and 20-minute stay in the ED.

During an interview on 12/10/20 at 11:57 AM, Staff P, RN, with Staff B,DPI/RM, present during the interview, Staff P, RN, stated she triaged Patient 17 as an ESI level three. She stated his blood pressure, oxygen saturation, heart rate were all stable so she had to send him out to the lobby to wait. She stated they later put him in ED bay four, so they could keep a closer eye on him. She stated that EMS (emergency medical services) brought a patient who was triaged as ESI level two shortly after Patient 17 was put in a room, and there was another ESI level two patient in the ED at the time. She stated that sometime later the admission clerk called and told her Patient 17 was leaving. She stated Patient 17 did have an x-ray. Staff P, RN, reviewed Patient 17's ED medical record and stated vital signs were documented at 1:44 PM and again at 6:00 PM. She stated they are supposed to take vital signs every 30 minutes to an hour for an ESI level three patient (policy shows a minimum of every hour and at discharge).

During a telephone interview on 12/10/20 at 3:46 PM, Patient 17 stated he "was at the hospital ED for six or seven hours, not sure how long." He stated they took him for an x-ray, and an hour later they took him to a room. He stated the next day he went to the ED at Hospital B seeking care and was "diagnosed with COVID and pneumonia."