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Based on document review, policy review and staff interview it was determined the hospital failed to ensure patients that presented to the emergency department were triaged in a reasonable time, removed from the Emergency Medical Services stretcher in a timely manner, were continuously reassessed for change in their medical condition while awaiting their medical screening exam (see Tag A 2406) and had a medical screening exam performed prior to signing the hospital financial agreement (see Tag A 2408).

A. Based on document review, policy review and staff interview it was determined the hospital failed to ensure patients were triaged in a timely manner (patients #6, 8, 10, 12, 13, 15, 16, 17 and 20). This failure has the potential to delay possible life-saving measures of the patient seeking a medical screening exam.

Findings include:

1. A review of the medical record for patient #6 revealed a fifty-three (53) year old male who presented to the emergency department (ED) on 1/12/21 at 6:24 p.m. via Emergency Medical Services (EMS) with complaints of alcohol withdrawal. The patient was triaged at 8:09 p.m., one (1) hour and forty-five (45) minutes after his arrival. His blood pressure was 155/106 and pulse was 119. He was given an acuity level of three (3) urgent. The patient left the ED at 9:56 p.m. without receiving a medical screening exam. The patient was never reassessed by the triage nurse.

2. A review of the medical record for patient #8 revealed a fifty (50) year old female that presented to the ED on 1/27/21 at 12:10 a.m. via EMS with complaints of seizure activity. The patient was triaged at 12:52 a.m., forty-two (42) minutes after arrival and was given an acuity level of three (3). The patient was left on the EMS cot until 5:43 a.m. when she left without a medical screening exam. The patient was never reassessed by the triage nurse while waiting to be seen by the provider.

3. A review of the medical record for patient #10 revealed a fifty-six (56) year old male that presented to the emergency department (ED) on 2/2/21 at 1:42 p.m. with complaints of dizziness and giddiness. The patient was triaged at 2:08 p.m. with a blood pressure of 165/107. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 1:56 p.m. prior to being triaged. The patient left prior to receiving a medical screening exam. He was never reassessed by the triage nurse.

4. A review of the medical record for patient #12 revealed a thirty-eight (38) year old female that presented to the ED on 2/5/21 at 10:44 p.m. with complaints of shortness of breath. The patient was triaged on 2/6/21 at 12:38 a.m., one (1) hour and fifty-four (54) minutes after her arrival. Her temperature at triage was 101.2 and her oxygen saturation was 92% with her respirations at 22 a minute. She was given an acuity level of three (3) urgent. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 12:53 a.m. prior to receiving a medical screening exam. The patient ultimately left the ED at 4:15 a.m. without receiving a medical screening exam or having her condition reassessed by the triage nurse.

5. A review of the medical record for patient #13 revealed a thirty-five (35) year old female that was sent to the ED for evaluation for a possible blood clot in her leg. She arrived at the ED on 3/8/21 at 2:47 p.m. and was not triaged until 4:30 p.m. The patient was there one (1) hour and forty-seven (47) minutes before she was triaged and left the hospital at 4:56 p.m. prior to receiving a medical screening exam.

6. A review of the medical record for patient #15 revealed a thirty-nine (39) year old female that arrived in the ED with complaints of an abscess on her left wrist. She arrived on 3/9/21 at 11:52 a.m. The patient was not called to be triaged until 1:00 p.m., one (1) hour and eight (8) minutes after her arrival to the ED. The patient left prior to being triaged or receiving a medical screening exam.

7. A review of the medical record for patient #16 revealed an eighteen (18) year old male that presented to the ED with complaints of suicidal ideation. The patient arrived on 3/9/21 at 6:14 p.m. He was not triaged until 8:28 p.m., two (2) hours and fourteen (14) minutes after his arrival. The patient was given an acuity level of two (2) emergent. The patient left at 9:15 p.m. without receiving a medical screening or being reassessed prior to leaving the ED.

8. A review of the medical record for patient #17 revealed a fifty-one (51) year old female with complaints of needing an infusion for low potassium. The patient arrived in the ED on 3/10/21 at 3:38 p.m. She was triaged at 5:08 p.m., one (1) hour and thirty (30) minutes after her arrival to the ED. The patient had lab work ordered per protocol while waiting in the waiting room until she received her medical screening exam. Her lab work revealed she had a critical potassium level was called to a Registered Nurse (RN) at 7:19 p.m. There was no documentation of notification to the physician. The patient did not receive a medical screening exam until 12:17 a.m. on 3/11/21. The patient had no vital sign reassessment for seven (7) hours and forty-five (45) minutes and no medical screening exam for eight (8) hours and thirty-nine (39) minutes. The patient ultimately signed out Against Medical Advice (AMA).

9. A review of the medical record for patient #20 revealed an eighteen (18) year old female that presented to the ED on 4/13/21 with complaints of a urinary tract infection or kidney infection. The patient arrived at 2:17 p.m. and was triaged at 2:32 p.m. She was given an acuity level of three (3) urgent. The patient was in the waiting room for five (5) hours and nineteen (19) minutes without reassessment. She left the facility at 7:51 p.m. without receiving a medical screening exam.

10. A review of the hospital document entitled 'Triage in the Emergency Department,' last revised 6/17/2020, states in part: "...If they are designated Urgent or Emergent, he/she will be reassessed by the triage nurse every hour while in the waiting room. The triage nurse will document the reassessment and vital signs on the electronic medical record (EMR). If the triage nurse is unable to complete the reassessment in a timely manner, they will notify the CNM." The policy further states, "In keeping with the standard of triage, within five (5) minutes of arrival, when multiple patients sign in to be triaged, the primary nurse and CNM may assist to triage."

11. A telephone interview was conducted with the Medical Director of the ED on 5/19/21 at approximately 2:00 p.m. He stated it was his expectation that no patient with suicidal ideation leave the hospital without a medical screening. He stated, "We have to see the patient to see what needs to be done. Just because the patient wants to leave doesn't mean that they can." He further stated, "We are doing the best we can with the resources that we have. We are limited with the staff we have and can only do so much. We are keeping admitted patients in the ED because we are waiting for beds to put them in."

12. An interview was conducted with the Director of the ED on 5/19/21 at approximately 2:25 p.m. She stated it was her expectation that it should never take over thirty (30) to forty-five (45) minutes for a patient to be triaged. She stated the policy stated if the patient had an acuity level of two (2) or three (3) the patient should be reassessed every hour. She concurred patients #12, 13, 15, 16, and 17 had a significant delay in being triaged, that patient #10 and #12 had their financial agreement signed before being triaged or having a medical screening exam and patients #6, 8,10, 12 13, 15, 16, 17 and 20 had no reassessments while waiting in the waiting room to have a medical screening exam.

B. Based on document review and staff interview it was determined the hospital failed to remove two (2) out of twenty (20) patients from the EMS cot in a timely manner (patient #1 and 8). This failure has the potential to negatively impact the patients awaiting to be seen by the physician for a medical screening exam.

Findings include:

1. A review of the medical record for patient #1 revealed a fifteen (15) year old female that presented to the ED via EMS after ingesting twenty-two (22) two hundred (200) milligram ibuprofen at home. The patient arrived at the ED at 11:26 a.m. on April 9, 2021. EMS picked the patient up at her home address and was told by the patient's father that she was to be taken to the above hospital because arrangements had been made by the patient's mental health counselor for her to be admitted to the Adolescent Psychiatric Unit of the hospital. The patient was triaged at 11:27 a.m. and was given an acuity level of three (3). Patient #1 was left on the EMS cot until a room was available at 7:20 p.m. for a total of seven (7) hours and fifty-four (54) minutes. The patient denied wanting to hurt herself during triage and a suicide risk assessment was not completed. A medical screening exam was conducted at 4:14 p.m. The patient was placed on one (1) to one (1) observation at 6:44 p.m. The patient was transferred to another psychiatric hospital on 4/10/21.

2. A review of the medical record for patient #8 revealed a fifty (50) year old female that presented to the ED on 1/27/21 at 12:10 a.m. via EMS with complaints of seizure activity. The patient was triaged at 12:52 a.m., forty-two (42) minutes after arrival and was given an acuity level of three (3). The patient was left on the EMS cot until 5:43 a.m. when she left without a medical screening exam. The patient was never reassessed by the triage nurse while waiting to be seen by the provider.

3. An interview was conducted with the Charge Nurse on 5/19/21 at approximately 9:00 a.m. She stated she remembered the day was "horrific." She stated, "We had had two (2) priority, two (2) traumas and was holding a bunch of admitted patients in the ED. I was told by triage the patient had an IV so we couldn't get her off the EMS cot but come to find out she didn't even have an IV." She further stated it was not normal to leave an EMS patient on the cot for over seven (7) hours but there were just no beds available because of all the admitted patients in the ED.

4. An interview was conducted with the Community Chief Nursing Officer on 5/17/21 at approximately 11:00 a.m. She stated it was not normal for patients to be left on EMS carts for a prolonged length of time. She concurred that seven (7) hours and fifty-two (52) minutes was too long for a patient to be left on an EMS cart.

C. Based on document review, policy review and staff interview it was determined the hospital failed to ensure seven (7) out of twenty (20) patients (patient #6, 8, 10, 12, 13, 15, 16, 17 and 20) were actively monitored while waiting to be seen for a potential emergency medical condition. This failure has the potential to delay possible life saving measures of the patient seeking a medical screening exam.

Findings include:

1. A review of the medical record for patient #6 revealed a fifty-three (53) year old male who presented to the ED on 1/12/21 at 6:24 p.m. via EMS with complaints of alcohol withdrawal. The patient was triaged at 8:09 p.m., one (1) hour and forty-five (45) minutes after his arrival. His blood pressure was 155/106 and pulse was 119. He was given an acuity level of three (3) urgent. The patient left the ED at 9:56 p.m. without receiving a medical screening exam. The patient was never reassessed by the triage nurse.

2. A review of the medical record for patient #8 revealed a fifty (50) year old female that presented to the ED on 1/27/21 at 12:10 a.m. via EMS with complaints of seizure activity. The patient was triaged at 12:52 a.m., forty-two (42) minutes after arrival and was given an acuity level of three (3). The patient was left on the EMS cot until 5:43 a.m. when she left without a medical screening exam. The patient was never reassessed by the triage nurse while waiting to be seen by the provider.

3. A review of the medical record for patient #10 revealed a fifty-six (56) year old male that presented to the ED on 2/2/21 at 1:42 p.m. with complaints of dizziness and giddiness. The patient was triaged at 2:08 p.m. with a blood pressure of 165/107. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 1:56 p.m. prior to being triaged. The patient left prior to receiving a medical screening exam. He was never reassessed by the triage nurse.

4. A review of the medical record for patient #12 revealed a thirty-eight (38) year old female that presented to the ED on 2/5/21 at 10:44 p.m. with complaints of shortness of breath. The patient was triaged on 2/6/21 at 12:38 a.m., one (1) hour and fifty-four (54) minutes after her arrival. Her temperature at triage was 101.2 and her oxygen saturation was 92% with her respirations at 22 a minute. She was given an acuity level of three (3) urgent. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 12:53 a.m. prior to receiving a medical screening exam. The patient ultimately left the ED at 4:15 a.m. without receiving a medical screening exam or having her condition reassessed by the triage nurse.

5. A review of the medical record for patient #13 revealed a thirty-five (35) year old female that was sent to the ED for evaluation for a possible blood clot in her leg. She arrived at the ED on 3/8/21 at 2:47 p.m. and was not triaged until 4:30 p.m. The patient was there one (1) hour and forty-seven (47) minutes before she was triaged and left the hospital at 4:56 p.m. prior to receiving a medical screening exam.

6. A review of the medical record for patient #15 revealed a thirty-nine (39) year old female that arrived in the ED with complaints of an abscess on her left wrist. She arrived on 3/9/21 at 11:52 a.m. The patient was not called to be triaged until 1:00 p.m., one (1) hour and eight (8) minutes after her arrival to the ED. The patient left prior to being triaged or receiving a medical screening exam.

7. A review of the medical record for patient #16 revealed an eighteen (18) year old male that presented to the ED with complaints of suicidal ideation. The patient arrived on 3/9/21 at 6:14 p.m. He was not triaged until 8:28 p.m., two (2) hours and fourteen (14) minutes after his arrival. The patient was given an acuity level of two (2) emergent. The patient left at 9:15 p.m. without receiving a medical screening or being reassessed prior to leaving the ED.

8. A review of the medical record for patient #17 revealed a fifty-one (51) year old female with complaints of needing an infusion for low potassium. The patient arrived in the ED on 3/10/21 at 3:38 p.m. She was triaged at 5:08 p.m., one (1) hour and thirty (30) minutes after her arrival to the ED. The patient had lab work ordered per protocol while waiting in the waiting room until she received her medical screening exam. Her lab work revealed she had a critical potassium level was called to a Registered Nurse (RN) at 7:19 p.m. There was no documentation of notification to the physician. The patient did not receive a medical screening exam until 12:17 a.m. on 3/11/21. The patient had no vital sign reassessment for seven (7) hours and forty-five (45) minutes and no medical screening exam for eight (8) hours and thirty-nine (39) minutes. The patient ultimately signed out Against Medical Advice (AMA).

9. A review of the medical record for patient #20 revealed an eighteen (18) year old female that presented to the ED on 4/13/21 with complaints of a urinary tract infection or kidney infection. The patient arrived at 2:17 p.m. and was triaged at 2:32 p.m. She was given an acuity level of three (3) urgent. The patient was in the waiting room for five (5) hours and nineteen (19) minutes without reassessment. She left the facility at 7:51 p.m. without receiving a medical screening exam.

10. A review of the hospital document entitled 'Triage in the Emergency Department,' last revised 6/17/2020, states in part: "...If they are designated Urgent or Emergent, he/she will be reassessed by the triage nurse every hour while in the waiting room. The triage nurse will document the reassessment and vital signs on the electronic medical record (EMR). If the triage nurse is unable to complete the reassessment in a timely manner, they will notify the CNM." The policy further states, "In keeping with the standard of triage, within five (5) minutes of arrival, when multiple patients sign in to be triaged, the primary nurse and CNM may assist to triage."

11. A telephone interview was conducted with the Medical Director of the Emergency Department on 5/19/21 at approximately 2:00 p.m. He stated it was his expectation that no patient with suicidal ideation leave the hospital without a medical screening. He stated, "We have to see the patient to see what needs to be done. Just because the patient wants to leave doesn't mean that they can." He further stated, "'We are doing the best we can with the resources that we have. We are limited with the staff we have and can only do so much. We are keeping admitted patients in the ED because we are waiting for beds to put them in."

12. An interview was conducted with the Director of the ED on 5/19/21 at approximately 2:25 p.m. She stated it was her expectation that it should never take over thirty (30) to forty-five (45) minutes for a patient to be triaged. She stated the policy stated if the patient had an acuity level of two (2) or three (3) the patient should be reassessed every hour. She concurred patients #12, 13, 15, 16, and 17 had a significant delay in being triaged, that patient #10 and #12 had their financial agreement signed before being triaged or having a medical screening exam and patients #6, 8,10, 12 13, 15, 16, 17 and 20 had no reassessments while waiting in the waiting room to have a medical screening exam.

Based on document review and staff interview it was determined the hospital failed to ensure two (2) out of twenty (20) patients received a medical screening exam prior to signing the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' (patient #10 and #12). This failure has the potential to discourage the patient from having a medical screening exam for a possible medical emergency.

Findings include:

1. A review of the medical record for patient #10 revealed a fifty-six (56) year old male that presented to the emergency department (ED) on 2/2/21 at 1:42 p.m. with complaints of dizziness and giddiness. The patient was triaged at 2:08 p.m. with a blood pressure of 165/107. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 1:56 p.m. prior to being triaged. The patient left prior to receiving a medical screening exam. He was never reassessed by the triage nurse.

2. A review of the medical record for patient #12 revealed a thirty-eight (38) year old female that presented to the ED on 2/5/21 at 10:44 p.m. with complaints of shortness of breath. The patient was triaged on 2/6/21 at 12:38 a.m., one (1) hour and fifty-four (54) minutes after her arrival. Her temperature at triage was 101.2 and her oxygen saturation was 92% with her respirations at 22 a minute. She was given an acuity level of three (3) urgent. The patient signed the hospital document entitled 'Conditions of Treatment and Responsibility for Payment' at 12:53 a.m. prior to receiving a medical screening exam. The patient ultimately left the ED at 4:15 a.m. without receiving a medical screening exam or having her condition reassessed by the triage nurse.

3. An interview was conducted with the Director of the ED on 5/19/21 at approximately 2:25 p.m. She stated, "Registration is never supposed to get the financial information prior to the medical screening. They know better than that. They are supposed to get them to sign after the patient has been triaged and seen by the provider, never before." She concurred patient #10 and patient #12 had their financial responsibility agreement signed prior to triage or before receiving a medical screening exam.