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Based on observation, interview, and record review, the hospital failed to post conspicuously a sign, with information to indicate whether the hospital participated in the State Medicaid program, the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor, in places likely to be noticed by all individuals entering the emergency department and individuals in the treatment area of the hospital emergency department. This deficiency practice resulted in the patients' inability to exercise their rights.

Findings:

On September 15, 2014 from 9:30 a.m. to 10:45 am., a tour of the emergency department (ED) was conducted with the director of licensing and accreditation (Admin 1) and the emergency department administrative director (Admin 2).

There was no conspicuously posted signage with information to indicate whether the hospital participated in State Medicaid program, the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor upon entering the facility ED.

In the walk-in entrance of the ED, there was a posted signage on the door leading to the main treatment area, from the waiting area on one side of the registration/front desk. The sign was not noticeable to patients upon registration nor for patients seated in the waiting area, on the other side of the registration/front desk.

At the same time during an interview, Admin 1 and admin 2 acknowledged there was no other signage in the registration/waiting area ED.

A posted signage was observed in the triage room. There were no other posted signage in the treatment areas except for a posting of patient rights between room number 24 and 25.

A review of the facility's policy and procedure titled, "EMTALA (Screening, Stabilization and Management of Emergency Tranfers)" last revised on June 30, 2014, indicated the facility shall post signs in conspicuous locations likely to be noticed by all individuals entering the dedicated emergency departments where patients are screened (including areas such as entrances, admitting areas, waiting rooms, treatment areas).

Based on record review, observation, and interview, the facility failed to ensure the patients arrived to the facility's emergency department received a medical screening examination by a qualified health professional for 2 of 22 sampled patients (Patient 3 and 18).

Patient 18 arrived at the facility's emergency department (ED) with a chief complaint of "suicidal" at 8:14 p.m., on June 4, 2014. Patient 18 was assessed as at risk for suicide at 8:31 p.m., and was placed in the waiting room and went to sleep. At 1:19 a.m., (five hours and five minutes after his arrival), Patient 18 was agitated, aggressive, and became upset when he was placed in a chair to be evaluated. Patient 18 became verbally abusive with staff and security. The security staff escorted him out the emergency department. Patient 18 did not receive a medical screening exam by a physician to determine if an emergency medical condition existed.

For Patient 3, the facility failed to evaluate the patient every 2 to 3 hours, and the patient left without being seen for medical screening examination.

This deficient practice resulted in the patients not receiving medical screening examination after arriving at the hospital emergency department.

Findings:

1. A review of Patient 18's electronic medical record was conducted with Registered Nurse (RN) 3 on September 16, 2014. The "Patient Care Timeline" dated June 4, 2014, indicated Patient 18 arrived at the facility's ED at 8:14 p.m. with the chief complaint, "suicidal" and was "out of Ativan, last used methamphetamines one week ago." A registered nurse completed the triage assessment at 8:27 p.m., which indicated the patient acuity was a Level 3 (level 1 is highest acuity, and level 5 is the lowest acuity), and the patient was not at risk for suicide. At 8:31 p.m., Patient 18's suicide risk assessment indicated the patient was at risk for suicide, had expressed suicidal/self-harm thoughts, and had a suicidal plan. The charge nurse was notified, the patient was cooperative and waiting for an examination room. Patient 18's acuity moved up to Level 2. There was no documentation of a medical screening examination performed for Patient 18 to address the patient's suicidal risk, suicidal thoughts, and suicidal plan.

According to the facility's policy and procedure titled, "Triage Patient Assessment" revised March 1, 2012, a Level 2 is defined as "the patient with a high risk situation, or one who is experiencing new onset confusion, lethargy, or disorientation, and consideration is given to the patient experiencing severe pain or distress." In an interview with the RN 2 on September 16, 2014 at 2 p.m., he stated a triage acuity Level 2 meant the patient is high risk for harming himself.

The facility's policy and procedure titled, "EMTALA (screening, Stabilization, and Management of Emergency Transfers) dated June 30, 2014, indicated "triage" means a "process to determine the order in which individuals will be provided a Medical Screening Examination and does not determine the presence or absence of an Emergency Medical Condition."

The "Patient Care Timeline" dated June 4, 2014, at 10:29 p.m., indicated Patient 18 was calm, cooperative, resting with eyes closed. Continue to wait for examination room. At 12:23 a.m. on June 5, 2014, Patient 18 was sleeping in the waiting room and continued to wait for an examination room.

The "Patient Care Timeline" dated June 5, 2014 indicated that at 12:54 a.m., a section under "Patient roomed in ED," and indicated "To room AL01." In an interview with the RN 3 on September 16, 2014 at 11:05 a.m., she stated "room AL01" was not a room but an area in the emergency department behind the two triage rooms.

During a tour of the facility's emergency department on September 15, 2014 at 9:50 a.m., there was an area behind the two triage rooms that had three gurneys, separated by a privacy curtain in between gurneys, and each gurney was labeled as "AL01, AL02, and AL03."

The "Patient Care Timeline" dated June 5, 2014, also indicated "Time the ED Physician first saw the patient, 0115 pt (patient) not in the room, not evaluated. In an interview with the RN 3 on September 16, 2014 at 11:05 a.m., she stated she could not explain what the documentation meant.

The "Patient Care Timeline" dated June 5, 2014 at 1:19 a.m., indicated Patient 18 was not at risk for suicide, but was agitated and aggressive. Patient 18 became upset when he was placed in a chair to be evaluated. Patient 18 became verbally abusive with staff and security. Patient 18 was requesting a gurney to sleep and to have a prescription for Ativan (medication for anxiety). Patient 18 would not calm down and a security staff escorted him out. The attending physician witnessed the patient's "outburst." There was no medical screening examination performed on Patient 18. At 1:23 a.m., on June 5, 2014, Patient 18's disposition was "Leaving Without Being Seen (LWBS)."

During an interview on September 16, 2014 at 11: 05 a.m. and 11:20 a.m., RN 3 stated the action plan for suicidal patient was to alert the charge nurse, physician, and security, to place the patient in medical detainment, and to have the emergency department physician see the patient. She stated Patient 18 should have been seen by the physician and not be escorted out of the emergency department.

An interview was conducted with the Physician 2 on September 16, 2014, at 3:15 p.m. When asked about no medical screening examination done for Patient 18, who was assessed as being suicidal, and was in the emergency department for more than four hours, Physician 2 stated it was not unusual to wait a long time for medical screening examination. Physician 2 stated the facility has a suicide protocol, if they have a room, they would place the patient in a room with a security personnel in a room or just outside the door. Physician 2 stated provide a "uniform response" as soon as possible when dealing with suicidal patient. Physician 2 stated Patient 18 should have not been escorted out of emergency department.

The facility's policy and procedure titled, "EMTALA (Screening, Stabilization, and Management of Emergency Transfers) revised June 30, 2014 indicated that all individuals requesting examination or treatment in the emergency department shall receive an appropriate MSE. The policy defined MSE as the "process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical condition exists."

The "Patient Care Timeline" dated June 5, 2014 at 2:13 a.m., indicated Patient 18 arrived to the emergency department brought by the UCPD (University Campus Police Department) on a "5150" (Health and Safety Code for 72 hours detention for psychiatric evaluation and the patient is danger to self) with the chief complaint "suicidal." Patient 18's triaged assessment at 2:20 a.m., indicated the patient acuity was a Level 2, was at risk for suicide, expressed suicidal/self harm thoughts, and had previous suicide attempts. The suicide interventions included security at the bedside, detainment initiated, charge nurse notified and UCPD (University Campus Police Department).

The Emergency Department Service Report dated June 5, 2014, at 2:23 a.m., indicated Patient 18 was brought into the emergency department by UCPD on a 5150. Patient 18 stated prior to arrival, he tried to commit suicide by wrapping a noose around his neck, trying to hang himself, but the rope broke after he jump off the chair. Patient 18 stated he wanted a prescription refill of Ativan medication. The physician impression was psychiatric disturbance, the patient had a history of bipolar disorder and depression. The plan was to have a psychiatric consultation for further evaluation.

The Psychiatric Consultation dated June 5, 2014, indicated Patient 18 had a history of substance abuse and mood disorder. Patient 18 was escorted out of the emergency department by security at 1:20 a.m. From the street corner outside the emergency department entrance, 15 minutes later, Patient 18 called 911 for complained of anxiety. Patient 18 reported to the staff from emergency medical system (EMS) that he was suicidal and tried to hang himself on 6/4/14. The EMS staff brought the patient back into the ED, on a 5150 by UCPD at 2 a.m. The diagnostic impression was polysubstance abuse, malingering and likely mixed substance withdrawal substances. Patient 18 reported that he does not desire to harm himself and would seek appropriate outpatient support. The patient's risk for suicide may be managed at an outpatient level of care.

The "Patient Care Timeline" dated June 5, 2014 indicated Patient 18 was discharged from the emergency department at 3:50 a.m.


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2. A review of the medical records of Patient 3 indicated the patient was seen in the ED on 7/8/2014., his chief complaint was bleeding status post rectal dysplasia (abnormal cells or lesion in the skin lining of the anal canal) removal on July 3. Patient 3 arrived at 6:22 p.m., and was triaged at 6:26 p.m. He described his pain as 10/10 with continuous burning. Patient 3 received no intervention for bleeding or pain, was triage class three. There is no documentation of reassessment of Patient 3 in the waiting room from 6:26 p.m. until 11:29 p.m. Patient 3 left without receiving a triage reassessment or medical screening examination.

On September 16, 2014, at 9:15 a.m., the triage nurse (RN 1) was interviewed. RN 1 stated she sat at the front desk in the waiting room, she usually completed the triage within 5 to 10 minutes of the patient's arrival. RN 1 stated the front desk triage assessment was a quick evaluation. The triage nurse gets the vital signs, pain score, medical history and assigns a triage level from 1 to 5. At the completion of the triage, the patient will proceed to the back triage room or the waiting area. RN 1 stated she would check the patients in the waiting room every 1 to 2 hours and document. RN 1 stated all three of us (triage nurses) would take patient vital signs every two hours. At any time the patient in the waiting room has a change in condition, she would change the patient triage level.

A review of the facility policy and procedure titled "Triage: Patient assessment " indicates that "Waiting room patients will be assessed every 2 hrs." A review of the facility policy and procedure, revised 8/2011, titled. "Emergency department nurse initiated protocol" under the titled, "Pain Protocol" indicates giving pain medication for isolated extremity injury.