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[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24.


Based on document and medical record review and interview, the facility does not have a mechanism in place to ensure that all patients are screened in a timely manner in order to prioritize when the individual will be seen by qualified medical personnel.

Please reference findings under Tag A2406.

Based on document and medical record review and interview, there is no evidence to indicate all patients are screened in a timely manner in order to prioritize when the individual will be seen by qualified medical personnel for 2 of 26 patients who presented to the Emergency Department (ED). (Patient # ' s 1 and 11)

Findings include:

Review of the policy and procedure entitled " Catholic Health Emergency Department Standards of Care " , Policy #ED-05, effective 10/21/14, revealed that " Triage is the process of rapid sorting of patients according to acuity and severity of illness/injury. " " The ED utilizes the Emergency Severity Index Version 4 (ESI) to prioritize patients and identify those patients that cannot wait to be seen. "

Review of the ED record for Patient #1, revealed that the patient arrived at the ED at 12:04 AM on 7/22/14. On presentation to the ED the patient completed an information form provided by the Patient Access Specialist. In the area for Complaints/Symptoms, the patient wrote "significant rectal bleeding". At 3:28 AM, 3.5 hours after presentation, the patient's vital signs were obtained and an ESI level of Acuity:3-Urgent was assigned. The patient was subsequently evaluated and admitted to the hospital for continued care.

Review of the ED record for Patient #11 revealed that the patient arrived at the ED at 1:30 AM on 6/04/14. When the patient presented to the ED, he completed an information form provided by the Patient Access Specialist. In the area for Complaints/Symptoms, the patient wrote "panic attack". A Triage Assessment documented as being completed at 1:00 AM does not indicate the patient ' s ESI level and there are no recorded vital signs. The patient is documented as leaving the ED at 3:34 AM " due to the wait time " .

Interview with Quality and Patient Safety Director, Staff #1 on 12/04/14 and Emergency Department Director of Nursing, Staff #3 on 12/11/14 confirmed the above noted findings.