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Based on record review and interview the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1) Failing to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to ensure the time of patient arrival to the emergency department was accurately documented on the Central Log (see findings at C2405), and;

2) Failing to ensure a patient presenting to the ED with an emergency medical condition was triaged in a timely manner for 1 of 22 sampled ED patients (#3). This resulted in Patient #3 waiting 1 hour and 26 minutes to be triaged and 1 hour and 29 minutes to receive a medical screening examination (see findings at C2406).

Based on review of the Emergency Department (ED) Central Log, ED patient records and staff interview, the hospital failed to ensure an accurate Central Log was maintained as evidenced by inaccurate patient arrival times on the Central Log for 4 of 4 (#3, #12, #14, #18) sampled patients and 1 random patient (R2) reviewed for arrival/log times. Findings:

Review of the hospital policy titled, ED (Electronic) Log Book, Policy number 01-03.10-0008, reviewed and approved 01/13 and provided as current by S2DON (Director of Nursing, revealed the following: It is the policy of [Hospital] to maintain a central log of all patients who come to the ED seeking treatment. The ED log will indicate whether refused treatment, treated, admitted, stabilized, transferred, discharged to home, eloped, AMA (Against Medical Advice), or placed in observation. The information will be entered into computer system by the staff upon disposition of the patient. If there is a computer down time, the information will be held at the clerk's station until which time it may be entered. If the computer down time exceeds 12 hours, the information will be entered into a manual logbook and the original documents sent to medical records.
There was no documented evidence of a provision in the policy for including the time of patient arrival or which time was considered the arrival time.

During the entrance conference on 11/12/13 at 9:50 a.m., the ED Central Log was requested for review.

On 11/12/13 at 1:00 p.m., S2DON provided the ED Central Log for the last 6 months for review. Review of the log revealed the disposition of the patients was not included in the log.

On 11/12/13 at 1:30 p.m., S2DON provided another ED Central Log for the last 6 months that included patient dispositions.

Patient #3
Review of the ED Central Log for 10/29/13 revealed the arrival time for Patient #3 was 7:32 p.m. and the chief complaint was Rectal Bleeding.

Review of the "Patient Care Timeline" dated 10/29/13 provided by S2DON (Director of Nursing) as the best record to view the sequence of patient care, revealed the following:
7:09 p.m. Kiosk arrival started
7:31 p.m. Temporary patient is identified
7:32 p.m. Patient arrived in ED - Patient requires immediate care or selected other as a diagnosis.
7:59 p.m. Registration completed
8:19 p.m. Triage start - Triage call 1 x
8:22 p.m. Triage start - Triage call 1 x
8:33 p.m. Vital Signs - Temperature: 99.2; Heart Rate: 96; Respiration: 40; Blood Pressure: 101/70; Oxygen Saturation: 96%; Weight 328 pounds.

In an interview on 11/12/13 at 3:20 p.m., S5ED Manager reviewed the "Patient Care Timeline" for Patient #3 and verified the patient arrived at the ED at 7:09 p.m. S5ED Manager stated when the patient "swipes" the kiosk or starts to enter their information, the system documents that time and that is the patient's time of arrival. S5ED Manager stated Patient #3 was not in the hospital's system and verified it took almost 30 minutes to get the patient identified in the system. S5ED Manager verified 7:32 p.m. was the time the system identified the patient and created a record for the patient.


Patient #12
Review of the ED Central Log for 05/13/13 revealed the arrival time for Patient #12 was 12:45 p.m. and the chief complaint was Flank Pain.

Review of the "Patient Care Timeline" dated 05/13/13 provided by S2DON as the best record to view the sequence of patient care, revealed the following:
12:30 p.m. Temporary patient created in ED.
12:30 p.m. Kiosk Arrival Started.
12:45 p.m. Patient arrived in ED.
12:45 p.m. Temporary patient is identified.
12:46 p.m. Triage started.


Patient #14
Review of the ED Central Log for 05/13/13 revealed the arrival time for Patient #14 was 7:57 p.m. and the chief complaint was Loss of Vision.

Review of the "Patient Care Timeline" dated 05/13/13 provided by S2DON as the best record to view the sequence of patient care, revealed the following:
7:43 p.m. Temporary patient created in ED.
7:43 p.m. Kiosk Arrival Started.
7:56 p.m. Temporary patient is identified.
7:57 p.m. Patient arrived in ED
8:13 p.m. Triage started.


Patient #18
Review of the ED Central Log for 05/14/13 revealed the arrival time for Patient #18 was 12:52 p.m. and the chief complaint was Suicidal.

Review of the "Patient Care Timeline" dated 05/14/13 provided by S2DON as the best record to view the sequence of patient care, revealed the following:
12:45 p.m. Temporary patient created in ED.
12:45 p.m. Kiosk Arrival Started.
12:52 p.m. Patient arrived in ED- Patient requires immediate care or selected other as a diagnosis.
12:52 p.m. Temporary patient is identified.
1:18 p.m. Triage started.


Patient #R2
Review of the ED Central Log for 10/29/13 revealed the arrival time for Patient #R2 was 7:22 p.m. and the chief complaint was Fever.

Review of the "Patient Care Timeline" dated 10/29/13 provided by S2DON as the best record to view the sequence of patient care, revealed the following:
6:50 p.m. Temporary patient is identified.
6:50 p.m. Kiosk arrival started
7:09 p.m. Temporary patient is identified.
7:09 p.m. Triage Started
7:12 p.m. Triage Completed
7:22 p.m. Patient arrived in ED

In an interview on 11/14/13 at 2:54 p.m., S2DON and S5ED Manager reviewed the above sampled and random patient records and the ED Central Log. S5ED Manager stated the "Patient Care Timeline" provided an accurate time of arrival. S5ED Manager verified the Central Log time of arrival was not accurate and the log recorded the arrival time as the time the patient's record was created. S5ED Manager stated she did not know why the system used the time the record was created for the arrival time. S5ED Manager and S2DON verified the above sampled and random patients were patients that were not in the hospital's system and the Central Log time of arrival was not accurate for these patients.

Based on review of policies and procedures, Emergency Department (ED) records, and staff interviews, the hospital failed to ensure a medical screening examination was not delayed as evidenced by failure to ensure a patient presenting to the ED with an emergency medical condition was triaged in a timely manner for 1 of 22 sampled ED patients (#3). This resulted in Patient #3 waiting 1 hour and 26 minutes to be triaged and 1 hour and 29 minutes to receive a medical screening examination. Findings:

Review of the hospital policy titled, Emergency Department Triage System, Policy number 01-03.1-0011, Reviewed and Approved date 01/13, provided by S5ED Manager as current, revealed in part the following:
III. It is the policy of Lallie Kemp Hospital to implement timely and accurate triage assessments to patients presenting to the emergency department areas of the hospital and to provide routine observation and further monitoring of all patients awaiting a medical screening examination in the waiting areas....
The primary goal of the rapid triage is to identify life-threatening conditions. The second goal is to prioritize patients according to acuity.
Rapid triage must be expedited in a timely manner.
Any individual who comes to the emergency department will be registered/entered into an emergency department electronic Kiosk system.
The first step in the rapid triage process involves initial screening by a registered nurse. The registered nurse will greet each patient on arrival, perform a preliminary survey (including a determination of complaints and brief history); perform a rapid patient assessment that includes vital signs (including pulse oximetry & pain level), ABC assessment (airway, breathing and circulation), disability (Glasgow Coma Scale, alert, verbal, pain, unresponsive) and a physical assessment detailed enough so as to allow the nurse to ascertain the nature and severity of the patient's condition.....
After initial rapid triage, the registered nurse will then assign a triage level (I, II, III, IV, V)....
Emergent (Level II): Conditions that are a potential threat to life or limb or function, requiring rapid medical intervention or delegated acts. These patients are immediately taken to the treatment area where they are evaluated and assessed by appropriate nursing and physician personnel.

Patient #3
Review of the emergency department record for Patient #3 revealed the patient was a 43 year old male who presented to the hospital emergency department on 10/29/13 at 7:09 p.m. The record revealed the arrival complaint was bleeding. The record revealed the patient arrived ambulatory by private vehicle.

Review of the "Patient Care Timeline" dated 10/29/13 provided by S2DON (Director of Nursing) as the best record to view the sequence of patient care, revealed the following:
7:09 p.m. Kiosk arrival started
7:31 p.m. Temporary patient is identified
7:32 p.m. Patient arrived in ED - Patient requires immediate care or selected other as a diagnosis.
7:59 p.m. Registration completed
8:19 p.m. Triage start - Triage call 1 x
8:22 p.m. Triage start - Triage call 1 x
8:33 p.m. Vital Signs - Temperature: 99.2; Heart Rate: 96; Respiration: 40; Blood Pressure: 101/70; Oxygen Saturation: 96%; Weight 328 pounds.
8:34 p.m. Patient roomed in ED - To room 07ED
8:35 p.m. ED Notes Addendum - Patient to bed from triage per stretcher. Patient diaphoretic and weak. Patient placed in gown and connected to NIVBP (Non invasive Blood pressure). Will continue to monitor. Patient awaiting MD (Medical Doctor). Abdomen soft, obese, non-tender to palpation.
8:36 p.m. Triage Plan - Patient Acuity: 2
8:38 p.m. S7MD assigned as attending (Medical Screening Examination done at this time).

There was no documented evidence of an initial screening of the patient upon arrival by the registered nurse. There was no documented evidence of any assessment until the patient was brought into the triage area at 8:33 p.m. and his condition had deteriorated. There was no triage level assigned to the patient until 8:36 p.m., 1 hour and 27 minutes after the patient presented to the ED.

In a telephone interview on 11/14/13 at 10:35 a.m., S8RN verified she was the triage nurse on 10/29/13 at 7:00 p.m., and she recalled Patient #3. S8RN stated the patient came in by private vehicle and some family members were with him but she did not recall how they were related. S8RN stated when he came in to the ED he sat down and a family member did the Kiosk Registration. S8RN stated the patient was not in distress when he arrived. S8RN stated the first time she called the patient to triage he did not answer. S8RN stated when she called again, one of the relatives told her he was outside and they would go get him. She stated she did not know how long it took for the patient to come inside but it was less than 30 minutes. S8RN stated when Patient #3 got to triage, he looked very weak and looked like he was going to faint. She stated she remembered having trouble getting his blood pressure reading, so she got a stretcher and the patient went to the back. S8RN stated the patient told her he was bleeding from his bottom. S8RN verified she did not enter any information about the patient before she obtained a stretcher and moved the patient to a room. When asked why the triaged of this patient was delayed, she stated she remembered she got backed up in triage and had several patients to triage at the same time. She stated she took the charts and got her co-workers to help.

In a telephone interview on 11/14/13 at 12:10 p.m. S9RN verified he was on duty on 10/29/13 for the 7 p.m. to 7 a.m. shift. S9RN stated he was in the back (patient treatment area of the ED) triaging a patient in Room #1 when the nurse practitioner came back to the area stating she needed help in triage. S9RN stated Patient #3 was in a chair in triage, was diaphoretic and would not get into a wheelchair. S9RN stated he got a stretcher and 2 nurses assisted the patient onto the stretcher. S9RN stated the patient, with assistance, was able to stand and they helped him up on the stretcher. S9RN stated the patient was over 300 pounds and was "slippery" due to the diaphoresis. S9RN stated when they got him onto the stretcher, they rolled him into a treatment room. S9RN stated S8RN couldn't get a blood pressure in the triage area, so he put him on the monitor and started an IV (Intravenous fluids). S9RN stated he thought S4ED Physician came to the room and examined the patient while he was starting the IV. S9RN verified he completed the triage assessment after the patient was moved into a treatment room.

Review of the ED Central Log for 10/29/13 and the patients' timelines revealed the following patients presented to the ED before and after Patient #3 (7:09 p.m.):
10/29/13 at 6:33 p.m., Patient R1 presented to the ED with a complaint of Gastroesophageal Reflux. The patient's triage was completed at 7:06 p.m. and the acuity level was 3 (can safely wait until a room is available). Patient was discharged at 8:10 p.m.
10/29/13 at 6:50 p.m., Patient R2 presented to the ED with a complaint of Fever. The patient's triage was completed at 7:12 p.m. and the acuity level was 3. Patient was discharged from the ED at 8:11 p.m.
10/29/13 at 7:17 p.m., Patient #1 presented to the ED with a complaint of Headache. The patient's triage was completed at 8:08 p.m., after the patient was moved to a treatment room and the acuity level was 3.
10/29/13 at 7:25 p.m., Patient R3 presented to the ED with a complaint of "Medication Refill". The patient's triage was completed at 8:14 p.m. and the acuity level was 4 (conditions that could benefit from intervention within 2-3 hours). Patient was discharged from the ED at 8:38 p.m.
10/29/13 at 7:38 p.m., Patient R4 presented to the ED with a complaint of Abscess/Boil. The patient was discharged at 8:48 p.m.
10/29/13 at 8:02 p.m., Patient R5 presented to the ED with a complaint of Cough.
10/29/13 at 8:09 p.m., Patient R6 presented to the ED with a complaint of Dental Pain.

In a face-to-face interview on 11/14/13 at 2:10 p.m., S5ED Manager verified Patient #3 presented to the ED at 7:09 p.m. and stated 7:32 was the time the patient's record was created in the software. After reviewing the patient's timeline, she verified the only documentation of triage was the 2 attempts to call the patient at 8:19 p.m. and 8:22 p.m. S5ED Manager verified S9RN who was assigned to the "back", entered the triage information at the time the patient was brought to a treatment room. S5ED Manager verified this patient was not triaged timely and stated the ED had an influx of patients. After reviewing the ED Central Log for 10/29/13, S5ED Manager verified the log did not reveal an influx of patients and verified 3 patients who arrived around the same time were treated and discharged before Patient #3 was triaged. When asked why Patient #3's triage was delayed, S5ED Manager stated, "Nurse error." After reviewing the hospital's policy for triage, S5ED Manager verified the policy directed the nurse to greet the patient upon arrival to the ED and to perform an initial rapid screening and assessment. S5ED Manager stated, "We may need to revise the policy."