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Based on record reviews and facility policy review the facility failed to follow its policies regarding Triage, Medical Screening Exams (MSE), Transfers and patient leaving prior to being seen for 4 (Patient (P)2, P11, P12, P16) of 20 sampled patient records. These failures have the potential to cause harm or death due to delay in care to all patients that present to the Emergency Department (ED). According to the facility provided information the 3 dedicated emergency departments (DED) see on average of 5,409 patients per month.

Also see A2406 and A2409

Findings Include:

A. Review of facility policy "Triage", approved 2/2023 revealed, all patients seeking emergency care will have a triage assessment by an Registered Nurse (RN) promptly upon arrival in the ED. Appropriate reassessments will be documented on the medical record.

B. Review of facility policy "Turn-Around Times and Delay of Testing Notification", approved 2/2024 revealed, testing ordered STAT (to be done immediately) will be given special consideration due to the emergency condition of the patient. Response to the patient for collection is expected to be within 10 minutes of notification. With reporting to be done within 60 minutes of order.

C. Review of facility policy "Patient Departure Prior to Dismissal (AMA)", approved 11/2023 revealed, to leave without being seen is specific to patients who have not received a medical screening examination in a dedicated emergency department.
- If the patient or legally recognized representative does not inform anyone prior to leaving:
-Attempts will be made to locate the patient in the waiting area and restrooms.
-If unable to locate, staff will note the same on "Refusal of Medical Screening Examination" form.
-Documentation in the medical record should include the following:
-Attempts made to inform patient or legally recognized representative of risks and/or attempts made to locate the patient.
-Impression of patient's mental and physical status, as able.
-Notification of Qualified Medical Provider (QMP).
- If a patient does not make the care team aware of the intent to leave (patient is found to be gone from care area)
-Staff will immediately notify the provider.
-Staff and/or provider will make reasonable attempt to locate or make contact with the patient to determine why they left and encourage them to return for completion of treatment.
-If the patient is located and declines to return, the provider should make attempts to inform the patient of the risks and document the departure (see section A- Against Medical Advice)
-If the patient is not located, this will be noted in the medical record.

D. Review of facility policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)", approved 2/2023 revealed, MSE is the process required to determine with reasonable clinical confidence whether an emergency medical condition (EMC) does or does not exist. Screening is to be conducted to the extent necessary, by physicians and/or other QMPs, as defined, to determine whether an EMC exists. The extent of the MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board.
The MSE is an on-going process. The medical record will reflect an ongoing assessment of the individual's condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the Hospital, is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital's capabilities, is discharged, or expires.
The MSE process must be documented in the medical record.
The off-campus DED must develop protocols to effectuate an Appropriate Transfer.
The DED at Lasting Hope Recover Center will provide all patients arriving at the Assessment Center with a MSE by a QMP.
-The Behavioral nurse will notify the On-Call behavioral physician regarding the results of the assessment.
-If during the MSE, it is determined that the patient needs additional medical screening, the patient will be transported to the medical Emergency Department for a medical evaluation and treatment as needed.

E. The facility failed to follow their policy dated 2/2023 titled, Triage and did not provide P11 with a prompt triage assessment by a RN upon arrival to the ED. P11 presented to the ED on 1/23/24 at 5:33AM. P11 was taken to triage at 6:37AM (64minutes after presentation to the ED). The facility failed to follow their policy dated 2/2024 titled, "Turn-Around Times and Delay of Testing Notification" P11 had a STAT lab ordered at 6:43AM that was not drawn until 8:54AM (71 minutes after ordered). STAT medication was ordered at 8:53AM and was never given to P11 prior to P11 eloping from ED. Due to incomplete physical exam and delay in lab P11 did not have a complete MSE to determine with reasonable clinical confidence that an EMC did not exist.

F. The facility failed to follow their policy dated 2/2024 titled, "Turn-Around Times and Delay of Testing Notification" MD-D placed a STAT order for hemoglobin (part of the red blood cell that carries oxygen from the lungs to tissues and organs) and hematocrit (the percentage by volume of red cells in your blood) at 10:26PM. P12 was discharged from the ED at 11:35PM without lab draw being completed as ordered nor a discontinue order documented for the lab. Due to ordered lab not being completed P12 did not have a complete MSE conducted to rule out an EMC prior to discharge.

G. Review of Facility A's medical record for P2 revealed, P2 presented to the ED on 5/21/23 at 3:54AM. P2 was taken to triage at 4:18AM and triage was marked complete at 4:22AM when P2 was also assigned an ED room. At 5:18AM documentation in the EMR reveals that P2's disposition was marked as left without being seen (84 minutes after arrival). The medical record lacks documentation of attempts made to inform patient of risks and/or attempts made to locate the patient. Notification of the QMP. The medical record also lacks the "Refusal of Medical Screening Examination" form with staff note of being unable to locate patient.

Based on record review, policy and procedure review and staff interviews the facility failed to provide 3 (P11, P12 and P16) of 20 sampled patient records a complete MSE to rule out an emergency medical condition (EMC) after presentation to the ED. This failed practice has the potential to cause harm or death to all patients that present to the ED. According to facility provided information the average number of patients seen per month is 5,409.

Findings include:

A. Review of facility policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)", approved 2/2023 revealed, MSE is the process required to determine with reasonable clinical confidence whether an EMC does or does not exist, or with respect to a pregnant woman experiencing contractions whether or not she is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMPs, as defined, to determine whether an EMC exists. The extent of the MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board. With respect to an individual manifesting behavioral or psychiatric symptom, the MSE consist of both a medical and behavioral /psychiatric health screening. The act of patient triage is not considered an MSE.
The MSE is an on-going process. The medical record will reflect an ongoing assessment of the individual's condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the Hospital, is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital's capabilities, is discharged, or expires.
The MSE process must be documented in the medical record.

B. Review of P11's medical record revealed, P11 presented to the ED on 1/23/24 at 5:33AM. P11 was taken to triage at 6:37AM. Vitals on admit to triage were T 97.7, P104, R18, BP 157/98, SpO2 99% on room air. Pain rating of 8 on 0-10 pain scale. P11 was given an emergency severity index (ESI- an algorithm tool used in the ED to triage patients from 1-most urgent to 5-least urgent) of 3 at 6:38AM. P11's chief complaint in triage was neck stiffness since 1/8, over the last week pain in neck has worsened, states "had meningitis last month." Denies trauma. Nurse Practioner (NP)-C reviewed P11's chart and noted P11 was hospitalized for sepsis and pneumonia last month not meningitis. NP-C placed STAT lab orders at 6:43AM. Lab orders included: salicylate level (a blood test that checks for overdose of aspirin), acetaminophen level ( a test to check level of acetaminophen or Tylenol for overdose), C-Reactive Protein (CRP - measures inflammation in the body), Comprehensive Metabolic Panel (CMP- test that checks electrolyte levels kidney and liver function), Complete blood count (CBC- measures the number of red and white blood cells and platelets ). At 8:49AM vitals were done P105, R16, BP145/108 SpO2 100% on room air, pain rating of 10 on a 0-10 pain scale. NP-C placed an order for Norflex (a muscle relaxer) 60mg intramuscular (IM) STAT at 8:53AM. Lab was not drawn until 8:54AM (2 hours and 11 minutes after STAT order placed). After lab was drawn P11 returned to the lobby. The medical record lacks documentation of ongoing assessment while P11 was in the lobby. Lab results were documented as unremarkable by NP-C. At 12:32PM a nurse went to lobby to call P11's name and P11 was not in lobby. A nurse returned to the lobby at 1:10PM and again called P11's name, P11 was not in lobby. At 1:11PM the nurse called P11's name again and P11 was still not in lobby. P11 was marked as eloped at 1:11PM. P11 did not receive STAT medication ordered at 8:53AM when pain was documented as a 10 nor was P11 reassessed while in lobby.

C. Review of P12's medical record revealed, P12 presented to the ED on 11/27/23 at 10:12PM with complaints of a nosebleed for the past 3 hours. Medical Doctor (MD)-D provided initial exam at 10:26PM. MD-D placed a STAT order for hemoglobin (part of the red blood cell that carries oxygen from the lungs to tissues and organs) and hematocrit (the percentage by volume of red cells in your blood) at 10:26PM. At 11:35PM P12 was discharged to home. The medical record lacks documentation of completed lab as ordered. The medical record lacks documentation of order to discontinue lab. The EMR automatically discontinued lab after P12 was discharged.

D. Review of P16's medical record revealed, P16 presented to DED-C on 1/15/24 at 5:41PM with complaints of attempting to kill themselves by freezing to death but "didn't know it was going to hurt so much." P16 complains of having frostbite on fingers and tip of finger is black. The medical record lacks documentation of which fingertip is black and assessment for frost bite of other limbs.

E. During an interview on 2/29/24 at 9:35AM, NP-C revealed if we (providers) give an order we would want that to be completed. When patients come into the ED and are evaluated if labs, tests, medications are ordered that is part of the MSE to make sure the patient is stable. It is part of the exam to evaluate if stable for discharge or if patient needs admission.

Based on record review, policy and procedure review and staff interviews the facility failed to provide 1 (P16) of 5 sampled patient transfers an appropriate transfer from an off-campus DED. CHI Health Creighton University Medical Center-Bergan Mercy system has 3 Dedicated Emergency Department's (DED); (DED A) is at the main campus, a level 1 trauma center capable of providing all levels of emergency care; (DED B) is an off campus facility which is a full service emergency department staffed with board-certified emergency physicians; and (DED C) is the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC). The main campus (DED A) is 6 miles from LHRC (DED C) and DED B is 1.5 miles from LHRC. This failure places all emergency patients presenting to DED C at risk of harm due to an inappropriate transfer without the receiving hospital agreeing to accept transfer of the individual. According to facility provided information all 3 DED's transfer an average of 96 patients per month.

Findings include:

A. Review of facility policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)", approved 2/2023 revealed, the qualified medical provider (QMP) on duty at the off-campus DED will either arrange for movement of the individual to the hospital's main campus DED or arrange for an appropriate transfer. The off-campus DED must develop protocols to effectuate an appropriate transfer.

B. Review of facility Organization and Functions Manual last approved 10/8/21 revealed, that patients arriving in the Assessment Center at LHRC will have a MSE for the existence of an EMC performed by the LHRC QMP nurse. The examination will include a complete set of vitals, if it is determined that the patient needs additional medical screening based on initial presentation beyond the capability of Lasting Hope, the behavioral health nurse will complete an MSE within the facility's capabilities and notify the on-call psychiatrist of the results and if necessary, obtain orders to transfer the patient to a medical facility.

C. Review of P16's medical record from DED-C revealed, P16 presented to DED C on 1/15/24 at 5:40PM an emergency encounter was created in the EMR. P16 walked into the lobby of DED-C. RN-E documented that P16 "triaged in lobby and is highly intoxicated and was attempting to kill herself by freezing to death but didn't know it was going to hurt so much. Breathalyzer reads 0.287 (intoxication level is 0.08). Patient states she has frostbite on fingers. Tip of finger is black." RN-E completed triage in the lobby at 5:44PM. RN-E documented P16 endorses having suicidal ideation. RN-E notified MD-F who gave order to send patient out from lobby via 911 at 5:52PM. At 5:52PM RN-E documented P16's vital signs as T 98.5, P 103, R16, BP 138/85, SpO2 96% on room air, pain 0 on 0-10 pain scale. 911 ambulance and law enforcement responded to DED C and report given. RN-G called Hospital D ED (a full service main campus DED 1.8 miles away) for report. ED staff at Facility D aware police may place P16 in emergency police custody (EPC). 911 Ambulance will take P16 to Hospital-D as it is the closest facility to DED C. RN-E and RN-G both signed form refusal to permit to medical screening examination. Indicating that P16 left the hospital without signing the form. The medical record lacked documentation indicating DED C had explained the risks and benefits of the transfer, had confirmation from a representative at Hospital-D that Hospital-D had available space, qualified personnel to treat P16, Hospital-D agreed to accept transfer of P16 and provide appropriate medical treatment. The medical record lacked a transfer consent form. P16's medical record indicates that P16 was transferred to ED at Facility D at 6:00PM.

D. During an interview on 2/29/24 at 8:45AM, RN-E revealed, that there had been confusion with staff in the Assessment Center. Staff do what is considered "triage" in the lobby. Staff believed since the patient did not go through the doors and into the Assessment Center that was considered left without being seen. Education was recently sent out by Director of Nursing (D.O.N.). D.O.N. and supervisors are also talking to each staff member regarding transfers and difference of left without being seen before and after triage.