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Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 1 and 15) and failed to ensure the annual performance was completed for RN 1. Cross reference to A2406.

2. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for three of 20 sampled patients (Patients 8, 17, and 18). Cross reference to A2407.

Based on observation, interview, and record review, the hospital failed to ensure the signage for EMTALA rights with respect to the examination and treatment for EMC and women in labor were posted conspicuously in the ED areas as evidenced by:

* Failure to ensure the EMTALA signage was posted in the ED's team triage room.

* Failure to ensure the EMTALA signage was posted in the ED's obstetric exam room.

* Failure to ensure the EMTALA signage was posted in the ED's behavioral room.

These failures had the potential to result in the individuals to not be aware of their rights to the examination and treatment in the event of an EMC.

Findings:

Review of the hospital's P&P titled EMTALA - Definitions and General Requirement dated December 2022 showed signage refers to the hospital requirement to post signs conspicuously in a DED or in a place or places likely to be noticed by all individual entering the DED as well as those individuals waiting for examination and treatment in areas other than the DED located on hospital property (e.g., outpatient departments, labor and delivery, waiting room, admitting area, entrance and treatment areas), informing individuals of their rights under federal law with respect to examination and treatment for medical conditions, EMCs and women in labor. The sign must also state whether or not the hospital participates in the state's Medicaid program in a stated plan approved under Title XIX.

On 7/31/24 at 0932 hours, the hospital's ED was toured with the ED and ICU Director. There was no EMTALA signage posted in the team triage room, obstetric exam room, and behavioral room. In a concurrent interview, the ED and ICU Director verified and acknowledge the findings.

On 8/1/24 at 1515 hours, a conference was held with the CEO, Interim CNO, Quality Manager, Quality Nurse, and ED and ICU Director. They were notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the ED Central Logs were accurately maintained for five of 20 sampled patients (Patients 6, 7, 8, 9, and 14). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED for the treatments of their emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA - Central Log Policy dated December 2022 showed in part:

* The hospital must maintain the Central Log in an electronic or paper format.

* The logs must contain at a minimum, the name of the individual; the date, time and means of the individual's arrival; the individual's age; the individual's sex; the individual's record number; the nature of the individual's complaint; the individual's disposition; the individual's time of departure; and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired.

1. On 7/31/24 at 1409 hours, an interview and concurrent record review was conducted with the ED and ICU Director.

Patient 8's closed medical record showed Patient 8 presented to the ED on 7/9/24, with a chief complaint of weakness.

Review of the ED Triage Aware Note dated 7/9/24 at 0705 hours, showed Patient 8 also had right shin pain and headache. The patient had no suicide risk and no further interventions required at this time.

However, review of the ED Central Log dated July 2024 showed Patient 8's chief complaint was "SUICIDAL IDEATION."

The ED and ICU Director acknowledged the above findings and confirmed the chief complaint listed on the ED Central Log for Patient 8 was incorrect.

2. On 7/31/24 at 1421 hours, an interview and concurrent record review was conducted with the ED and ICU Director.

Patient 9's closed medical record showed Patient 9 presented to the ED via EMS on 6/30/24, with a chief complaint of shoulder pain/injury.

Review of the ED Triage dated 6/30/24 at 1005 hours, showed Patient 9 had no suicide risk and no further interventions required at this time.

However, review of the ED Central Log dated June 2024 showed Patient 9's chief complaint was "5150 HOLD" and the mode of arrival was "Walk In."

The ED and ICU Director acknowledged the above findings and confirmed the chief complaint and mode of arrival listed on the ED Central Log were wrong.


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3. On 7/31/24 at 1350 hours, an interview and concurrent record review was conducted with LVN 1.

Review of Patient 6's closed medical record showed Patient 6 arrived at the ED on 7/14/24 at 0412 hours and was transferred to the L&D Department on 7/14/24 at 0423 hours.

Review of Patient 6's Admission Note Obstetric Nursing dated 7/14/24 at 0521 hours, showed Patient 6 was admitted for spontaneous rupture of membranes.

However, review of the ED Central Log showed Patient 6's disposition was "Routine Home or Self Care."

4. On 7/31/24 at 1350 hours, an interview and concurrent record review was conducted with LVN 1.

Review of Patient 14's closed medical record showed Patient 14 arrived at the ED on 7/15/24 at 1748 hours, presenting with complaints of abdominal pain while 38.5-weeks pregnant; Patient 14 was transferred to the L&D Department on 7/15/24 at 1805 hours.

However, review of the ED Central Log showed Patient 14's disposition was "Routine Home or Self Care."

5. On 7/31/24 at 1350 hours, an interview and concurrent record review was conducted with LVN 1.

Review of Patient 7's closed medical record showed Patient 7 arrived at the ED on 7/23/24 at 1116 hours, presenting with complaints of chest pain.

Review of the ED Provider Aware Note dated 7/23/24 at 1143 hours, showed Patient 7 was admitted to the ICU for acute coronary syndrome.

However, review of the ED Central Log showed Patient 7's disposition was transferred to another hospital.

On 7/31/24 at 1550 hours, the above findings for Patients 6, 7, and 14 were verified by both the ED and ICU Director and Quality Manager. The ED and ICU Director stated the ED central log showed the patients' final disposition rather their ED disposition.

Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 1 and 15) and failed to ensure the annual performance was completed for RN 1 as evidenced by:

1. For Patient 1, the ED staff triaged and assigned Patient 1 with the ESI level of 3 which was not accurately as per the hospital's P&P.

2. RN 1 did not have an annual performance review of his role in the ED since becoming an ED RN.

3. For Patient 15, the triage nurse failed to implement the Triage P&P and the patient LWBT.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services.

Findings:

Review of the hospital's P&P titled EMTALA - Definitions and General Requirements dated December 2022 showed EMTALA requires the hospital to provide an appropriate MSE to the individual within the capability of the hospital's emergency department to determine whether or not an EMC exists.

Review of the hospital's P&P titled Triage and Assessments of Patients Using Emergency Severity Index (ESI) dated September 2023 showed the following:

* All patients presenting to the ED requesting emergency care services will be initially triaged by a qualified RN or ED physician in a timely manner to determine priority of medical screen and care based on physical, psychological, and social needs.

* Triage is a dynamic process and may require that the patient be re-triaged if their condition changes or deteriorates prior to being seen by a treating clinician.

* The patient's level of urgency is indicated using the ESI.

* Triage is used to determine the patient's clinical urgency and to assess patient acuity based on their presentation in the ED and the expected level of care they will require.

* Responsibilities of the Triage RN include to respond upon notification of a patient requesting medical treatment; perform an overview of the patients waiting to be seen to determine if any patients appear to require priority triage and categorization; if priority triage is not indicated, triage will be conducted based on the patient's arrival.

* After a triage assessment is completed, the triage RN will categorize the patient with an ESI level of 1 (most urgent) to 5 (least urgent).

- An ESI level 2 is an emergency condition which requires immediate care and has a strong potential for a major injury or illness. When an ESI level 2 condition is identified, the triage process stops, and the patient is taken directly to a treatment area if available and immediate physician intervention is requested.

- An ESI level 3 is an urgent condition which requires prompt but not immediate care. The patient with ESI level 3 is stable with multiple types of resources to investigate and treat. The patient presents with a condition that could progress to a serious problem requiring emergency interventions.

Review of the ESI Triage Attachment A of the hospital's P&P titled Triage and Assessments of Patients Using Emergency Severity Index (ESI) showed an ESI Triage algorithm. The first prompt is "requires immediate life-saving intervention?". A "yes" response will suggest an ESI level 1. A "no" response will lead to the second prompt which is "high risk situation? or confused/lethargic/disoriented? or severe pain/distress?". A "yes" response will suggest an ESI level 2. A "no" response will lead to the third prompt which is "how many different resources are needed?". If many resources are needed, the fourth prompt will lead back to the ESI level 2 if the heart rate is greater than 100 bpm, the respiratory rate is greater than 20 breaths per minute, or the oxygen saturation is less than 92%. If vital signs are not in the danger zone, then the ESI level is 3.

1. On 8/1/24 at 0901 hours, Patient 1's closed medical record was conducted with LVN 1.

Patient 1's medical record showed Patient 1 visited the ED on 7/16/24 at 1258 hours.

Review of the ED Triage Aware Note dated 7/16/24 at 1300 hours, showed RN 1 documented Patient 1's chief complaint as "meth overdose" after swallowing an "8ball of meth 3 hours ago." RN 1 documented Patient 1 was diaphoretic and slightly nauseous. Further review of the document showed Patient 1's blood pressure was 163/124 mmHg, the patient's heart rate was 120 bpm, and the patient's temperature was 99.2 degrees Fahrenheit. RN 1 assessed Patient 1 with the ESI level of "3".

Review of the ED Provider Aware Note dated 7/16/24 at 1340 hours, showed MD 1 performed an MSE on Patient 1. The MDM/ED Course Narrative section showed at 1330 hours (or 30 minutes later), MD 1 assessed Patient 1; it was determined that an EMC existed after the initial MSE; MD 1 reviewed the ABG results which were consistent with respiratory acidosis; the patient was highly agitated, tachycardic, diaphoretic, paranoid, and unable to sit still; the patient was placed on a BiPAP with improvement; and the patient was admitted to ICU.

On 8/1/24 at 1145 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the ED and ICU Director and Quality Manager. When asked if Patient 1's ESI level was assessed according to the hospital's P&P, the Quality Manager stated Patient 1 was considered high risk, according to the algorithm on the hospital's P&P. The Quality Manager stated Patient 1's ESI level should have been the ESI level 2. When asked what the normal process was if a patient was assigned with the higher acuity ESI, the ED and ICU Director stated the RN would immediately share a severe case with the ED MD. The ED and ICU Director stated the MD would also monitor the tracking board and know from there which patients needed to be seen according to the ESI level and presenting symptoms.

The ED and ICU Director acknowledged and verified the above findings.

2. On 8/1/24 at 1304 hours, an interview and concurrent review of RN 1's training and personnel file was conducted with the HR Generalist and the ED and ICU Director.

Review of RN's personnel file showed RN 1's last performance evaluation was on 11/4/22.

Review of RN 1's job description showed RN 1 transitioned from a Telemetry RN to an ED RN role on 11/9/22.

Further review of RN 1's personnel and training file failed to show an annual performance evaluation for RN 1 since 11/4/22.

When asked, the HR Generalist stated the ED and ICU Director role was vacant for some time and no annual evaluations were conducted as expected. When asked, the ED and ICU Director stated the annual performance evaluation for each employee involved conducting observations, getting feedback from the charge nurses and doctors, and reviewing triage notes. The ED and ICU Director stated the performance evaluation should be done annually.

On 8/1/24 at 1310 hours, the above findings were shared and acknowledged by the Quality Manager.


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3. On 7/31/24 at 1446 hours, an interview and concurrent record review of Patient 15's closed medical record was conducted with the ED and ICU Director.

Patient 15's medical record showed the patient presented to the ED on 5/11/24 at 2040 hours, with leg pain.

Review of the ED Triage RN Note dated 5/11/24 at 2140 hours, showed Patient 15 was called to triage with no response at 2140 (one hour after arrival to the ED), 2150, and 2200 hours. The documentation showed the patient LWBT.

On 8/1/24 at 1502 hours, an interview and concurrent record review was conducted with the Interim CNO. The Interim CNO confirmed there was a delay of one hour before the Triage RN called the patient to triage. And there was no documentation to show the Triage RN performed an overview of Patient 15 upon arrival to the ED to determine if the patient appeared to require priority triage and categorization. The Interim CNO confirmed and acknowledged the findings.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for three of 20 sampled patients (Patients 8, 17, and 18) as evidenced by:

1. For Patient 18, the ED staff failed to discuss with the patient the risk and benefits involved in leaving against medical advice and take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form as per the hospital's P&P.

2. For Patients 8 and 17, the ED staff did not implement the hospital's P&P related to pain management for the patients.

a. The ED staff failed to assess the pain level when Patient 8 complained of a headache and pain to the right shin.

b. The ED staff failed to assess the pain level for Patient 17 (a pediatric patient) who had dysuria.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services.

Findings:

Review of the hospital's P&P titled EMTALA - Definitions and General Requirement dated December 2022 showed in part:

* If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer.

* Leaving DED after the MSE: for those individuals indicating a desire to leave the DED against medical advice ("AMA") after receiving an MSE, the facility should use its best efforts to:

- Discuss with the individual the risk and benefits involved in leaving against medical advice and document same;

- Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form, if possible;

- Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn; and

- Sign, date, and time the entry.

1. On 7/31/24 at 1448 hours, an interview and concurrent review of Patient 18's closed medical record was conducted with the ED and ICU Director.

Patient 18's closed medical record showed Patient 18 presented to the ED on 6/3/24, with suspected alcohol intoxication.

Review of the ED Provider Aware Note dated 6/3/24, showed Patient 18 presented via ambulance complaining of intoxication and alcohol use. The patient attempted to step in front of a bus earlier today. The patient denied suicidal ideation. The MDM/ED Course Narrative section showed "Patient wishes to go home." The Disposition Status from ED was documented as "eloped."

There was no documentation showing the physician discussed with the patient the risk and benefits involved in leaving against medical advice, took all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form as per the hospital's P&P.

On 8/1/24 at 1359 hours, an interview and concurrent record review was conducted with the Interim CNO. The Interim CNO confirmed and acknowledged the findings.

2. Review of the hospital's P&P titled Pain Management dated August 2023 showed in part:

* Pain will be assessed in all patients.

* When pain or the potential for pain is identified, a more comprehensive assessment is performed. This assessment includes a measure of pain intensity and quality, appropriate to the patient's age.

* The patient and family can expect the patient in pain to be assessed and treated promptly, effectively and for as long as pain persists.

* The pain assessment tools used at the hospital include the numeric 0-10 pain intensity scale and FLACC scale.

* The Numeric Intensity Scale is: 1-3 = Mild Pain, 4-6 = Moderate Pain, 7-10 = Severe Pain.

* FLACC (face, legs, activity, crying, and consolability) pain scale is developed to help medical observers measure the level of pain in children who are too young to cooperate verbally. This scale can be used for patients 2 months old to 7 years old. Zero indicates that patient is relaxed and comfortable. 1-3 indicates the patient has mild discomfort. 4-6 indicates the patient has moderate pain. 7-10 indicates the patient has severe discomfort/pain.

* Where pain is identified, the patient is treated or referred for treatment.

a. On 7/31/24 at 1409 hours, an interview and concurrent review of Patient 8's closed medical record was conducted with the ED and ICU Director.

Patient 8's closed medical record showed the patient presented to the ED on 7/9/24, with a chief complaint of weakness.

Review of the ED Triage Aware Note dated 7/9/24 at 0705 hours, showed Patient 8 had the right shin pain and headache.

Review of the Visit Record showed Patient 8 was discharged from the ED on 7/9/24 at 0810 hours.

In a concurrent interview, the ED and ICU Director confirmed there was no documentation to show Patient 8's pain was assessed or addressed.

b. On 7/31/24 at 1500 hours, an interview and concurrent review of Patient 17's closed medical record was conducted with the ED and ICU Director.

Patient 17's closed medical record showed the patient (a pediatric) presented to the ED on 5/8/24.

Review of the ED Triage Aware Note dated 5/8/24 at 0924 hours, showed Patient 17 had dysuria.

Review of the Visit Record showed Patient 17 was discharged on 5/8/24 at 1116 hours.

In a concurrent interview, the ED and ICU Director confirmed there was no documentation to show Patient 17 was assessed for pain.