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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases.

FINDINGS INCLUDE:

Hospital policy titled "ESI Assessment and Reassessment," revealed: "...Reassessment will be based on the patient's diagnosis and the patient's response to care and treatment rendered. The following table lists the minimum requirements for repeat vitals, however, the staff will perform vitals more frequently per physician orders or where the patient's status requires it. Vital signs will be repeated as follows: ESI Level...3,4,5 Repeat at least every 60 minutes - 90 minutes...."

Hospital policy titled "Left Without Being Seen/AMA," revealed: "...To ensure continuity and follow up on those patients who present to the hospital for emergent care and for various reasons, leave the area without being seen by a physician or nurse. Patients may be classified as left without being seen or AMA under conditions such as but not limited to the following: 1. The patient presents to the hospital, completes the quick registration, and makes the decision to leave without a medical screening exam or nursing assessment. Or, 2. The patient has had an initial assessment by a registered nurse and makes the decision to leave without treatment or further medical screening exam. 3. Any person who comes to the hospital seeking emergency treatment and then refuses further medical examination or treatment, shall be informed of the risks and benefits to the individual from such examination and treatment. 4. If the patient, or person acting on the patient's behalf, refuses treatment even after the risks and benefits have been explained, the patient's informed refusal of treatment shall be documented on the Leaving Against Medical Advice (AMA) form. 5. If a patient refuses to sign the AMA form, this shall be documented. 6. If the patient leaves the premises before anyone can discuss the risks and/or benefits with the patient, this will be documented in the medical record...."

Hospital policy titled "MSE and Transfer Procedures for Patients Seeking Emergency Treatment," revealed: "...The medical record will reflect continued monitoring according to the individual's needs until it is determined whether or not the individual has an emergency medical condition and if he/she does, until he/she is stabilized or appropriately transferred...."

Patient #1's medical record dated 07/11/2023 at 16:20, revealed: "...ED Arrival Date/Time: 07/11/2023 14:57:00 Triage Date/Time: 07/11/2023 16:21...Triage Level: 3 - Urgent...Temperature: 98 F (36.7 C) Pulse: 91 bpm Respirations: 18 breaths/min Blood Pressure: 120/83 O2 Saturation: 98%...." While in the ED, Patient #1 had vital signs documented next at 23:06, a time span of 6 hours and 46 minutes between reassessments.

Patient #10's medical record dated 07/17/2023 at 21:34, revealed: "...ED Arrival Date/Time: 07/17/2023 21:25...Triage Level: 3 - Urgent...Temperature: 98.4 F (36.9 C) Pulse: 74 bpm Respiration: 18 breaths/min Blood Pressure: 153/92, O2 Saturation: 100%...."

Patient #10's medical record dated 07/17/2023 at 23:51, revealed: "...Disposition: Left without being seen ED Departure Date / Time: 07/17/2023 23:49...." Patient #10 had no other vital signs taken during the 2 hours and 17 minutes s/he was in the ED. There was no further documentation in the medical record.

Employee #4 confirmed in an interview on 09/19/2023, that Patients #1 and #10 did not have vital signs reassessed per policy. Employee #4 also confirmed that Patient #10 had an initial assessment by a registered nurse and made the decision to leave without treatment. Employee #4 further confirmed there was no documentation of explaining risks and benefits to Patient #10, nor was there a signed AMA form or documentation of refusal to sign.

Based on review of hospital records, and staff interviews, it was determined that the Hospital delayed examination and treatment for one (1) patient (Patient #1) that presented to the Emergency Department.

Hospital policy titled "Emergency Services Scope of Services," revealed: "...Upon arrival of a patient seeking emergent treatment or services, a designated team will be mobilized to assess the patient. A triage nursing assessment occurs on arrival using subjective (patient chief complaint) and objective information (appearance and vital signs, if appropriate) in order to assess the severity of the emergency. The patient will be escorted to the Emergency Room for further evaluation. A Medical Screening Exam will be provided by a physician as indicated...."

Hospital policy titled "ESI Assessment and Reassessment," revealed: "...An RN will perform an initial physical assessment of all patients upon arrival in terms of triage...."

Hospital Policy titled "Patient Flow Process," revealed: "...Patients arriving at Exceptional Community Hospital seeking emergency care will register at the front desk. Following Check In/Registration, the patient will be escorted to Triage by ER personnel for Initial Medical Screening Examination. Following examination, patients will be prioritized for treatment and, based on room availability and clinical status, will either be placed in a treatment room or returned to the waiting room until called. Following examination, a determination for care needs will be made by the medical staff...."

Hospital policy titled "MSE and Transfer Procedures for Patients Seeking Emergency Treatment," revealed: "...The hospital will provide an appropriate MSE to individuals presenting to the hospital seeking examination or treatment of a medical condition or emergency...The medical record will reflect continued monitoring according to the individual's needs until it is determined whether or not the individual has an emergency medical condition and if he/she does, until he/she is stabilized or appropriately transferred...."

Patient #1's medical record revealed: "...ED Arrival Date/Time: 07/11/2023 14:57:00 Triage Date/Time: 07/11/2023 16:21...Moderate Distress...Triage Level: 3 - Urgent...Seen here yesterday for lower back pain radiating down legs. Today is feeling weak, unable to ambulate, cramping...Temperature: 98 F (36.7 C) Pulse: 91 bpm Respirations: 18 breaths/min Blood Pressure: 120/83 O2 Saturation: 98%...."

Patient #1's medical record contained a note titled "ED Provider Note," dated 07/11/2023 at 18:45, which revealed: "...presents to the ED by POV with with {sic} chief complaint of severe bilateral low back ( for which [he] was seen here on 07/10/2023, and was treated empirically with NSAIDs and D/C home, in conjunction with chronic nausea, and inability to take oral liquids or solids, reportedly with severe dehydration... Assessment & Plan 1.) Dehydration; 2) acute on chronic lower back pain...3.) nitrite positive urinary tract infection; 4.) hyponatremia and hypokalemdia {sic} 5.) lactic acidosis secondary to above: 6.) hepatic steatosis; 7.) thrombocytopenia; 8.) hyperglycemia without ketosis; 9) medical noncompliant (secondary to nausea and vomiting, patient has not been able to take {sic} any oral medications for the last 3 days) Given the above constellation of findings, patient will be admitted to inpatient for hydration, to correct electrolyte abnormality, to get blood sugar controlled and to correct acid-base abnormality...."

Patient #1 received IV Hydromorphone, Toradol and 1 liter of normal saline at 18:53. Patient #1 was then treated with Ondansetron, Promethazine at 19:09, followed by Cefepime at 20:56, and a fentanyl drip at 21:32. Patient #1 was admitted for further treatment on 07/12/2023, at 02:10 and transferred to a higher level of care at 12:25.

Employee #4 confirmed in an interview on 09/19/2023, that Patient #1 was not triaged for 84 minutes after arrival, and did not receive an MSE for 3 hours and 48 minutes. Employee #4 confirmed Patient #1 was then able to begin receiving treatment within eight minutes of the MSE.