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Based on interview it was determined the Hospital failed to ensure emergency department policies and procedures were current and revised as necessary.

Findings included:

I. Clinical Record review indicated Patient #1 presented to the ED and during triage (the process of determining the order in which individuals will be seen by a medical care provider based on their need for immediate medical treatment.), at 6:30 PM, reported experiencing a bad reaction to medication that had been taken three months prior to the visit. Patient #1 reported it felt like his/her heart was going to burst since taking the medication and was in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. Patient #1 was assigned a triage Priority Level of III (Triage Priotiy Levels include Levels I to V; with I being the most acute/urgent.), and sent to the waiting area. Patient #1, while in the waiting area made rude hand gestures and used foul language toward nursing staff members. At 7:48 PM the Nursing Supervisor was notified of the behavior Patient #1 was exhibiting in the waiting room and Hospital security staff escorted Patient #1 off of Hospital Property. Documentation indicated Patient #1's had left without being seen.

The Hospital Policy that addressed patients who leave the emergency department without being been by a physician was reviewed. The policy was last reviewed and signed off as approved on August 13, 2007. The policy stated If the patient chooses to leave without being seen by a physician he/she will receive a follow-up telephone call the next day shift from the Emergency Department Patient Advocate. During this call the patient will again be encouraged to return to the hospital for medical treatment of the illness or injury. A variance report will be made out by the charge nurse and forwarded to the Director of Emergency and Outpatient Services. The follow-up call will be documented on the ED Patient Call Back Sheet and will be kept in a file in the Emergency Department Patient Advocate's office.

The Director of Quality and Safety (Director) was interviewed in person and by telephone at various times during the Survey. The Director said there was no longer a ED Patient Advocate and the call backs to patient's leaving without being seen, in some cases were made by an ED Physician Assistant, but this was not happening consistently and had not happened in regard to Patient #1. In addition no variance report had been made out related to Patient #1's leaving the ED without being seen. There was no documentation to indicate all cases involving a patient who leaves the ED without being seen were forwarded to the Director of the ED.

II. The Hospital policy that addressed evaluation of crisis patients was reviewed. The policy stated a patient presenting in need of crisis evaluation represents a potentially unstable and fatal condition. Crisis patients are classified as Priority II (urgent) and will be evaluated by an Emergency Department attending physician to determine suicide risk, as soon as possible after all Priority I (emergency) patients are stable.

Review of Patient #5's medical record documentation indicated Patient #5 presented to the Hospital ED with a chief complaint of severe depression, suicidal ideation and uncontrollable temper rage. Patient #5 was classified as a crisis patient in need of a crisis evaluation. Patient #5 at triage was classified as a Priority III. Patient #5 left without being seen after waiting room for one hour.

Review of Patient #9's medical record documentation indicate Patient #9 presented to the ED with the chief complaint of alcohol withdrawal and was classified as a crisis patient in need of a crisis evaluation. Patient #9 left without being seen after waiting over 2 hours.

Review of Patient #10's medical record documentation indicated Patient #10, who had a history of attention deficit disorder and bi-polar/mood disorder, presented to the Hospital ED and reported increased aggression, that they had been off medication to treat the bi-polar/mood disorder for a year and had requested to be started back on the medications. Patient #10 reported feeling the desire to act out. Patient #10 was assessed as needing a crisis evaluation, classified as a Priority III and sent to the waiting room. When Patient #10's name was called over two hours later it was determined Patient #10 had left without being seen.

Review of Patient #13 medical record documentation indicated Patient #13, who had been diagnosed as bi-polar and a post traumatic stress disorder and who had a long history cutting, presented to the Hospital's ED with healing lacerations on the left forearm and reported he/she felt suicidal. When triaged Patient #13 was classified as a crisis patient in need of a crisis evaluation. Patient #13 was evaluated and classified as a Priority III by the triage nurse. Patient #13 left the ED without being seen after waiting 2 hours.

Also refer to EMTALA deficiency: Tag A-2406.

Based on interview it was determined the Hospital failed to ensure emergency department policies and procedures were current and revised as necessary.

Findings included:

I. Clinical Record review indicated Patient #1 presented to the ED and during triage (the process of determining the order in which individuals will be seen by a medical care provider based on their need for immediate medical treatment.), at 6:30 PM, reported experiencing a bad reaction to medication that had been taken three months prior to the visit. Patient #1 reported it felt like his/her heart was going to burst since taking the medication and was in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. Patient #1 was assigned a triage Priority Level of III (Triage Priotiy Levels include Levels I to V; with I being the most acute/urgent.), and sent to the waiting area. Patient #1, while in the waiting area made rude hand gestures and used foul language toward nursing staff members. At 7:48 PM the Nursing Supervisor was notified of the behavior Patient #1 was exhibiting in the waiting room and Hospital security staff escorted Patient #1 off of Hospital Property. Documentation indicated Patient #1's had left without being seen.

The Hospital Policy that addressed patients who leave the emergency department without being been by a physician was reviewed. The policy was last reviewed and signed off as approved on August 13, 2007. The policy stated If the patient chooses to leave without being seen by a physician he/she will receive a follow-up telephone call the next day shift from the Emergency Department Patient Advocate. During this call the patient will again be encouraged to return to the hospital for medical treatment of the illness or injury. A variance report will be made out by the charge nurse and forwarded to the Director of Emergency and Outpatient Services. The follow-up call will be documented on the ED Patient Call Back Sheet and will be kept in a file in the Emergency Department Patient Advocate's office.

The Director of Quality and Safety (Director) was interviewed in person and by telephone at various times during the Survey. The Director said there was no longer a ED Patient Advocate and the call backs to patient's leaving without being seen, in some cases were made by an ED Physician Assistant, but this was not happening consistently and had not happened in regard to Patient #1. In addition no variance report had been made out related to Patient #1's leaving the ED without being seen. There was no documentation to indicate all cases involving a patient who leaves the ED without being seen were forwarded to the Director of the ED.

II. The Hospital policy that addressed evaluation of crisis patients was reviewed. The policy stated a patient presenting in need of crisis evaluation represents a potentially unstable and fatal condition. Crisis patients are classified as Priority II (urgent) and will be evaluated by an Emergency Department attending physician to determine suicide risk, as soon as possible after all Priority I (emergency) patients are stable.

Review of Patient #5's medical record documentation indicated Patient #5 presented to the Hospital ED with a chief complaint of severe depression, suicidal ideation and uncontrollable temper rage. Patient #5 was classified as a crisis patient in need of a crisis evaluation. Patient #5 at triage was classified as a Priority III. Patient #5 left without being seen after waiting room for one hour.

Review of Patient #9's medical record documentation indicate Patient #9 presented to the ED with the chief complaint of alcohol withdrawal and was classified as a crisis patient in need of a crisis evaluation. Patient #9 left without being seen after waiting over 2 hours.

Review of Patient #10's medical record documentation indicated Patient #10, who had a history of attention deficit disorder and bi-polar/mood disorder, presented to the Hospital ED and reported increased aggression, that they had been off medication to treat the bi-polar/mood disorder for a year and had requested to be started back on the medications. Patient #10 reported feeling the desire to act out. Patient #10 was assessed as needing a crisis evaluation, classified as a Priority III and sent to the waiting room. When Patient #10's name was called over two hours later it was determined Patient #10 had left without being seen.

Review of Patient #13 medical record documentation indicated Patient #13, who had been diagnosed as bi-polar and a post traumatic stress disorder and who had a long history cutting, presented to the Hospital's ED with healing lacerations on the left forearm and reported he/she felt suicidal. When triaged Patient #13 was classified as a crisis patient in need of a crisis evaluation. Patient #13 was evaluated and classified as a Priority III by the triage nurse. Patient #13 left the ED without being seen after waiting 2 hours.

Also refer to EMTALA deficiency: Tag A-2406.