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Based on document review and staff interview it was determined the hospital failed to ensure Emergency Department (ED) reassess twelve (12) out of twenty (20) patients that were seeking the services of the ED providers for a potential medical emergency (patient #4, 5, 6, 7, 9, 10, 11, 13, 15, 17, 19 and 20). This failure has the potential to lead to serious harm or potential death of these patients.

Findings include:

1. A review of the medical record for patient #4 revealed patient #4 was seen in the ED on 4/22/21 at 9:16 a.m. with a complaint of possible ingestion of nicotine. Patient #4 was triaged at 9:21 a.m. and left against medical advice (AMA) at 1:42 p.m. Patient #4 was in the ED for four (4) hours and twenty-two (22) minutes with no reassessment. On 4/22/21 at 1:56 p.m. Child Protective Services was notified of the patient leaving AMA. Patient #4 was eleven (11) months old.

2. A review of the medical record for patient #5 revealed patient #5 was seen in the ED on 4/27/21 at 6:11 p.m. with a complaint of motor vehicle accident. Patient #5 was triaged at 6:21 p.m. and AMA at 11:03 p.m. Patient #5 was in the ED for four (4) hours and twenty-one (21) minutes with no reassessment. Patient #5 was nineteen (19) years old and was nineteen (19) weeks pregnant.

3. A review of the medical record for patient #6 revealed patient #6 was seen in the ED on 4/21/21 at 6:11 p.m. with a complaint of chest pain. Patient #6 was triaged at 6:24 p.m. and left AMA at 1:02 a.m. Patient #6 was in the ED for four (4) hours and twenty-eight (28) minutes with no reassessment. Patient #6 was eighty (80) years old.

4. A review of the medical record for patient #7 revealed patient #7 was seen in the ED on 4/21/21 at 6:32 p.m. with a complaint of shortness of breath. Patient #7 was triaged at 6:32 p.m. and left AMA at 1:42 a.m. Patient #7 was in the ED for five (5) hours and ten (10) minutes with no reassessment. Patient #7 was forty-seven (47) years old.

5. A review of the medical record for patient #9 revealed patient #9 was seen in the ED on 4/23/21 at 1:44 p.m. with a complaint of chest pain. Patient #9 was triaged at 1:47 p.m. and left AMA at 5:10 p.m. Patient #9 was in the ED for three (3) hours and twenty-two (22) minutes with no reassessment. Patient #9 was fifty-one (51) years old. Patient #9 was in the waiting area of the ED with an IV that had been placed by emergency medical services. The facility failed to have a consent for treatment signed.

6. A review of the medical record for patient #10 revealed patient #10 was seen in the ED on 4/21/21 at 9:56 p.m. with a complaint of congestion. Patient #10 was triaged at 10:39 p.m. and left AMA at 1:48 a.m. Patient #10 was in the ED for three (3) hours and eighteen (18) minutes with no reassessment. Patient #10 was three (3) months old.

7. A review of the medical record for patient #11 revealed patient #11 was seen in the ED on 4/26/21 at 12:35 p.m. with a complaint of abdomen pain. Patient #11 was triaged at 1:07 p.m. and left AMA at 8:20 p.m. Patient #11 was in the ED for seven (7) hours and thirteen (13) minutes with no reassessment. Patient #11 was forty-nine (49) years old.

8. A review of the medical record for patient #13 revealed patient #13 was seen in the ED on 4/21/21 at 4:35 p.m. with a complaint of abdominal pain, post-op. Patient #13 was triaged at 4:49 p.m. and left AMA at 8:19 p.m. Patient #13 was in the ED for three (3) hours and forty-four (44) minutes with no reassessment. Patient #13 was seventy-four (74) years old.

9. A review of the medical record for patient #15 revealed patient #15 was seen in the ED on 4/07/21 at 3:50 p.m. with a complaint of chest pain. Patient #15 was triaged at 4:00 p.m. and left AMA at 6:23 p.m. Patient #15 was in the ED for two (2) hours and twenty-three (23) minutes with no reassessment. Patient #15 was fifty-three (53) years old.

10. A review of the medical record for patient #17 revealed patient #17 was seen in the ED on 4/14/21 at 1:40 p.m. with a complaint of shortness of breath. Patient #17 was triaged at 1:51 p.m. and left AMA at 8:06 p.m. Patient #17 was in the ED for six (6) hours and thirty (30) minutes with no reassessment. Patient #17 was seventy-five (75) years old. On triage patient #17's blood pressure was 119/110 and pulse was 122.

11. A review of the medical record for patient #19 revealed patient #19 was seen in the ED on 4/28/21 at 4:12 p.m. with a complaint of abdominal pain for one (1) week. Patient #19 was triaged at 4:30 p.m. and left AMA at 9:43 p.m. Patient #19 was in the ED for five (5) hours and thirteen (13) minutes with no reassessment. Patient #19 was seven (7) years old.

12. A review of the medical record for patient #20 revealed patient #20 was seen in the ED on 4/30/21 at 11:45 a.m. with a complaint of chest pain. Patient #20 was triaged at 12:19 p.m. and left AMA at 6:01 p.m. Patient #20 was in the ED for five (5) hours and forty-six (46) minutes with no reassessment. Patient #20 was fifty-seven (57) years old.

13. A telephone interview was conducted with the Medical Director of Emergency Services on 5/5/21 at approximately 9:20 a.m. While discussing the lack of reassessments of patients waiting in the waiting room of the emergency room he stated, "I know there is an issue with patients not being reassessed in the waiting room."

14. An interview with the Director of Risk Management and Patient Safety was conducted on 5/5/21 at approximately 3:00 p.m. He concurred with the above findings.

Based on document review and staff interview it was determined the hospital failed to ensure the triage nurse in the Emergency Department (ED) performed reassessments on twelve (12) out of twenty (20) patients awaiting to be evaluated by the ED providers for a potential medical emergency (patient #4, 5, 6, 7, 9, 10, 11, 13, 15, 17, 19 and 20). This failure could have led to the death of a patient having an medical emergency.

Findings include:

1. A review of the medical record for patient #4 revealed patient #4 was seen in the ED on 4/22/21 at 9:16 a.m. with a complaint of possible ingestion of nicotine. Patient #4 was triaged at 9:21 a.m. and left against medical advice (AMA) at 1:42 p.m. Patient #4 was in the ED for four (4) hours and twenty-two (22) minutes with no reassessment. On 4/22/21 at 1:56 p.m. Child Protective Services was notified of the patient leaving AMA. Patient #4 was eleven (11) months old.

2. A review of the medical record for patient #5 revealed patient #5 was seen in the ED on 4/27/21 at 6:11 p.m. with a complaint of motor vehicle accident. Patient #5 was triaged at 6:21 p.m. and AMA at 11:03 p.m. Patient #5 was in the ED for four (4) hours and twenty-one (21) minutes with no reassessment. Patient #5 was nineteen (19) years old and was nineteen (19) weeks pregnant.

3. A review of the medical record for patient #6 revealed patient #6 was seen in the ED on 4/21/21 at 6:11 p.m. with a complaint of chest pain. Patient #6 was triaged at 6:24 p.m. and left AMA at 1:02 a.m. Patient #6 was in the ED for four (4) hours and twenty-eight (28) minutes with no reassessment. Patient #6 was eighty (80) years old.

4. A review of the medical record for patient #7 revealed patient #7 was seen in the ED on 4/21/21 at 6:32 p.m. with a complaint of shortness of breath. Patient #7 was triaged at 6:32 p.m. and left AMA at 1:42 a.m. Patient #7 was in the ED for five (5) hours and ten (10) minutes with no reassessment. Patient #7 was forty-seven (47) years old.

5. A review of the medical record for patient #9 revealed patient #9 was seen in the ED on 4/23/21 at 1:44 p.m. with a complaint of chest pain. Patient #9 was triaged at 1:47 p.m. and left AMA at 5:10 p.m. Patient #9 was in the ED for three (3) hours and twenty-two (22) minutes with no reassessment. Patient #9 was fifty-one (51) years old. Patient #9 was in the waiting area of the ED with an IV that had been placed by emergency medical services. The facility failed to have a consent for treatment signed.

6. A review of the medical record for patient #10 revealed patient #10 was seen in the ED on 4/21/21 at 9:56 p.m. with a complaint of congestion. Patient #10 was triaged at 10:39 p.m. and left AMA at 1:48 a.m. Patient #10 was in the ED for three (3) hours and eighteen (18) minutes with no reassessment. Patient #10 was three (3) months old.

7. A review of the medical record for patient #11 revealed patient #11 was seen in the ED on 4/26/21 at 12:35 p.m. with a complaint of abdomen pain. Patient #11 was triaged at 1:07 p.m. and left AMA at 8:20 p.m. Patient #11 was in the ED for seven (7) hours and thirteen (13) minutes with no reassessment. Patient #11 was forty-nine (49) years old.

8. A review of the medical record for patient #13 revealed patient #13 was seen in the ED on 4/21/21 at 4:35 p.m. with a complaint of abdominal pain, post-op. Patient #13 was triaged at 4:49 p.m. and left AMA at 8:19 p.m. Patient #13 was in the ED for three (3) hours and forty-four (44) minutes with no reassessment. Patient #13 was seventy-four (74) years old.

9. A review of the medical record for patient #15 revealed patient #15 was seen in the ED on 4/07/21 at 3:50 p.m. with a complaint of chest pain. Patient #15 was triaged at 4:00 p.m. and left AMA at 6:23 p.m. Patient #15 was in the ED for two (2) hours and twenty-three (23) minutes with no reassessment. Patient #15 was fifty-three (53) years old.

10. A review of the medical record for patient #17 revealed patient #17 was seen in the ED on 4/14/21 at 1:40 p.m. with a complaint of shortness of breath. Patient #17 was triaged at 1:51 p.m. and left AMA at 8:06 p.m. Patient #17 was in the ED for six (6) hours and thirty (30) minutes with no reassessment. Patient #17 was seventy-five (75) years old. On triage patient #17's blood pressure was 119/110 and pulse was 122.

11. A review of the medical record for patient #19 revealed patient #19 was seen in the ED on 4/28/21 at 4:12 p.m. with a complaint of abdominal pain for one (1) week. Patient #19 was triaged at 4:30 p.m. and left AMA at 9:43 p.m. Patient #19 was in the ED for five (5) hours and thirteen (13) minutes with no reassessment. Patient #19 was seven (7) years old.

12. A review of the medical record for patient #20 revealed patient #20 was seen in the ED on 4/30/21 at 11:45 a.m. with a complaint of chest pain. Patient #20 was triaged at 12:19 p.m. and left AMA at 6:01 p.m. Patient #20 was in the ED for five (5) hours and forty-six (46) minutes with no reassessment. Patient #20 was fifty-seven (57) years old.

13. A telephone interview was conducted with the Medical Director of Emergency Services on 5/5/21 at approximately 9:20 a.m. While discussing the lack of reassessments of patients waiting in the waiting room of the emergency room he stated, "I know there is an issue with patients not being reassessed in the waiting room."

14. An interview with the Director of Risk Management and Patient Safety was conducted on 5/5/21 at approximately 3:00 p.m. He concurred with the above findings.

Based on document review, record review and staff interview it was determined the hospital failed to ensure Emergency Department (ED) staff failed to follow ED policy and procedure by not providing reassessments of twelve (12) of twenty (20) patients waiting in the ED waiting room that could have possibly been having a medical emergency (patient #4, 5, 6, 7, 9, 10, 11, 13, 15, 17, 19 and 20) and failed to ensure consents for treatment were signed for two (2) out of twenty (20) patients seen in the ED (patient #9 and 12) (see tag A 1104).

A. An Immediate Jeopardy (IJ) on Emergency Services was called on 5/5/21 at 3:55 p.m. A review of twenty emergency room (ER) records revealed twelve (12) out of twenty (20) patients failed to be reassessed within the two (2) hour time frame as expected by the hospital's 'Assessment/Reassessment Policy Emergency Department.'

B. Harm or Potential Harm: The hospital's failure to reassess patients awaiting the services of the ER has the potential to lead to a decline in the patient's health status or potentially death of a patient.

C. Immediacy: The hospital needs to take immediate action to prevent the potential death of a patient in the waiting room awaiting the services of the ER.

D. A remedial plan of correction was received and accepted by the State agency Program Manager. It was accepted by the onsite surveyor and the IJ was abated on 5/5/21 at 5:30 p.m. The facility revised the policy titled "Assessment and Reassment Policy-Emeregency Department", all emergency room staff will be trained prior to their next oncoming shift and sign an asstestation confirming the education, random monitoring will begin for 30 records a month for assessments and reassessments.

A. Based on document review, record review and staff interview it was determined the hospital failed to follow Emergency Department (ED) policy and reassess patients waiting in the ED waiting room to receive the care of the ED providers for a potential medical emergency in twelve (12) out of twenty (20) medical records reviewed (patient # 4, 5, 6, 7, 9, 10, 11, 13, 15, 16, 17, 19 and 20). The hospital's failure to reassess patients awaiting the services of the emergency room has the potential to lead to a decline in the patient's health status or potentially death of a patient.

Findings include:

1. A review of the medical record for patient #4 revealed patient #4 was seen in the ED on 4/22/21 at 9:16 a.m. with a complaint of possible ingestion of nicotine. Patient #4 was triaged at 9:21 a.m. and left against medical advice (AMA) at 1:42 p.m. Patient #4 was in the ED for four (4) hours and twenty-two (22) minutes with no reassessment. On 4/22/21 at 1:56 p.m. Child Protective Services was notified of the patient leaving AMA. Patient #4 was eleven (11) months old.

2. A review of the medical record for patient #5 revealed patient #5 was seen in the ED on 4/27/21 at 6:11 p.m. with a complaint of motor vehicle accident. Patient #5 was triaged at 6:21 p.m. and AMA at 11:03 p.m. Patient #5 was in the ED for four (4) hours and twenty-one (21) minutes with no reassessment. Patient #5 was nineteen (19) years old and was nineteen (19) weeks pregnant.

3. A review of the medical record for patient #6 revealed patient #6 was seen in the ED on 4/21/21 at 6:11 p.m. with a complaint of chest pain. Patient #6 was triaged at 6:24 p.m. and left AMA at 1:02 a.m. Patient #6 was in the ED for four (4) hours and twenty-eight (28) minutes with no reassessment. Patient #6 was eighty (80) years old.

4. A review of the medical record for patient #7 revealed patient #7 was seen in the ED on 4/21/21 at 6:32 p.m. with a complaint of shortness of breath. Patient #7 was triaged at 6:32 p.m. and left AMA at 1:42 a.m. Patient #7 was in the ED for five (5) hours and ten (10) minutes with no reassessment. Patient #7 was forty-seven (47) years old.

5. A review of the medical record for patient #9 revealed patient #9 was seen in the ED on 4/23/21 at 1:44 p.m. with a complaint of chest pain. Patient #9 was triaged at 1:47 p.m. and left AMA at 5:10 p.m. Patient #9 was in the ED for three (3) hours and twenty-two (22) minutes with no reassessment. Patient #9 was fifty-one (51) years old. Patient #9 was in the waiting area of the ED with an IV that had been placed by emergency medical services (EMS). The facility failed to have a consent for treatment signed.

6. A review of the medical record for patient #10 revealed patient #10 was seen in the ED on 4/21/21 at 9:56 p.m. with a complaint of congestion. Patient #10 was triaged at 10:39 p.m. and left AMA at 1:48 a.m. Patient #10 was in the ED for three (3) hours and eighteen (18) minutes with no reassessment. Patient #10 was three (3) months old.

7. A review of the medical record for patient #11 revealed patient #11 was seen in the ED on 4/26/21 at 12:35 p.m. with a complaint of abdomen pain. Patient #11 was triaged at 1:07 p.m. and left AMA at 8:20 p.m. Patient #11 was in the ED for seven (7) hours and thirteen (13) minutes with no reassessment. Patient #11 was forty-nine (49) years old.

8. A review of the medical record for patient #13 revealed patient #13 was seen in the ED on 4/21/21 at 4:35 p.m. with a complaint of abdominal pain, post-op. Patient #13 was triaged at 4:49 p.m. and left AMA at 8:19 p.m. Patient #13 was in the ED for three (3) hours and forty-four (44) minutes with no reassessment. Patient #13 was seventy-four (74) years old.

9. A review of the medical record for patient #15 revealed patient #15 was seen in the ED on 4/07/21 at 3:50 p.m. with a complaint of chest pain. Patient #15 was triaged at 4:00 p.m. and left AMA at 6:23 p.m. Patient #15 was in the ED for two (2) hours and twenty-three (23) minutes with no reassessment. Patient #15 was fifty-three (53) years old.

10. A review of the medical record for patient #17 revealed patient #17 was seen in the ED on 4/14/21 at 1:40 p.m. with a complaint of shortness of breath. Patient #17 was triaged at 1:51 p.m. and left AMA at 8:06 p.m. Patient #17 was in the ED for six (6) hours and thirty (30) minutes with no reassessment. Patient #17 was seventy-five (75) years old. On triage patient #17's blood pressure was 119/110 and pulse was 122.

11. A review of the medical record for patient #19 revealed patient #19 was seen in the ED on 4/28/21 at 4:12 p.m. with a complaint of abdominal pain for one (1) week. Patient #19 was triaged at 4:30 p.m. and left AMA at 9:43 p.m. Patient #19 was in the ED for five (5) hours and thirteen (13) minutes with no reassessment. Patient #19 was seven (7) years old.

12. A review of the medical record for patient #20 revealed patient #20 was seen in the ED on 4/30/21 at 11:45 a.m. with a complaint of chest pain. Patient #20 was triaged at 12:19 p.m. and left AMA at 6:01 p.m. Patient #20 was in the ED for five (5) hours and forty-six (46) minutes with no reassessment. Patient #20 was fifty-seven (57) years old.

13. A telephone interview was conducted with the Medical Director of Emergency Services on 5/5/21 at approximately 9:20 a.m. While discussing the lack of reassessments of patients waiting in the waiting room of the emergency room he stated, "I know there is an issue with patients not being reassessed in the waiting room."

14. An interview with the Director of Risk Management and Patient Safety was conducted on 5/5/21 at approximately 3:00 p.m. He concurred with the above findings.



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B. Based on document review, medical record review and staff interview it was revealed the facility failed to follow their policy for the ED for obtaining a consent for treatment before services were provided. This failure was identified in two (2) of twenty (20) medical records reviewed (patient #9 and 12). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #9 revealed patient #9 was seen in the ED on 4/23/21 at 1:44 p.m. with a complaint of chest pain. Patient #9 was triaged at 1:47 p.m. and left AMA at 5:10 p.m. Patient #9 was in the ED for three (3) hours and twenty-two (22) minutes with no reassessment. Patient #9 was fifty-one (51) years old. Patient #9 was in the waiting area of the ED with an IV that had been placed by EMS. The facility failed to have a consent for treatment signed.

2. A review of the medical record for patient #12 revealed patient #12 was seen in the ED on 4/27/21 at 8:40 p.m. with a complaint of COVID-19. Patient #12 was triaged at 8:43 p.m. and discharged at 11:47 p.m. The facility failed to have a consent for treatment signed. Patient #12 was seventy (70) years old.

3. A review of the policy titled "Disclosure and Informed Consent/Consent to Treatment," effective 1/2020, stated in part: "It is the policy of the Hospital that consent to treatment be obtained etc.... In all cases consent must be obtained when individuals present themselves for: 3. Emergency Room services."

4. An interview was conducted with the Director of Risk Management and Patient Safety on 5/5/21 at approximately 3:00 p.m. He concurred no consent for treatment was located in the medical records.