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A. Based on observation, review of facility policy and procedure, review of facility documents and staff interviews, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor.

Findings include:

Reference: Facility policy, "Transfer of Patient, Acute (E.M.T.A.L.A. [Emergency Medical Treatment and Labor Act]) ...Policy: ... 5. Signage. Signs which explain the rights of individuals seeking emergency services ... must be conspicuously displayed in the ED, Labor and Delivery and in other areas of the hospital where individuals seeking care for an emergency medical condition may be waiting for examination and treatment at the facility. ...Signs must be clearly visible from a distance of 20 feet. Signs should be approximately 18" X 20" and should be posted in English and a foreign language where applicable. ..."

1. A tour of the facility, conducted on 9/14/17 revealed that there were no EMTALA signs posted in the following areas:

a. Labor and Delivery Triage Room A, and Triage Room C

b. ED (Emergency Department) Hallway Waiting area, near the Adult and Peds (Pediatrics) Triage Rooms

c. ED Intake Room #1

d. ED Bay #E9

e. Peds ED #P2

f. Peds ED #P3

g. Peds ED #P5

h. Peds ED #P6

i. Peds ED #P9

j. Peds ED #P10

k. Peds ED Gyn Room

2. The above findings were confirmed by Staff #1 and Staff #5.

3. A tour of the facility, conducted on 9/14/17 revealed that the EMTALA signs posted in the following areas were not visible to patients and visitors:

a. Old Lobby entrance

b. ED Hallway Waiting Area between public restrooms

c. Peds ED #P7

d. Peds ED #P8

4. The above findings were confirmed by Staff #1 and Staff #5.

B. Based on observation, facility record review and staff interview, it was determined that the facility failed to post EMTALA signage in the language(s) that are understandable by the population served by the hospital.

Findings include:

Reference: Facility Document: "2015 By Race Patient Race/Ethnicity Description", "...Hispanic- 14.3%", of ER (Emergency Room) discharges and volume."

1. A tour of the facility, conducted on 9/14/17, revealed the following:

a. The ED Intake Waiting Room #7 had signage in Spanish only.

b. The ED Intake Room #10 had signage in English only.

c. The ED Intake Room #13 had signage in Spanish only.

d. The ED Intake Room #14 had signage in English only.

e. The ED Bay #E2 had signage in English only.

2. Facility document review indicated that the Spanish speaking population accounts for ten (10) percent of the population served by the hospital and was confirmed by Staff #1.

3. The above findings were confirmed by Staff #1 and Staff #5.

Based on a review of facility policy and procedure and review of the medical records of 30 patients who presented to the emergency department (ED), it was determined that not all individuals who came to the emergency department were provided with an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed.

Findings include:

Reference #1: Policy titled "Triage" states: ".....
PURPOSE: The purpose of triage is to:
* Provide immediate and appropriate assessment and intervention for all patients in the Emergency Department.
* Rapidly identify patients with life threatening conditions to determine the most appropriate treatment area for patients presenting to the department.
.....
* Ensure the safety and well-being of those patients who are waiting to be seen by a physician.
.....
* Constantly reassess patients as waiting times increase. The patient's acuity level can change as the patient's condition changes and the wait time increases. This change in acuity/status must be reflected in EHR (Electronic Health Record.) [sic]
POLICY: All patients presenting to the Emergency Department will be seen by a Registered Nurse who has been assessed as competent in the triage process and be assigned an appropriate acuity level utilizing the 5 Level (ESI) Emergency Severity Index 24 hours a day [sic] 7 days a week. Triage is the continuous process of assessment and prioritization that begins at the time of patient presentation to the ED. The triage assessment must be thorough enough to determine the treatment acuity level and be brief enough to determine the treatment acuity level and be brief enough to ensure that the flow of patients through the department is smooth and safe.
.....
Triage Acuities
.....
Level 2: Patients are presenting potentially unstable and must be seen by a physician/provider emergently. Failure to act can potentially result in the loss of life, limb, or organ. Problems require rapid evaluation and stabilization or treatment which is related to critical time factor (needle sticks, bodily fluid exposures.) [sic] This includes [sic] but is not limited to patients who or [sic] experiencing symptoms related to chest pain, stroke, ..... altered mental status, neurological deficits, .....
Level 3: Patients presenting as Level 3 are stable and should be seen urgently. They often require diagnostic evaluation and treatment in the ED. VS (Vital Signs) are stable and condition is not likely to deteriorate or require time sensitive treatment. .....
....."

Reference #2: Policy titled ADULT ACUTE STROKE MANAGEMENT PROTOCOL states: ".....
DEFINITIONS:
1. "Acute Stroke" is defined as the rapid onset of one or more focal neurological deficits with signs or symptoms persisting longer than 1 hour and not otherwise attributable to another disease process. The term "acute stroke" includes the subtypes acute hemorrhagic stroke and ischemic stroke.
.....
POLICY:
.....
3. Patients whose symptom onset time is determined to be greater than or equal to six (6) hours from presentation or obvious contraindications to tPA (tissue Plasminogen Activator) will not require the Code FAST (Face, Arms, Speech, Time) Team to be activated and the [sic] Emergency Department will be responsible for initiating the appropriate sections of the Acute Stroke Management Protocol.
a. The Emergency Department Physician and/or treating physician will order a consult with the on-call Neurologist for assistance with the management of acute cerebrovascular events whose onset time are greater than or equal to six (6) hours from presentation or for potentially serious or life threatening stroke syndromes.
.....
7. Diagnostic Clinical Services Time and Availability
.....
c. For all patients presenting with signs and symptoms onset greater than or equal to six (6) hours, a CT (Computed Tomography) Scan will be performed as ordered by the physician responsible for care of the physician.
d. For all patients presenting with signs and symptoms of acute stroke, regardless of time of onset, the following diagnostic clinical tests which are available 24 hours a day, seven (7) days a week shall be performed and reported:
i. STAT (immediately) blood glucose via fingerstick
ii. Stroke Panel:
* STAT CBC (Complete Blood Count), PT/INR (Prothrombin Time/International Normalized Time), PTT
(Partial Thromboplastin Time) within 45 minutes
* BMP (Basic Metabolic Panel), Troponin, Lipid Profile, PT/PTT, INR, Pregnancy test if applicable.
iii. Type and Screen for blood products.
iv. STAT 12 Lead EKG (Electrocardiogram)
v. STAT Chest X-Ray, if applicable
.....
10. All protocols are time sensitive and will be monitored for compliance with treatment goals, and within the performance improvement initiatives for Stroke Care. The following guidelinesoutline [sic] timing for the care of the acute stroke patient:
a. Time from presentation to RN triage/assessment = 5 minutes
b. Time from presentation to ED physician/ House Physician = 10 minutes
.....
d. Time from presentation to Lab results of PT/INR = 45 minutes
e. Time from presentation to CT order/imaging = 25 minutes
f. Time from presentation to imaging interpretation = 45 minutes
.....
h. Time from presentation to transfer for patients requiring neurointervention = 120 minutes
.....
PROCEDURE:
Emergency Department Presentation
.....
3. The Emergency Department Physician:
a. Perform a medical screening examination within five (5) minutes of arrival and determine time of onset of symptoms.
....."

1. Review of the medical record of Patient #13 revealed:

a. The patient presented to the ED on 9/8/17 at 10:00 PM. The triage of the patient began at 10:16 PM and was completed at 10:23 PM.

b. The "Visit Reason" section of an Emergency Department Clinical Summary form stated: "Medical screening exam: Weakness; STROKE LIKE SYMPTOMS" and the "Reason for Visit//Problems/Past Medical Hx (History)" section of a "Triage Note" stated: "Triage Additional Information: pt (patient) rcvd (received) aaox4 (awake, alert, and oriented times four spheres), c/o (complains of) difficulty speaking x 1 day & chronic weakness. pt has hx of autoimmune disorder called synthease."

c. The patient was assigned by the triage nurse as a Level 3 on the Emergency Severity Index.

d. The patient was documented as LWOBS (left without being seen) at 12:55 AM on 9/9/17.

(i) The patient should have been assigned an ESI Level 2, not a Level 3 due to the possibility of a stroke. (Reference #1)

(ii) The patient was not seen by the triage nurse until 16 minutes after arrival to the ED. The PROCEDURE section of Reference #2 states that a patient presenting with a symptom, or symptoms of stroke have a medical screening examination within 5 minutes of arrival to the ED. The patient was documented as having been in the ED for 2 hours and 55 minutes without being examined by a physician, or other licensed independent practitioner.

(iii) Policy section 7c of Reference #2 was not implemented since a physician was not assigned to care for the patient.

(iv) Policy Section 7d of Reference #2 was not implemented. It is unclear whether the tests included in this section, were part of a protocol to be initiated by the triage nurse as standing orders or if a physician is responsible to order the tests.

2. An " ED Clinical Summary" sheet in the medical record of Patient #14 indicated that the patient's "Arrival" to the ED was 6:58 PM on 9/8/17. The "Visit Reason" section of the form stated: "CHEST PAIN" and the "Checkout" section stated "9/08/2017 8:32 PM."

a. There was no documentation that the patient was provided an immediate and appropriate assessment and intervention.

b. There was no documentation that nursing staff attempted to rapidly identify whether the patient presented with a life threatening condition.

c. There was no documentation that nursing staff attempted to ensure the safety and well-being of the patient for the 1 hour and 34 minutes until it was determined that the patient was no longer in the waiting room.

d. The patient was not provided a medical screening exam.




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3. Review of the medical record of Patient #26 revealed:

a. The patient presented to ED on 8/31/2017 at 1:55 PM. The patient was triaged at 1:55 PM.

b. The "Visit Reason" section of an Emergency Department Clinical Summary form stated: "Difficulty speaking; ACUTE CVA."

c. The patient was assigned by the triage nurse as a Level 2 on the Emergency Severity Index.

(i) The PROCEDURE section of Reference #2 states that a patient presenting with a symptom, or symptoms of stroke have a medical screening examination within 5 minutes of arrival to the ED. The patient had a MSE (medical screening exam) at 2:13 PM.

(ii) The patient did not have a MSE within 5 minutes of arrival to the ED.

d. The above finding was confirmed by Staff #1.

A. Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure all patients receive appropriate assessment, management, and treatment of pain.

Findings include:

Reference: Facility policy "Pain Assessment and Management" states, "Purpose ... To ensure the right of every patient to have his/her pain assessed and effectively managed throughout the continuum of care. ... For patients who can self-report pain, the initial plan for pain relief measures will be implemented to reach the patient's acceptable comfort level. ... The reassessment time frame to evaluate the effectiveness of pain management interventions shall be within 60 minutes. ..."

1. Review of Medical Records #20, #22 and #31 revealed the following:

a. Medical Record #20 indicated the patient arrived at the Emergency Department (ED) on 7/31/17 at 4:05 AM with a complaint of a laceration to the left side of the mouth, injury to left jaw, and status post assault.

(i) At 8:57 AM, the patient's pain level was assessed at 10/10 (10 out of 10) on the facility's numeric pain scale. The patient's stated comfort goal was not documented.

(ii) The Medication Administration Record indicated Morphine 2 mg IV(2 milligrams intravenous) was given at 8:57 AM.

(iii) The patient's pain level was not reassessed within 60 minutes as per the referenced policy.

(v) Pain relief measures were not implemented to reach the patient's acceptable comfort level.

b. Medical Record #22 indicated the patient arrived at the ED on 3/11/17 at 2:18 AM with a complaint of an acute headache.

(i) At 2:22 AM, the patient's pain level was assessed as 10/10 (10 out of 10) on the facility's numeric pain scale. The patient's stated comfort goal was not documented.

(ii) The Medication Administration Record indicated Ketorolac 15 mg IV and Acetaminophen 1000 mg (oral) was given at 3:55 AM. This was one (1) hour and thirty three (33) minutes after the patient's pain level was initially assessed.

(iii) At 5:16 AM, the patient's pain level was re-assessed and remained 10/10. The patient's stated comfort goal was 0 (no pain).

(iv) The patient's pain level was not re-assessed within 60 minutes.

(v) Pain relief measures were not implemented to reach the patient's acceptable comfort level.

c. Medical Record #31 indicated the patient arrived at the ED on 8/26/17 at 2:17 AM with a complaint of bilateral foot pain and suicidal thoughts.

(i) At 2:28 AM, the patient's pain level was assessed as 10/10 (10 out of 10) on the facility's numeric pain scale. The patient's stated comfort goal was 0 (no pain).

(ii) The Medication Administration Record indicated no medication for pain was administered.

(iii) At 5:53 AM, the patient's pain level was re-assessed and was 6/10 (6 out of 10). The patient's comfort goal was not documented.

(iv) The patient's pain level was not re-assessed within 60 minutes.

(v) Pain relief measures were not implemented to reach the patient's acceptable comfort level.

2. The facility failed to implement the Pain Assessment and Management policy.

3. The above findings were confirmed by Staff #1 and Staff #2.

B. Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that patients presenting to the emergency department who choose not to continue treatment are properly dispositioned.

Findings include:

Reference: Facility policy, Discharge Dispositions, states, "...Procedure: ...LWBS (left without being seen): Any patient who leaves prior to receiving triage and/or a Medical Screening Exam (MSE) will be considered LWBS (left without being seen). The patient will be called at a minimum of every 15 minutes for three attempts. ..."

1. Review of Medical Record #3 revealed the following:

a. The patient arrived at the Emergency Department (ED) on 8/15/17 at 10:02 AM.

b. The facility called for the patient at 10:19 AM and 10:43 AM.

c. The facility did not call for the patient every 15 minutes.

d. The facility did not call for the patient three times.

2. The facility failed to implement the above referenced policy.

3. The above findings were confirmed by Staff #1 and Staff #2.

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment, unduly discouraging individuals from seeking emergency medical treatment.

Findings include:

1. Medical Record review revealed nine (9) of thirty (30) patients were fully registered before triage.

a. Medical Record #1 indicated that on 8/15/17, the patient arrived at the Emergency Department (ED) at 19:14, was registered at 19:16 and was triaged at 19:41.

b. Medical Record #2 indicated that on 8/15/17, the patient arrived at the ED at 00:35, was registered at 00:51 and was triaged at 2:21.

c. Medical Record #7 indicated that on 7/31/17, the patient arrived at the ED at 19:21, was registered at 19:27 and was triaged at 20:18.

d. Medical Record #8 indicated that on 7/01/17, the patient arrived at the ED at 21:09, was registered at 21:09 and was triaged at 21:26.

e. Medical Record #16 indicated that on 5/17/17, the patient arrived at the ED at 10:43, was registered at 10:47 and was triaged at 11:00.

f. Medical Record #19 indicated that on 7/31/17, the patient arrived at the ED at 4:08, was registered at 4:08 and was triaged at 4:12.

g. Medical Record #21 indicated that on 3/28/17, the patient arrived at the ED at 9:44, was registered at 9:45 and was triaged at 9:49.

h. Medical Record #23 indicated that on 7/04/17, the patient arrived at the ED at 15:06, was registered at 15:11 and was triaged at 15:25.

i. Medical Record #24 indicated that on 8/22/17, the patient arrived at the ED at 3:05, was registered at 3:09 and was triaged at 3:12.

2. This is a possible deterrent to individuals seeking treatment, unduly discouraging patients from coming in to the ED for evaluation/treatment.

3. The above findings were confirmed by Staff #1 and Staff #2.