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Based on review of facility policy, medical record review, review of Emergency Department (ED) video footage and interviews, the facility failed to provide a triage assessment or a medical screening examination for 1 patient (#24) of 26 ED patients reviewed.

Cross Refer to A-2406.

Based on review of facility policy, medical record review, review of Emergency Department (ED) video footage and interviews, the facility failed to provide a triage assessment or medical screening examination for 1 patient (#24) who presented to the ED with hypertension, nausea and vomiting of 26 ED records reviewed.

The findings include:

Review of the facility policy "Emergency Medical Treatment & Active Labor ACT (EMTALA)," revised 5/2024, showed "...comes to the emergency department...has presented at a hospital's emergency department, and request examination or treatment for a medical condition...triage-refers to the clinical assessment if the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be seen by a physician or other qualified medical personnel [QMP] for completion of the medical screening examination. Medical Screening Examination [MSE] will be performed for any individual that...had requested for examination or treatment...MSE may include [1] assessment of the chief complaint as recorded in the patient's triage record [2] vital signs upon admission and upon discharge..."

Review of the facility policy "Documentation and nursing care of the patient in the Emergency Department," revised 1/2020, showed "...Triage Assessment: Registered Nurse or Provider will complete a triage assessment and triage classification on all patients who present to the Emergency Department. The nature of illnesses and injuries of these patients will govern the classification to assign priorities for a patient's treatment. The triage process should never delay care of a patient presenting with life threatening needs. The Emergency Severity Index (ESI) triage system (tool used for Emergency Department triage) will be used to prioritize patients presenting to the Emergency Department seeking care..."

Review of the ED Central Log showed Patient #24 presented to the ED on 9/2/2024 at 10:08 PM, with complaints of headache, nausea and vomiting and at 11:51 PM, the patient was coded as left the ED prior to triage.

Medical record review of an ED Nurses Note, dated 9/2/2024 at 11:50 PM, showed at 11:12 PM, the patient was called for triage and the patient was not in the ED lobby. Continued review showed at 11:30 PM, the patient was called for triage, the patient was not in the ED lobby, and the patient was removed from the tracking board "...assumed to have left prior to triage..." There was no documentation of vital signs for the patient or documentation of the risk and benefits of leaving prior to a nursing triage assessment.

Medical record review showed the patient arrived at Facility B on 9/2/2024 at 11:33 PM.

Medical record from Facility B revealed an ED Nursing Triage record, dated 9/2/2024 at 11:38 PM, showed the patient had complaints of a headache which started around noon on 9/2/2024 and she had a previous history of elevated blood pressure. She complained of a headache with a pain score of a 10 (0-10 scale with 10 being the worst). The triage record showed an Emergency Severity Index score of a 2, indicating urgent needs.

Review of Facility A's ED video footage for 9/2/2024 showed the following:
10:08 PM: The patient ambulated into the main ED entrance with another female. The patient went to the ED lobby desk where she was met by the ED Greeter. The patient walked toward the ED restroom.
10:09 PM (45 seconds): the greeter took the patient's registration paperwork to the triage room.
10:11 PM (36 seconds): the patient ambulated from the ED restroom with another female to a seat in the waiting room. The female went to desk and got an emesis bag for the patient.
10:24 PM: there were patients going into and coming out of the triage room.
10:35 PM (24 seconds): the female with the patient got a blanket from the greeter for the patient.
11:10 PM (24 seconds) (62 minutes after arrival): the patient went to the desk and gave the blanket back to the greeter and walked out the ED main entrance door.

During a telephone interview on 9/16/2024 at 6:25 PM, the complainant stated she had a previous history of hypertension. She stated they went to [Facility A] ED on 9/2/2024 around 9:00 PM-10:00 PM with an elevated blood pressure, nausea and vomiting. The patient's vital signs were never taken and she was not taken into a room for evaluation. They waited in the ED Lobby for 45 minutes and left the ED. The patient went to [Facility B] where she was evaluated, an EKG and a CT of the head was performed.

During an interview on 9/19/2024 at 10:45 AM, the ED Director stated the patient was listed on the ED Central Log as a "left prior to triage." The ED Director confirmed a quick registration was completed for Patient #24 and the triage nurse was notified. Interview confirmed the patient was not triaged and no vital signs were obtained.

During a telephone interview on 9/19/2024 at 1:40 PM, the ED Medical Director stated any patient who presented to the ED for evaluation would be registered, triaged and a medical screening examination would be performed.

During a telephone interview on 9/23/2024 at 6:50 PM, Patient Care Technician #1 stated Patient #24 presented with hypertension, nausea and vomiting. She confirmed she registered the patient, but did not obtain vital signs for the patient. The patient came to the desk stating she was leaving the ED prior to the triage and she did not notify the triage nurse Patient #24 was leaving.