HospitalInspections.org

Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure an accurate ED log is maintained for each patient who comes to the emergency department, to include patients who was refused treatment.

Findings include:

Review of facility policy titled, "EMTALA" (last reviewed on 03/20/23) states, "... Log a. Maintenance of a Log for ED patients - An electronic log is maintained for each individual arriving in the ED for medical assistance. ..."

5/17/23 at 10:15 AM, upon review of the ED log, it was revealed that Patient (P)2's name was not in the ED log for 4/1/23. P2's medical record was requested for the 4/1/23 visit. At 10:20 AM, upon interview S6 (ED Director) stated that the triage nurse identified P2 as a "frequent flyer" who had to go to the shelter/warming center and uberhealth was called. The registration was cancelled because the patient was not seen in the ED. S6 confirmed that there is no medical record for P2 on the 4/1/23 visit, that P2 should have been triaged and seen for an MSE, and the registration should not have been cancelled.

Based on the medical record review of six of twenty Emergency Department (ED) patients, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1) all patients presenting to the ED receive a medical screening exam (MSE); and 2) completion of a medical screening examination (MSE) in order to rule out an emergency medical condition (EMC) in the ED, including continued monitoring of patients waiting for an MSE.

Findings include:

Review of the facility policy titled, "EMTALA" (Published on 4/17/2023) states, "... Process 1. Medical Screening Examination (MSE) The hospital must provide a MSE within the capability of its ED, ... to determine whether an EMS exists, to all of the following persons: a) Each individual who comes to any hospital dedicated emergency department and requests, ... for examination or treatment for any medical condition, ... "

1) On 5/17/23 at 10:15 AM, during an attempt to review Patient (P)2's ED medical record, in the presence of Staff (S)2 (Performance and Safety Improvement Coordinator) and S6 (Director of ED), it was revealed that there was no record found concerning P2 in the ED log or in the EMR (electronic medical record). A Patient Summary Report was provided by S5 (Patient Safety Manager), where it stated, "... ENCOUNTER INFORMATION Arrival Date: 04/01/23 00:42:00 [12:42 AM] - Visit Reason: FOOT PAIN HERNIA ... Discharge Date: 04/01/23 00:42:00 [12:42 AM] ...Encounter Type: Cancelled ..."

An interview was conducted with S6 on 5/17/23 at 10:20 AM. According to S6, P2 is a patient who is known to the ED as he/she frequently comes in often seeking shelter. The patient was brought in by ambulance (BLS), was ambulatory and walked into triage. Triage was not performed. The triage nurse identified that P2 had to go to the shelter/warming center and uberhealth was called. The registration was cancelled because the patient was not seen in the ED. During the interview, S6 stated that he/she was made aware of the incident during morning report from the charge nurse, where an EMTALA violation concern was identified. An investigation was conducted concerning this event.

A review of the facility document titled, Potential EMTALA Investigation Summary, a case investigation provided by S14 (Chief Compliance Officer), it was revealed that the Triage nurse took report from EMS, the patient was escorted to the waiting room after arrival as there was no bed available in the ED. A full registration was completed at 1:11 AM. It was stated in the document that P2 often comes to the ED seeking shelter and resources and that the patient had 30 visits in the month of March within the health system. It was further stated in the document, "After discussion with several staff members including the ED physician, Registrar, charge Nurse, Unit Clerk, and Triage Nurse, it is our understanding that they did not think the patient needed to be seen therefore the patient did not receive a triage or MSE and arrangements were made to transfer the patient to a Warming Center as there was a Code Blue [cold weather alert issued by the county] activation by the county of Passaic. The patient did not object to the transfer and was sent to the Warming Center at approx. [approximately] 2am." The registration was cancelled and removed from the ED log after the patient's departure from the ED. The facility's corrective actions included: counseling and re-education of all staff members involved. Extensive in-person and web-based education provided to all hospital staff.

During the interview with S6, it was stated that EMTALA education was conducted for all hospital staff. S6 stated that EMTALA education was ongoing for other departments at the time of the survey. Proof of education and attendance sign-off sheets were reviewed. There was no documented evidence in the medical record of continuous monitoring of the patient in accordance with facility policy.

The above finding was confirmed with S3 (Director of Nursing), S4 (VP Site Administrator), S6, and S40 (Manager Patient Safety and Accreditation) upon discovery and on 5/18/23 during the exit conference.

2) Facility policy titled, "EMTALA" states, "...Process ...2. Ongoing Process A MSE is an ongoing process not an isolated event. The patient's record shall reflect continued monitoring in accordance with the patient's needs and must continue until the patient is stabilized or transferred or discharged. There should be evidence of this evaluation in the medical record prior to discharge or transfer. ..."

Review of facility document titled, "Ascent Triage Waiting Room Management and Safety" states, " Waiting Room Management - Reassessments · Vital signs ·Pain score ·General appearance ·Mental Status ·DOCUMENTATION ·Triage care does not end after acuity is assigned. Triage nurse is clinically and legally responsible for al patients in the waiting room..."

On 5/17/23 at 11:45 AM, during medical record review in the presence of S2, the following was revealed:

On 12/28/22 at 23:27 (11:27 PM), P15 (a pediatric patient) arrived in the ED with complaints of "fever all day with cough and runny nose." The patient was triaged at 23:59 (11:59 PM), vital signs were documented and acuity level "3" was assigned. On 12/29/22 at 3:53 AM, S41 (RN) documented, "Triage Patient Called No Answer: Patient called, no answer." S41 entered the patient's ED discharge disposition as "left without being seen ... Patient left after triage." There was no documentation in the medical record that the patient had received an MSE to rule out an EMC during the four hours and 26 minutes that P15 was in the ED. On 5/17/23 at 1:10 PM, S13 (Manager of Registration) provided documentation stating that the patient was fully registered at 23:56 (11:56 PM).

A review of the facility policy titled "Triage Protocol" did not address monitoring of patients in the waiting room. There was no documentation in the medical record of continuous monitoring of the patient while waiting for a MSE, including reassessment of the patient's status in accordance with facility procedures for triage waiting room management. Upon interview, S6 (ED Director) stated that while there is no policy on the monitoring of patients in the waiting room, there is a process that all triage nurses were trained on. S6 then provided the document titled, "Ascent Triage Waiting Room Management and Safety."



41646

On 5/17/23 at 12:56 PM, during medical record review in the presence of S18 (Resource Nurse) and S19 (Nurse Informatics), the following was revealed:

On 12/26/22 at 20:01 (8:01 PM), Patient (P)17 arrived in the ED. At 20:12 (8:12 PM), S31 (Registered Nurse RN), documented in the "ED Triage" notes the patient's chief complaint as follows: "was [here] Monday and Wednesday of last week for n/v [nausea/vomiting], dizziness, dehydration, hot flashes; today c/o [complains of] nausea, dry mouth, hot flashes, dizziness, back and neck pain, headache." Vital signs were documented, and S31 (RN ED), documented an acuity level of "3" and the patient's pain assessment level as a "6"/10 on a numeric pain scale. On 12/27/22 at 00:35 (12:35 AM), S31 entered the patient's ED disposition as "Left without being seen." There was no documentation in the medical record that the patient had received an MSE to rule out an EMC during the four hours and 33 minutes that P17 was in the ED. On 5/17/23 at 1:10 PM, S13 provided documentation stating that the patient had been fully registered at 20:42 (8:42 PM). There was no documentation in the medical record of continuous monitoring of the patient while waiting for a MSE, including reassessment of the patient's status in accordance with facility policy, and established procedure for triage waiting room management.

On 2/2/23 at 10:58 AM, P18 arrived in the ED. At 11:23 AM, S32 (ED RN) documented in the "ED Triage" notes the patient's chief complaint as follows: "states began with menstrual period today and has had hot flashes lower abd [abdominal] pain and vomitng [sp] states happens every time she gets her period." Vital signs were documented, and S32, documented an acuity level of "3" and the patient's pain assessment level as an "8"/10 on the numeric pain scale. At 15:13 (3:13 PM), S33 (ED RN) entered the patient's ED disposition as "Left without being seen." There was no documentation in the medical record that the patient had received an MSE to rule out an EMC during the four hours and 11 minutes that P18 was in the ED. On 5/17/23 at 1:10 PM, S13 provided documentation stating that the patient had been fully registered at 15:07 (3:07 PM). There was no documentation in the medical record of continuous monitoring of the patient while waiting for a MSE, including reassessment of the patient's status in accordance with facility policy, and established procedure for triage waiting room management.

On 1/14/23 at 00:24 (12:24 AM), P19 a 14-year old patient, arrived in the ED with his/her parent. At 1:09 AM, S34 (ED RN) documented in the "ED Triage" notes the patient's chief complaint as follows: "vomitted [sp] x2 after dinner and some diarrhea, no abd [abdominal] pain, just nausea." Vital signs were documented, and S34, ED RN, documented an acuity level of "3." At 4:28 AM, S34, entered the patient's ED disposition as "Left without being seen." There was no documentation in the medical record that the patient had received an MSE to rule out an EMC during the four hours and four minutes that P19 was in the ED. On 5/17/23 at 1:10 PM, S13 provided documentation stating that the patient had been fully registered at 1:43 AM. There was no documentation in the medical record of continuous monitoring of the patient while waiting for a MSE, including reassessment of the patient's status in accordance with facility policy, and established procedure for triage waiting room management.

On 5/18/23 at 10:16 AM, a review of P17, P18, and P19's medical records were completed with S8 (ED Nurse Manager). The above findings were confirmed with S8.


47131


On 5/17/22 at 12:07 PM, during medical record review in the presence of S20 (Nurse Informatics), the following was revealed:

On 12/30/22 at 18:12 (6:12 PM), P13 arrived at the ED. At 18:37 (6:37 PM), S28 (RN) documented the patient's chief complaint as follows: "Fell on ice, slipped and hit [his/her] head around 4am, denies LOC [loss of consciousness], no blood thinners, no pain-just wants to be checked out." The patient's vital signs were documented and S28 documented the patient's acuity level of "3." On 12/30/22 at 21:39 (9:39 PM), the patient completed a full registration. On 12/31/22 at 00:05 (12:05 AM), S39 entered the patient's ED disposition as "Left without being seen." S39 entered patient's ED Reason for Leaving as follows: "Wait too long." There was no documentation in the medical record that the patient received a MSE to rule out an EMC during the five hours and 53 minutes that P13 was in the ED. The medical record for P13 lacked evidence of continuous monitoring of the patient waiting for a MSE, including any further assessments. On 5/17/23 at 2:03 PM, S20 confirmed that the patient completed a full registration and was discharged from the ED without receiving an MSE. There was no documentation in the medical record of continuous monitoring of the patient while waiting for a MSE, including reassessment of the patient's status in accordance with facility policy, and established procedure for triage waiting room management.

The above findings were confirmed by S20 upon discovery and on 5/18/23 with S3, S4, S6, and S40, during the exit conference.