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Based on policy review, medical record review, and interview, the facility failed to ensure an individual who presented to the emergency department was provided with an appropriate ongoing medical screening examination within the capability of the hospital's emergency department (ED) for one (1) of 20 (Patient #1) sampled patients.

The findings included:

Refer to A2406.

Based on policy review, medical record review, and interview, the facility failed to ensure an individual who presented to the emergency department was provided with an appropriate ongoing medical screening examination within the capability of the hospital's emergency department (ED) for one (1) of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's policy, "Emergency Screening, Stabilization, and Transfer," revealed, "...Purpose: To establish procedures for the medical screening exam (MSE) of patients presenting to [Hospital #1] requesting or requiring evaluation for determining if the patient has an emergency medical condition (EMC), and to provide appropriate stabilizing treatment...Medical Screening Exams...If not brought to a treatment room immediately, patients are triaged to facilitate treatment and screening according to acuity and an MSE is performed as soon as possible..."

Review of the facility's policy, "Emergency Department Triage," revealed, "...Procedure...The triage staff will escort the patient to the triage exam room...The triage nurse will perform and document a triage assessment pertinent to the patient's chief complaint and assign the appropriate severity score by using the ESI [Emergency Severity Index]...The triage nursing assessment documentation will include ...Subjective and objective data, rating on pain scale if applicable...Neurological abnormalities...Assigning Severity Index...Level II patients are defined as those patients in a high-risk situation confused/lethargic/disoriented or in severe pain/distress...Severe pain is defined as 7 out of 10 or greater on the pain scale. However, these patients must exhibit signs of severe pain including but not limited to facial grimacing, inability to sit still, paleness or diaphoresis. The triage nurse must document in the nurse objective section of the triage form what behaviors he/she is observing in the patient..."

Review of the facility's policy, "Documentation Standards for Treat and Release Patients," revealed, "...Purpose: To define documentation standards in the Emergency Department (ED) for patients who are treated and released, to confirm that patient records are consistently and accurately maintained from initial presentation to ED until disposition...Nursing documentation...Pain assessment and intervention...Document reassessment every two hours and after intervention ..."

Review of the facility's policy, "Pain Management," revealed, "...Purpose: To establish a comprehensive approach to the needs of patients who experience pain...Patient rights include an assessment and appropriate management of pain..Pain management is a multidisciplinary responsibility...The patient's physician or other provider with prescriptive privileges is responsible to develop a plan and prescribe medications based on the patient's medical condition...RNs [registered nurses] have responsibility for evaluating the effectiveness of pain management in the inpatient setting, to include the assessment of pain...Determination of Pain...The pain intensity goal is established in collaboration with the patient when possible, during initial comprehensive assessment using an appropriate pain scale for patient..."

Review of the facility's policy, "Your Rights and Responsibilities as a Patient," revealed, "...You have the right to considerate and respectful care, including the right to...Have your pain treated..."

2. Medical record review revealed Patient #1 was a 52-year-old female who presented to the Hospital #1 ED on 8/22/2022 at 1:37 PM with chief complaints of severe headache, generalized tremors, nausea, and associated pressure behind the right eye.

Registered Nurse (RN) #1 triaged Patient #1 on 8/22/2022 at 2:26 PM (49 minutes after arrival to the ED) and documented she reported a history of brain aneurysm and had a scheduled appointment with the neurosurgeon on 8/23/2022. RN #1 documented Patient #1 reported her symptoms became worse yesterday which prompted her visit to the ED. RN #1 documented Patient #1 was alert and oriented to person, place, time, and situation, her breathing was even and unlabored, and she was in no apparent distress. Her vital signs were: temperature 98.1 degrees Fahrenheit, pulse rate 88, respiratory rate 20, blood pressure 133/87, and oxygen saturation level 93% on room air. RN #1 documented triage was completed at 2:31 PM and assigned Patient #1 an ESI level of 3. RN #1 documented for Patient #1, "Arrived in high risk situation? Or confused/lethargic/disoriented or severe pain/distress: No..." There was no documented assessment by RN #1 of Patient #1's pain from her chief complaint of a severe headache or any documented interventions to address her pain.

ED Physician #1 documented on 8/22/2022 at 2:32 PM (55 minutes after arrival to the ED), "First Provider Evaluation of Patient." There was no documented assessment by ED Physician #1 of Patient #1's pain from her chief complaint of a severe headache or any documented plan or orders to address her pain.

RN #1 documented on 8/22/2022 at 6:58 PM for Patient #1, "...Emergency Severity Index...Arrived in high risk situation? or confused/lethargic/disoriented or severe pain/distress: Yes...Patient Acuity: 2..." There was no specific documentation by RN #1 why Patient #1 was changed from acuity 3 (assigned at 2:31 PM) to acuity 2, and there was no assessment of Patient #1 documented by a medical provider or nursing staff when Patient #1's acuity was changed.

RN #2 documented vital signs for Patient #1 on 8/22/2022 at 7:34 PM (5 hours 58 minutes after arrival to the ED): pulse rate 92, respiratory rate 17, blood pressure 153/85, and oxygen saturation level of 98% on room air. RN #2 documented a pain assessment with a pain score of 8 on a 0-10 pain scale with a pain goal of 4. RN #2 documented Patient #1 reported aching pain in her head, but her airway, breathing, and circulation were intact, respirations were even and unlabored, and Patient #1 was in no apparent distress. There were no documented interventions by ED staff to address Patient #1's pain, and there was no documentation the medical provider was notified about Patient #1's pain.

The CT angiogram of the head and neck was performed on 8/22/2022 from 8:19 PM to 8:33 PM.

RN #3 documented on 8/22/2022 at 9:02 PM that Patient #1 was noted to be tremoring in the waiting room and brought to the triage bay for ED Physician #2 to assess. RN #3 documented Patient #1's vital signs were stable, and respirations were even and unlabored. There was no further documentation about this event by RN #3 or ED Physician #2.

The final results of the CT angiogram of the head and neck were resulted on 8/22/2022 at 9:56 PM with no acute intracranial findings, no finding of stenosis or occlusion of the cervical or intracranial vasculature, and no intracranial aneurysm evident.

RN #3 documented on 8/23/2022 at 2:32 AM (12 hours 55 minutes after arrival to the ED) that Patient #1 decided to leave the ED without being seen by the attending physician, resident physician, or Advanced Practice Provider. RN #3 documented Patient #1 signed the "Left AMA [against medical advice]/LWBS [left without being seen] Report" form after the risks and benefits of leaving the ED had been explained. RN #3 documented Patient #1 left the ED on 8/23/2022 at 2:37 AM.

Patient #1 presented to the ED on 8/22/2022 at 1:37 PM with chief complaints which included severe headache. Patient #1 was triaged at 2:26 PM (49 minutes after arrival to the ED) with an ESI of 3. There was no pain assessment documented by the nursing staff until RN #2 documented Patient #1 reported a pain level of 8 on a 0-10 scale on 8/22/2022 at 7:34 PM. There were no further pain assessments documented by the nursing staff for Patient #1 for the rest of the ED stay until Patient #1 left the ED on 8/23/2022 at 2:37 PM (13 hours after arrival to the ED). There were no interventions for pain management documented by the nursing staff. There was no documentation of a pain assessment by an ED medical provider or any documented plan or orders to address her reported severe pain.

3. During an interview on 9/28/2022 at 12:30 PM, RN #3 stated she was the assigned waiting room monitor on 8/22/2022. RN #3 stated it was hard to give pain medication such as narcotics in the waiting room and hard to keep up with a pain scale for 40 patients in the waiting room. RN #3 stated she brought Patient #1 to the triage bay for ED Physician #2 to assess due to patient tremoring in the waiting room. RN #3 stated the physician was not concerned about the tremoring. RN #3 stated she assumed that Patient #1 left the ED due to the wait time and not getting a room.

During an interview on 9/28/2022 at 1:00 PM, RN #1 stated he vaguely remembered Patient #1. RN #1 stated the triage nurse would get vital signs and assess for any emergent medical conditions in the triage area. RN #1 stated that if a patient complained of pain, the triage nurse would typically do a pain assessment. RN #1 stated there was a medical provider in the triage area who would see the patient briefly and talk to the patient and triage nurse. RN #1 stated the medical provider would read the triage note and decide on priority placement for the patient. RN #1 stated if a patient was stable, and there were no rooms available, the patient would be sent back out into the waiting room. RN #1 stated he remembered Patient #1 was alert and oriented but did not exhibit any seizure activity that he could remember.

During an interview on 9/28/2022 at 1:15 PM, the ED Nursing Director stated the triage provider would begin the MSE by ordering radiology and labs. The ED Nursing Director stated this was documented in the medical record with an electronic signature as, "First Provider Evaluation of Patient." The ED Nursing Director stated there was a triage provider scheduled from 8:00 AM to midnight each day who would lay eyes on the patient, but the triage provider would not document an assessment. The ED Nursing Director stated the triage nurse had an assessment form to follow and would get a full set of vital signs. The ED Nursing Director stated if a patient had a chief complaint of headache, he would expect to see a pain assessment documented. The ED Nursing Director stated the waiting room monitor was an RN who took vital signs on patients out in the waiting room every 2 hours. The ED Nursing Director stated the waiting room monitor would notify the physician if a patient reported their pain was worsening.

During an interview on 9/28/2022 at 3:30 PM, ED Physician #1 confirmed she was the triage physician on 8/22/2022. ED Physician #1 stated she would talk to patients and determine which patients were a priority. ED Physician #1 stated patients would come to the registration desk, get checked in, and registration would get a one-word complaint from the patient. ED Physician #1 stated registration would then call back to the triage bay. ED Physician #1 stated she would listen to the triage nurse and then click on "patient seen" on the computer screen. ED Physician #1 stated the triage providers did not specifically document an assessment. ED Physician #1 stated once the patient was triaged, the patient was typically placed back out in the waiting room. ED Physician #1 stated the waiting room monitor would check vital signs routinely and notify the triage physician for any concerns about the patients in the waiting room.

During an interview on 9/29/2022 at 8:30 AM, the ED Medical Director stated when a patient presented to the ED, the patient came to the registration desk, and the nurse did a rapid assessment. The ED Medical Director stated from 8:00 AM to midnight, there was a triage provider in the triage area. The ED Medical Director stated the triage provider would assess the patient based on the patient complaint and determine which type of bed the patient would require. The ED Medical Director stated the higher acuity patients needed a pod bed, and the lower acuity patients could go to a bed in the continuous flow unit (6 recliner area). The ED Medical Director stated the triage provider did not specifically document an assessment due to the high volume of patients. The ED Medical Director stated it was not feasible to document an assessment due to the high volume of patients in the ED. The ED Medical Director stated the triage providers put in orders and reassess patients based on the lab results. The ED Medical Director stated the nurse could give anti-inflammatory medication in the waiting room for patients who presented with pain.