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Based on interviews and record review, the facility failed to ensure patients who presented at the Emergency Department (ED) were assessed and triaged (assessment of patients to determine the urgency of the need to be seen by a licensed provider such as a physician) timely, in accordance with the facility's policy and procedure, for 10 of 21 sampled patients (Patients 1, 2, 3, 4, 5, 14, 15, 18, 19, and 20). This failure had the potential for delay of medical treatment for these patients.

Findings:

On August 9, 2023, at 2:50 p.m., an unannounced visit was conducted for an EMTALA survey.

On August 9, 2023, at 4:10 p.m., an interview with the Chief Nursing Officer (CNO) was conducted. The CNO stated some registered nurses (RN) would perform two nursing roles in a day. She stated the House Supervisor (HS) would also work as a triage nurse (TN) at the ED when needed.

On August 10, 2023, at 9:20 a.m., an interview with HS 1 was conducted. She stated the facility uses a 1-5 scale for triage. She stated level 5 is low acuity (severity of patients' illness) and level 1 is high acuity. She further stated that at times, patients will come into the ED, sign in, and see a lot of people in the waiting area, then leave the ED without telling anyone.

On August 10, 2023, Patients 1, 2, 3, 4, 5, 14, 15, 18, 19, and 20's records were reviewed. The records indicated the following:

- The facility document titled, "Face Sheet," dated, November 2, 2022, indicated Patient 1 presented to the ED with a chief complaint of vaginal bleeding on November 2, 2022, at 9:08 a.m. The facility's untitled document, dated November 2, 2022, indicated Patient 1 arrived at the ED at 9:08 a.m., on November 2, 2022, and was triaged at 10:20 a.m.(one hour and 12 minutes after Patient 1's arrival at the ED);

- The facility document titled, "Face Sheet," dated November 3, 2022, indicated Patient 2 presented to the ED with a chief complaint of suicidal ideation on November 3, 2022, at 2:39 p.m. The facility's untitled document, dated November 3, 2022, indicated Patient 2 arrived at the ED at 2:39 p.m., on November 3, 2022, and was triaged at 3:27 p.m., (48 minutes after Patient 2's arrival at the ED);

- The facility document titled, "Face Sheet," dated December 16, 2022, indicated Patient 3 presented to the ED with a chief complaint of stomach pain on December 16, 2022, at 4:29 a.m. The facility's untitled document, dated December 16, 2022, indicated Patient 3 was not triaged. There was no documented evidence when Patient 3 left the ED without being seen;

-The facility document titled, "Face Sheet," dated December 27, 2022, indicated Patient 4 presented to the ED with a chief complaint of numbness of the hands and feet on December 27, 2022, at 3:22 p.m. The facility untitled document, dated December 27, 2022, indicated Patient 4 was not triaged and left without being seen at 4 p.m. (44 minutes after Patient 4's arrival at the ED);

- The facility document titled, "Face Sheet," dated December 15, 2022, indicated Patient 5 presented to the ED with a chief complaint of feeling lethargic and weak on December 15, 2022, at 5:49 p.m. The facility untitled document, dated December 15, 2022, indicated Patient 5 arrived at the ED at 5:49 p.m., on December 15, 2022, and was triaged at 7:31 p.m. (one hour 42 minutes after Patient 5's arrival at the ED);

- The facility document titled, "Face Sheet," dated July 12, 2023, indicated Patient 14 presented to the ED with a chief complaint of a headache on July 12, 2023, at 12:32 p.m. The facility's untitled document, dated July 12, 2023, indicated Patient 14 arrived at the ED at 12:32 p.m., on July 12, 2023, and was triaged at 1:08 p.m. (36 minutes after Patient 14's arrival at the ED);

- The facility document titled, "Face Sheet," dated December 6, 2022, indicated Patient 15 presented to the ED with a chief complaint of shortness of breath and cough at 11:22 p.m. The facility's untitled document, dated December 7, 2022, indicated Patient 15 arrived at the ED at 11:22 p.m., on December 6, 2022, and was triaged at 1:36 a.m. on December 7, 2022 (two hours 14 minutes after Patient 15's arrival at the ED);

- The facility document titled, "Face Sheet," dated December 8, 2022, indicated Patient 18 presented to the ED with a chief complaint of cellulitis on the right third finger on December 8, 2022, at 11:28 a.m. The facility's untitled document, dated December 8, 2022, indicated Patient 18 arrived at the ED at 11:28 a.m., on December 8, 2022, and was triaged at 12:41 p.m. (one hour 13 minutes after Patient 18's arrival at the ED);

- The facility document titled, "Face Sheet," dated December 11, 2022, indicated Patient 19 presented to the ED with a chief complaint of pregnancy, 32 weeks, with "water ruptured [rupture of amniotic fluid membrane]" on December 11, 2022, at 8:17 a.m. The facility's untitled document, dated December 11, 2022, indicated Patient 19 arrived at the ED at 8:17 a.m. on December 11, 2022, and was triaged at 9:31 a.m. (1 hour and 14 minutes after Patient 19's arrival at the ED); and

- The facility document titled, "Face Sheet," dated December 13, 2022, indicated Patient 20 presented to the ED with a chief complaint of overdose on December 13, 2022, at 4:16 a.m. The facility's untitled document, dated December 13, 2022, indicated Patient 20 arrived at the ED at 4:16 a.m. on December 13, 2022, and was triaged at 4:40 a.m. (24 minutes after Patient 20's arrival at the ED).

On August 10, 2023, at 2 p.m. an interview with RN 1 was conducted. She stated she works in the ED. She further stated a patient should be triaged within 10-15 minutes of arriving in the ED. RN 1 stated there have been instances when patients left due to them not being triaged timely.

On August 10, 2023, at 3 p.m., an interview with Admitting Clerk was conducted. She stated there are times when there is no triage nurse available. She stated when a patient comes in and the triage nurse is helping the other ED nurses, she would have to go look for the triage nurse and let the triage nurse know there is a patient and what their chief complaint is. She further stated when they are short staffed, the triage nurse is not always available.

On August 10, 2023, at 3:44 p.m., an interview with HS 1 was conducted. She stated the expectation is to triage a patient immediately if not then, within 15 minutes of patient arriving in the ED. HS 1 stated if a patient appears to have emergent symptoms, the triage nurse would call the physician right away to see the patient.

On August 10, 2023, at 4 p.m., an interview and concurrent record review was conducted with HS 1. She stated for Patient 1, one hour and 12 minutes is a long time to wait to be triaged. She stated for Patient 2, 48 minutes is a long time to wait to be triaged. She stated there was no documentation of when Patient 3 left as he was not triaged. She stated for Patient 4, 44 minutes was a long time to wait to be triaged. She stated for Patient 5, one hour and 42 minutes was a long time to be triaged. She further stated the triage process needs to be changed as it is taking a long time to triage a patient.

The facility's policy and procedure titled, "Triage Policy," dated April 2023 was reviewed. The policy indicated, "...Objectives: To assure the timeliness, appropriateness, and effectiveness of the triage process...to meet and treat patients based on the severity of illness and related priority...The Emergency Severity Index (ESI) (a tool used in triaging patients at the emergency department) five level triage algorithm that categorizes emergency department patients by evaluating both acuity and resource needs. Initially, the triage nurse assesses only the acuity level...The triage nurse is trained to triage patients rapidly and accurately into one of five explicitly defined and mutually exclusive levels...The triage process should be conducted immediately upon the patient's arrival, not to exceed 15 minutes..."