HospitalInspections.org

Based on review of facility policies, medical records, Emergency Medical Services (EMS) Run Reports, Transport Medical Record, documentation located in an envelope labeled N.P.A (No Physician Available), observations and interviews, it was determined the facility failed to ensure that provide a medical screening examination (MSE) was provided by a Qualified Medical Personnel to any individual who comes to the emergency department to determine whether or not an emergency medical condition existed for 6 (Patient Identifier [PI] # 1, PI # 2, PI # 4, PI # 27, PI # 28 and PI # 42) of 6 patients, as evidenced by there were no physicians on duty at the facility and medical screening examinations were not performed.

Findings include:

Refer to findings in Tag A-2406.

Based on observational tours, review of facility policies, Emergency Medical Services (EMS) Run Report, Emergency Room (ER) Registers, documentation located in an envelope labeled N.P.A (No Physician Available) and interviews, it was determined the facility failed to maintain an accurate ER register on each individual who came to the Emergency Department (ED) seeking medical screening examination or if the patient was treated and discharged, refused treatment, admitted to the facility and treated or stabilized and transferred to another healthcare provider.

This deficient practice affected 38 of 58 sampled patients, including Patient Identifier (PI) # 1, PI # 5, PI # 6, PI # 7, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 16, PI # 17, PI # 18, PI # 19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, PI # 30, PI # 31, PI # 32, P I #33, PI # 34, PI # 35, PI # 36, PI # 37, PI # 38, PI # 39, PI # 40 and PI # 50.

On 1/9/18 at 10:15 AM, the surveyors conducted an observational tour of the ED with EI #4, ED Registered Nurse (RN). The surveyor asked if there was a log of patients who come to the ED when the hospital was on diversion. EI # 4 stated there was no log, "We just fill out a triage sheet and put it in an envelope labeled, N.P.A. (No physician available)."

Facility Policy:
Emergency Department Patient Registration

Policy:
This hospital will provide emergency medical screening and stabilizing treatment, as necessary, to all individuals "coming to the Emergency Department" without delaying care to inquire about the patient's ability to pay...

Procedure:
The Admitting Department Clerk will immediately notify the Triage Nurse if any individual presents with:

Chest pain, Shortness of breath, Severe bleeding, Severe trauma, Severe pain...

All patients will have the appropriate demographic information obtained by the Admitting Department Clerk. Demographic information will be entered into the computer and a patient chart will be created.

If the patient is taken directly back to the Emergency Department after triage, the Admitting Department Clerk may obtain information from a relative or from the patient in the Emergency Department...

All Emergency Department patient information will be maintained in a central log (see Emergency Department Log Maintenance policy and procedure)...


Facility Policy:
Subject: Emergency Room Register
Department: Emergency Department
Effective: 12/20/11
Revised: 3/21/17

Policy:
The Emergency Room Register is a permanent record which is kept in the department and/or medical record area for reference. An entry is made for each patient treated and the information indicated is recorded. This includes persons DOA (Dead on Arrival).

The following information is recorded:

ER record number, Time of arrival, Patient full name, Age, Sex, Date, Address... Nurse logging in patient, Physician seeing patient (private doctor is listed if patient has one), Present complaint, Treatment rendered in ER, Disposition, Time leaving ER

A review of the documentation, which was located in the envelope labeled, "N.P.A." revealed the following patients presented to the ED requesting to be examined by a physician on the following dates with chief complaints:

2.) PI # 5 presented on 10/17/17 at 5:25 PM with chief complaint of infection right leg times 3 weeks.

3.) PI # 6 presented on 10/18/17 at 4:20 PM with chief complaint of cough.

4.) PI # 7 presented on 10/18/17 at 4:40 PM with chief complaint of rash above right eye.

5.) PI # 8 presented on 10/21/17 at 10:55 AM with complaints of stomach and back pain.

6.) PI # 9 presented on 10/21/17 at 11:55 AM with complaint of back pain.

7.) PI # 10 presented on 11/1/17 at 7:52 AM with chief complaint of back pain.

8.) PI # 11 presented on 11/1/17 at 9:30 AM with chief complaint of right ankle swollen with pain.

9.) PI # 12 presented on 11/1/17 at 10:00 AM with chief complaint of boil.

10.) PI # 13 presented on 11/1/17 at 12:20 PM with chief complaint of right eye, "I got something in my right eye 2 days ago."

11.) PI # 14 presented on 11/1/17 at 4:35 PM with chief complaint of suture removal from the back.

12.) PI # 15 presented on 11/2/17 at 10:00 AM with chief complaint of sore throat since early... and vomiting.

13.) PI # 16 presented on 11/5/17 at 1:00 AM with chief complaint of allergic reaction.

14.) PI # 17 presented on 11/5/17 at 10:00 AM with complaints of cold symptoms.

15.) PI # 18 presented on 11/5/17 at 10:55 AM with complaint of abdominal pain.

16.) PI # 19 presented on 11/5/17 at 11:15 AM with complaint of foot injury.

17.) PI # 20 presented on 11/5/17 at 12:30 PM with complaint of ingestion of blood pressure pill.

18.) PI # 21 presented on 11/5/17 at 4:00 PM with complaint of laceration.

19.) PI # 22 presented on 11/5/17 at 7:20 PM with complaint of allergic reaction.

20.) PI # 23 presented on 11/5/17 at 9:10 PM with complaints of weakness, diarrhea times 1 week, out of seizure medication.

21.) PI # 24 presented on 11/9/17 at 8:00 PM with complaint injury to right arm.

22.) PI # 25 presented on 11/10/17 at 10:50 AM with chief complaints of chills and nausea.

23.) PI # 26 presented on 11/10/17 at 11:30 AM with chief complaint of cough.

24.) PI # 27 was a 1 year old child who presented on 11/10/17 at undocumented time with chief complaint of fever.

25.) PI # 28 presented on 11/24/17 at 4:20 PM with chief complaints of status post stroke, in 21 day at rehab facility.

26.) PI # 29 presented on 12/24/17 at 12:15 PM with chief complaints of body hurting.

27.) PI # 30 presented on 12/24/17 at 2:45 PM with chief complaints of needing prescriptions refilled.

28.) PI # 31 presented on 12/24/17 at 4:10 PM with chief complaints of arthritis pain and unable to walk.

29.) PI # 32 presented on 12/24/17 at 5:30 PM with chief complaints of painful toothache.

30.) PI # 33 presented on 12/26/17 at 9:20 AM with chief complaints of pain in left temporal area.

31.) PI # 34 presented on 12/26/17 at 2:45 PM with chief complaints of large amount of swelling in left forearm with redness and pain over mid arm.

32.) PI # 35 presented on 12/26/17 at 4:55 PM with chief complaints of headache all day, body aches which come and go.

33.) PI # 36 presented on 12/26/17 at 7:00 PM with chief complaints of upper airway congestion.

34.) PI # 37 presented on 12/27/17 at 9:35 AM with chief complaints of upper respiratory symptoms.

35.) PI # 38 presented on 12/31/17 at 9:40 AM with complaints of back ache.

36.) PI # 39 presented on 12/31/17 at 9:55 AM with complaints of runny nose and low grade fever.

37.) PI # 40 presented on 12/31/17 at 3:30 PM with complaints of back ache.

38.) PI # 50: Review of the Triage Note dated 12/26/17 at 10:15 AM revealed the nurse documented, "... Chief Complaint Flu symptoms/fever... Following call to switchboard to check on (four) 4 pts with flu symptoms. The pts left together before my arrival to switchboard was told at that time one of the patients was a young child with fever..."

The surveyor was unable to determine how many patients the above Triage Note represented (1) one or (4) four patients and was unable to interview the nurse that completed this documentation.

Review of the Emergency Room (ER) Register revealed no documentation the above patients were logged into the register to include Date Admitted, ER record number, Time of arrival, Patient full name, Age, Sex, Date, Address... Nurse logging in patient, Physician seeing patient (private doctor is listed if patient has one), Present complaint, Treatment rendered in ER, Disposition, Time leaving ER.

When questioned about the process if a patient presents to the ED and the hospital is on diversion. EI # 5, ED RN stated that she would assess the patient and let them know the doctor had to leave or was running late and give them the option to stay and wait until a doctor arrived. The surveyors asked if there was a log of patients who present to the ED while on diversion. EI # 5 stated the patients are placed on the ED log. She stated she thought that all patients are placed in the log book, even if the patients do not stay for the doctor to come and see them.

The facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for Patient Identifier (PI) # 1, PI # 5, PI # 6, PI # 7, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 16, PI # 17, PI # 18, PI # 19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, PI # 30, PI # 31, PI # 32, P I #33, PI # 34, PI # 35, PI # 36, PI # 37, PI # 38, PI # 39, PI # 40 and PI # 50.

Based on review of facility policies, medical records, Emergency Medical Services (EMS) Run Reports, Transport Medical Record, documentation located in an envelope labeled N.P.A (No Physician Available), observations and interviews, it was determined the facility failed to provide a medical screening examination (MSE) for Patient Identifier (PI) # 2, a medically unstable trauma patient who was brought to the facility's Emergency Department (ED) on 9/1/17 at 9:50 PM by EMS after the patient went into cardiac arrest. There was no physician available at the facility and a medical screening examination was not performed. The EMS crew along with the Air Ambulance crew performed resuscitative measures in the facility's ED. The Air Ambulance crew member spoke with their medical control physician on the telephone, reported the patient's condition and resuscitative measures that had been attempted. The patient was pronounced dead on 9/1/17 at 10:01 PM by the Air Ambulance crew's Medical Control physician.

This also affected PI # 1, a patient who was experiencing cardiac arrest on 12/25/17. EMS was attempting to take the patient to Hill Hospital, which was on diversion. Through interviews with facility staff and ambulance crew members, it was determined the ambulance presented to the hospital, the Registered Nurse (RN) exited the ED and informed the ambulance crew there was no physician available at the hospital. Subsequently, another ambulance crew was called by the first ambulance crew, who arrived at the hospital. The RN informed the ambulance crew the patient and first ambulance crew were still in the ambulance. The EMS team exited the ED, boarded the first ambulance which left the hospital and transported the patient to Hospital # 2, which was 32 miles from Hill Hospital. According to interviews, the patient was pronounced dead at Hospital # 2. There was no documentation a MSE was performed for PI # 1.

PI # 3 presented to the facility's ED on 11/4/17 at 2:06 PM with a laceration to the right eyebrow. A triage assessment was performed by the RN who applied steri-strips to the site. There was no documentation a MSE was performed, nor was there documentation the RN contacted a physician. The RN instructed patient's caregiver to take the patient to another ED for sutures. The patient was discharged from the ED at 2:20 PM.

PI # 4 was brought to the facility's ED on 11/11/17 at 11:40 AM by the "Chief of York" (city in which Hill Hospital is located). PI # 4's chief complaint was the patient was "found on the ground." Review of the Triage Assessment revealed the RN documented having informed them that the facility did not have a doctor. The RN documented EMS was contacted by the Fire Chief to transport the patient to Hospital # 3 (27 miles from Hill Hospital) "at mother's request." There was no documentation a MSE was performed for PI # 4.

It was also determined there was no documentation MSEs were performed for PI # 5, PI # 6, PI # 7, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 16, PI # 17, PI # 18, PI # 19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, PI # 30, PI # 31, PI # 32, PI # 33, PI # 34, PI # 35, PI # 36, PI # 37, PI # 38, PI # 39, PI # 40, PI # 41, PI # 42, PI # 43, PI # 44, PI # 45, PI # 46, PI # 47, PI # 48, PI # 49, PI # 50, PI # 51 and PI #52, all of whom were patients that presented to the facility's ED between 10/17/17 and 12/31/17 requesting to be seen by a physician and there was no physician coverage in the ED at the time the patients' requests to be seen were made.

This affected 52 of 58 medical records reviewed.

Findings include:

Facility Policy:
Reference # 2302
EMTALA (Emergency Medical Treatment and Labor Act) Guideline for Emergency Department Services

Policy:
All patients presenting to Hill Hospital's Emergency... Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.

In the absences of an actual request for services, if a "prudent layperson" observer would believe, based on the individuals appearance or behavior that the individual needs an examination or treatment for medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.

All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic.

The triage of a patient for managed care contracts without a medical screening exam is not acceptable under EMTALA. Prior authorization may be obtained after medical screening and stabilization services are completed. This does not preclude qualified medical personnel from consulting with the patient's private physician as long as the consultation does not inappropriately delay required medical services...

Medical Screening Exams:

Medical Screening Exams should include at a minimum the following:

Emergency Department Log entry including disposition of patient, Patient's triage record, Vital signs, History, Physical exam of affected systems and potentially affected systems, Exam of known chronic conditions, Necessary testing to rule out emergency medical conditions... Vital signs upon discharge or transfer, Complete documentation of the medical screening exam

Emergency Medical Conditions:
An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:

Undiagnosed, acute pain which is sufficient to impair the normal functioning... Substance abuse symptoms, i.e. alcohol ingestion, Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt...

Facility Policy:
Transfer of Patient to Another Facility

Purpose: Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility.

Policy:

All patients will be evaluated by the House physician regardless of condition, race, religious preference or ability to pay.

If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed:

The patient must:

Have no life-threatening condition... Be medically stable, Agree to the transfer

Acceptance to the receiving facility must be made physician to physician...


1. Patient Identifier (PI) # 2

Review of the EMS Run Report for dated 9/1/17 for PI # 2 revealed the chief complaint was Major Trauma to the head, musculoskeletal system with bleeding. EMS documented the patient was unresponsive, skin color was pale, cool and moist. There patient's peripheral pulses were strong and the patient's blood pressure was 60/systolic via carotid pulse palpation. The patient had deformities to bilateral upper and lower extremities. EMS documented the patient was found entangled under a steel pipe barrier and shrubs. Patient is driver of motorcycle that was thrown approximately thirty (30) feet... is unresponsive... had weak carotid pulse, shallow respirations at approximately 10 per minute. Deformity was noted to all extremities. Cardiac monitor shows normal sinus rhythm... held manual C (cervical) spine immobilization and placed a C collar on patient. The barrier was then lifted off of the patient and patient was placed on back board in a supine position. Once patient was in a supine position an avulsion was noted to... right shoulder and left knee. Placed patient on Oxygen at 15 liters per minute. Secured patient to stretcher with straps, securing... head last with a head immobilizer. When in ambulance attempting IV (intravenous) access patient went into asystole and cardiac arrest. Began CPR (Cardiopulmonary resuscitation) at a rate of 30 compressions to two ventilations with a bag valve mask on 15 liters per minute of Oxygen. While ventilating patient blood began to come from... airway. Suctioned patient's airway and ... was then intubated with a 7.5 ET (endotracheal) tube... Chest rise and fall was noted with ventilation, bilateral breath sounds were auscultated, and condensation was noted in the tube. Diverted to Hill Hospital due to patient being in cardiac arrest. Transported emergency to Hill Hospital ER (Emergency Room). Patient left... bed with rails up and bed in lowered position and locked. Verbal report given and patient care turned over to staff present... Patient report and care released to (Name of Flight Crew - air ambulance crew member)... Upon arrival at Hill Hospital ER nurse staff states that there was not a doctor on staff. During report call to the ER this was not advised. Contacted online medical control (physician's name) and advised of patient status and that Hill Hospital did not have a doctor. (Medical control physician) advised that the ER staff had to assume care and stabilize the patient before (he/she) could be transported away from the hospital. At this time (air ambulance) transport services arrived in the ER and began to assume care for the patient. During the time (Air ambulance crew) was providing patient care they contacted their medical control doctor (Physican's name) and stated that their med (medical) control advised to discontinue resuscitative efforts. (EMS - medical control physician) was contacted again and advised of what (Air ambulance crew) advised and he was in agreement to stop resuscitative efforts...

Review the Transport Medical Record of the air ambulance dated 9/1/17 revealed the air ambulance arrived at the scene at 9:46 PM, "... Pt is a 25 yo (year old)... found lying fully spinal immobilized on hospital bed at charted location. Pt came... via ambulance after... was involved in motorcycle collision vs (versus) tree line. EMS reports that pt was breathing and moaning when they loaded... into their ambulance but quickly decline into arrest shortly afterwards. EMS transported pt to Hill Hospital, Alabama without the knowledge that the facility did not have a physician working in the hospital tonight. On arrival nursing staff assisted EMS with trauma code. Tx (treatment) PTA (prior to arrival) includes CPR, spinal immobilization, and multiple intubation and IV attempts by EMS and IV attempts by ED (Emergency Department) staff..."

At 9:49 PM, the air ambulance crew member documented, "... Advised there is no MD or NP (Nurse Practitioner) in the hospital... EMS reports pt has been in asystole for over 30 min. with CPR in progress..."

"... Treatments, Interventions and Assessments... at 9:50 PM - Airway... Assessment reveals: Failure to Oxygenate, Failure to Protect Airway, Failure to Ventilate... Pre-oxygenated via 15 lpm (liters per minute). Patient prepared for oral intubation. Procedure performed by (Air ambulance crew member)... ET (endotracheal) tube - cuffed 7.5 placed... Invasive lines... Gauge 45 mm (milli-meters) EZ - IO (intraosseous) placed in left humerus Secured... blood return... infuses well... Bolus of 500 ml (milli-liters) NS (normal saline)..."

Review of the Transport Medical Record dated 9/1/17 revealed the patient's physical examination as follows: "... Unconscious, Unresponsive... Pupils fixed and dilated... no movement... Reflexes: Gag absent, Non-reactive. Sensory: Severe or total loss... Skin... pale. Peripheral temperature: Cool, Central temperature: warm... diaphoretic. Capillary refill: more than 2 seconds... Eyes: Left pupil dilated, Pupils non-reactive, Right pupil dilated... Throat: Intact palate Noted bleeding to mouth with missing teeth... Breathing: Apneic. Assisted. Breath sounds: diminished, left decreased, right decrease... Cardiac... Monitored rhythm: Asystole. Abrasion located chest, left chest... Extremities... Laceration located leg - large open laceration to left upper leg. Which was reported to have been bleeding profusely by EMS but has stopped... Noted dressing applied by EMS PTA... Shoulder - Open wound to right shoulder with no bleeding noted..."

Further review of the Transport Medical Record dated 9/1/17 revealed Epinephrine 1 mg (milli-gram) was administered at 9:52 PM and 9:57 PM. On 9/1/17 at 10:01 PM, the air ambulance crew documented having contacted, "MS (Mississippi) MEDCOM" (Air ambulance Medical Control Physician) and spoke with (Physician's name). Advised of pt condition with 30+ min (minutes) of CPR with trauma arrest. Pt pronounced at 10:01 PM..."

The air ambulance crew documented after the patient was pronounced dead by online medcontrol physician, the body was left in the care of the hospital staff and county sheriff.

Review of the medical record from Hill Hospital Emergency Department (ED) revealed the patient arrived at the facility on 9/1/17 at 9:50 PM via ambulance in cardiopulmonary arrest. The RN documented the patient had obvious fractures to left arm, right ankle/foot, left knee, fracture to the chin. The patient was on a cardiac monitor with O2 at 15 liters non-rebreather mask. The patient was brought in by ambulance and CPR was in progress, vital signs were absent and patient was asystole. The RN documented at 9:53 PM the patient was intubated and an intraosseous (IO) access was placed by air ambulance crew member and at 9:55 PM, 1 milligram (mg) Epinephrine was administered by air ambulance crew member via IO. At 10:01 PM, the patient was pronounced dead by (Air ambulance crew Medical Control physician). Further review of the medical record revealed the Code II Record dated 9/1/17 at 9:40 PM revealed the team members documented in the code were (1) RN and (1) Licensed Practical Nurse (LPN). There was no documentation of "Physicians in attendance." Compressions were documented as being performed by (Air ambulance Emergency Medical Technicians).

There was no documentation the RN and/or LPN actively participated in the resuscitative measures that were attempted for PI # 2 and there was no documentation a physician was present in the ED at the time PI # 2 was brought into the facility's ED.

An interview was conducted on 1/10/18 at 1:40 PM with Employee Identifier (EI) # 5 ED RN.

The surveyors asked if anyone had presented to the ED while the hospital was on diversion. She stated that one time, there was a motorcycle accident and the ambulance knew the facility was on diversion. She stated the patient was dead on arrival to the ED. She stated the patient was to be transported to another facility via air ambulance. The staff had gone to the front parking lot to make sure all of the cars had been moved out of the area so the helicopter could land. When we got back to the ED, the ambulance crew had brought the patient into the ED and was performing CPR (cardiopulmonary resuscitation). She stated that air ambulance crew came into the ED and took over the code (CPR).

2. PI # 1

Review of the EMS Run Report for dated 12/25/17 for PI # 1 revealed, PI # 1's chief complaint was difficulty breathing/shortness of breath. The patient experienced cardiac arrest after EMS arrival at the scene. The patient's cardiac rhythm was (PEA) pulseless electrical activity. The EMS initiated cardiopulmonary resuscitation (CPR) and the patient's pulse returned. EMS documented, "family states... (patient) was discharged from (hospital) a couple of days ago for atrial fib (fibrillation). Radial pulse rapid and weak. Pt (patient) in living room on... knees. Pt assisted to the stretcher at the bottom of about 10 steps of a mobile home. While rolling to the truck pt became unresponsive. No pulse. CPR started. EKG (electrocardiogram) PEA rate of 24. Oral airway BVM (bag valve mask) with high flow O2 (oxygen). IV (intravenous) NS (normal saline)... left hand. EPI (epinephrine) given every 5 minutes. ET (endotracheal tube) attempted twice WO (without) success. Starting transport to Hill Hospital. Hill on diversion and wouldn't accept the patient. Med (medical) control... contacted and discussed... Picked up additional EMT (Emergency Medical Technician) and transported to (Hospital Name - 32 miles from Hill Hospital).

An interview was conducted on 1/9/18 at 8:00 AM with Employee Identifier (EI) # 8 Emergency Department (ED) Registered Nurse (RN). The surveyors asked about PI # 1. She stated the ambulance called and she told them that the hospital did not have a physician. She stated the ambulance informed her that they had to come to the hospital. EI # 8 stated she called EI # 3, Chief of Staff, who stated the ambulance needed to send the patient to (Name of city, which is 32 miles from the hospital). She stated she called the ambulance and told them the hospital was unable to support Advanced Cardiopulmonary Life Support (ACLS) because there was no physician in the hospital. She stated she could help with Cardiopulmonary Resuscitation (CPR), but was unable to perform ACLS without a physician. She stated that she set up the trauma room. EI # 8 stated the ambulance stayed out in the parking lot. Another ambulance pulled up, two staff members got out and came into the ED. I informed them the ambulance staff and patient were still in the truck (ambulance). They walked out of the ED, got into the other ambulance and left the hospital.


3. PI # 3

PI # 3 presented to the facility's ED on 11/4/17 at 2:06 PM with a laceration to the right eyebrow. A triage assessment was performed by the RN and applied steri-strips to the site. There was no documentation a MSE was performed, nor was there documentation the RN contacted a physician. The RN instructed patient's caregiver to take the patient to another ED for sutures. The patient was discharged from the ED at 2:20 PM.

On 1/10/18 at 2:00 PM an interview was conducted with EI # 2, Director of Nursing, who verified there was no documentation of MSE because there was no physician in the ED on 11/4/17.

4. PI # 4

PI # 4 was brought to the facility's ED on 11/11/17 at 11:40 AM by the "Chief of York" (city in which Hill Hospital is located). PI # 4's chief complaint was the patient was "found on the ground." Review of the Triage Assessment revealed the RN documented having informed them that the facility did not have a doctor. The RN documented having contacted the ambulance company to transfer the patient to Hospital # 3 at the request of the patient's mother. The nurse further documented having attempted to contact EI # 3, Chief of Staff once, but was unsuccessful and contacted the ED staff at Hospital # 3 to inform them of the situation. There was no documentation a MSE was performed for PI # 4.

On 1/10/18 at 2:00 PM an interview was conducted with EI # 2, who verified there was no documentation of MSE because there was no physician in the ED on 11/11/17.

On 1/9/18 at 10:15 AM, the surveyors toured the Emergency Department (ED). During this tour, EI # 4, ED RN verified there was no physician in the ED since 1/9/17 at 7:00 AM. The surveyor asked if there was a log of patients who come to the ED when the hospital was on diversion. EI # 4 stated there was no log, "We just fill out a triage sheet and put it in an envelope labeled, N.P.A. (No physician available)."

A review of the documentation, which was located in the envelope labeled, "N.P.A." revealed the following patients presented to the ED requesting to be examined by a physician on the following dates with chief complaints:

5.) PI # 5 presented on 10/17/17 at 5:25 PM with chief complaint of infection right leg times 3 weeks. There was no documentation a triage assessment or MSE was completed for PI # 5. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 5.

6.) PI # 6 presented on 10/18/17 at 4:20 PM with chief complaint of cough. There was no documentation a triage assessment or MSE was completed for PI # 6. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 6.

7.) PI # 7 presented on 10/18/17 at 4:40 PM with chief complaint of rash above right eye. There was no documentation a triage assessment or MSE was completed for PI # 7. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 7.

8.) PI # 8 presented on 10/21/17 at 10:55 AM with complaints of stomach and back pain. There was no documentation of a triage assessment or MSE for PI # 8. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 8. PI # 8's information was documented on a plain white sheet of paper with information related to PI # 9.

9.) PI # 9 presented on 10/21/17 at 11:55 AM with complaint of back pain. There was no documentation of a triage assessment or MSE for PI # 9. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 9. PI # 9's information was documented on a plain white sheet of paper with information related to PI # 8.

10.) PI # 10 presented on 11/1/17 at 7:52 AM with chief complaint of back pain. There was no documentation a triage assessment or MSE was completed for PI # 10. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 10.

11) PI # 11 presented on 11/1/17 at 9:30 AM with chief complaint of right ankle swollen with pain. There was no documentation a triage assessment or MSE was completed for PI # 11. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 11.

12.) PI # 12 presented on 11/1/17 at 10:00 AM with chief complaint of boil. There was no documentation a triage assessment or MSE was completed for PI # 12. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 12.

13.) PI # 13 presented on 11/1/17 at 12:20 PM with chief complaint of right eye, "I got something in my right eye 2 days ago." The RN further documented, "pt states... going to local clinic to see if someone can see (him/her)." There was no documentation a triage assessment or MSE was completed for PI # 13. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 13.

14.) PI # 14 presented on 11/1/17 at 4:35 PM with chief complaint of suture removal from the back. There was no documentation a triage assessment or MSE was completed for PI # 14. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 14.

15) PI # 15 presented on 11/2/17 at 10:00 AM with chief complaint of sore throat since early and vomiting. There was no documentation a triage assessment or MSE was completed for PI # 15. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 15.

16.) PI # 16 presented on 11/5/17 at 1:00 AM with chief complaint of allergic reaction. There was no documentation a triage assessment or MSE was completed for PI # 16. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 16.

17.) PI # 17 presented on 11/5/17 at 10:00 AM with complaints of cold symptoms. There was no documentation of a triage assessment or MSE for PI # 17. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 17. PI # 17's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

18.) PI # 18 presented on 11/5/17 at 10:55 AM with complaint of abdominal pain. There was no documentation of a triage assessment or MSE for PI # 18. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 18. PI # 18's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

19.) PI # 19 presented on 11/5/17 at 11:15 AM with complaint of foot injury. There was no documentation of a triage assessment or MSE for PI # 19. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 19. PI # 19's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

20.) PI # 20 presented on 11/5/17 at 12:30 PM with complaint of ingestion of blood pressure pill. There was no documentation of a triage assessment or MSE for PI # 20. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 20. PI # 20's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

21.) PI # 21 presented on 11/5/17 at 4:00 PM with complaint of laceration. There was no documentation of a triage assessment or MSE for PI # 21. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 21. PI # 21's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

22.) PI # 22 presented on 11/5/17 at 7:20 PM with complaint of allergic reaction. There was no documentation of a triage assessment or MSE for PI # 22. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 22. PI # 22's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

23.) PI # 23 presented on 11/5/17 at 9:10 PM with complaints of weakness, diarrhea times 1 week, out of seizure medication. There was no documentation of a triage assessment or MSE for PI # 23. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 23. PI # 23's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

24.) PI # 24 presented on 11/9/17 at 8:00 PM with complaint injury to right arm. There was no documentation of a triage assessment or MSE for PI # 24. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 24. PI # 24's information was documented on a "Nurse's Notes" along with 6 other patient identifier names.

25.) PI # 25 presented on 11/10/17 at 10:50 AM with chief complaints of chills and nausea. There was no documentation a triage assessment or MSE was completed for PI # 25. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 25.

26.) PI # 26 presented on 11/10/17 at 11:30 AM with chief complaint of cough. There was no documentation a triage assessment or MSE was completed for PI # 26. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 26.

27.) PI # 27 was a 1 year old child who presented on 11/10/17 at undocumented time with chief complaint of fever. There was no documentation a triage assessment or MSE was completed for PI # 27. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 27.

28.) PI # 28 presented on 11/24/17 at 4:20 PM with chief complaints of status post stroke, in 21 day at rehab facility. No other complaints were documented. There was no documentation a triage assessment or MSE was completed for PI # 28. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 28.

29.) PI # 29 presented on 12/24/17 at 12:15 PM with chief complaints of body hurting. There was no documentation a triage assessment or MSE was completed for PI # 29. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 29.

30.) PI # 30 presented on 12/24/17 at 2:45 PM with chief complaints of needing prescriptions refilled. There was no documentation a triage assessment or MSE was completed for PI # 30. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 30.

31.) PI # 31 presented on 12/24/17 at 4:10 PM with chief complaints of arthritis pain and unable to walk. There was no documentation a triage assessment or MSE was completed for PI # 31. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 31.

32.) PI # 32 presented on 12/24/17 at 5:30 PM with chief complaints of painful toothache. There was no documentation a triage assessment or MSE was completed for PI # 32. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 32.

33.) PI # 33 presented on 12/26/17 at 9:20 AM with chief complaints of pain in left temporal area. The RN documented, "... Told pt other clinics open in area. Pt states will wait until tomorrow if (Physician's name) clinic remains closed... will see another physician..." There was no documentation a triage assessment or MSE was completed for PI # 33. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 33.

34.) PI # 34 presented on 12/26/17 at 2:45 PM with chief complaints of large amount of swelling in left forearm with redness and pain over mid arm. The RN documented having contacted a physician's office, spoke with a nurse and the patient was instructed to go to a clinic for evaluation. There was no documentation a triage assessment or MSE was completed for PI # 34. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 34.

35.) PI # 35 presented on 12/26/17 at 4:55 PM with chief complaints of headache all day, body aches which come and go. The RN documented, "...Pt states will follow up in AM with (physician's name)..." There was no documentation a triage assessment or MSE was completed for PI # 35. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 35.

36.) PI # 36 presented on 12/26/17 at 7:00 PM with chief complaints of upper airway congestion. The RN documented, "... Pt states will go to (name of city 32 miles away from Hill Hospital) tomorrow..." There was no documentation a triage assessment or MSE was completed for PI # 36. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 36.

37.) PI # 37 presented on 12/27/17 at 9:35 AM with chief complaints of upper respiratory symptoms. There was no documentation a triage assessment or MSE was completed for PI # 37. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 37.

38.) PI # 38 presented on 12/31/17 at 9:40 AM with complaints of back ache. There was no documentation of a triage assessment or MSE for PI # 38. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 38. PI # 38's information was documented on a "Nurse's Notes" along with 2 other patient identifier names.

39.) PI # 39 presented on 12/31/17 at 9:55 AM with complaints of runny nose and low grade fever. There was no documentation of a triage assessment or MSE for PI # 39. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 39. PI # 39's information was documented on a "Nurse's Notes" along with 2 other patient identifier names.

40.) PI # 40 presented on 12/31/17 at 3:30 PM with complaints of back ache. There was no documentation of a triage assessment or MSE for PI # 40. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 40. PI # 40's information was documented on a "Nurse's Notes" along with 2 other patient identifier names.

41.) PI # 41 presented on an undocumented date at 1:11 AM with chief complaint of alleged assault. There was no documentation a triage assessment or MSE was completed for PI # 41. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 41.

42.) PI # 42 presented on an undocumented date at 9:00 AM with chief complaint of chest pain. There was no documentation a triage assessment or MSE was completed for PI # 42. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 42.

43.) PI # 43 presented on an undocumented date at 9:00 AM with chief complaint of non-productive cough. There was no documentation a triage assessment or MSE was completed for PI # 43. There was no documentation of interventions, refusal of care by the patient or the disposition of PI # 4