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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-(i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Based on observations, interviews and document reviews, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a registered nurse (RN) conducted the patient triage assessment, assigned the emergency severity index (ESI) score and provided nursing oversight for the care provided by a licensed practical nurse (LPN) for three of twenty patients reviewed (Patient #1, #4 and #17). Additionally, the facility failed to ensure patients who were triaged had repeat vital signs and pain assessments performed hourly for three of twenty patients reviewed. (Patient #7, #8 and #16)

Based on observations, interviews and document reviews, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a registered nurse (RN) conducted the patient triage assessment, assigned the emergency severity index (ESI) score and provided nursing oversight for the care provided by a licensed practical nurse (LPN) for three of twenty patients reviewed (Patient #1, #4 and #17). Additionally, the facility failed to ensure patients who were triaged had repeat vital signs and pain assessments performed hourly for three of twenty patients reviewed. (Patient #7, #8 and #16)

Facility findings:

Facility policies:

The EMTALA policy read, the hospital will provide an appropriate MSE within the capability of the hospital's dedicated ED, including ancillary services routinely available to the dedicated ED, to determine whether or not an emergency medical condition (EMC) exists. The MSE will be performed by a physician or a Qualified Medical Person (QMP) as designated by Medical Executive Committee and the governing body. If determined that the individual has an EMC, the hospital will provide further medical examination and treatment as required to stabilize the EMC, within the capability of the hospital.

The MSE is an ongoing process. The medical record must reflect an ongoing assessment of the patient's condition. Monitoring of the individual must continue until the individual is stabilized. There should be evidence of this monitoring and the MSE must be documented in the electronic health record (EHR). Medical records should contain documentation of all medically indicated screenings, tests, mental status, impressions, and diagnoses (supported by a history & physical (H&P), laboratory and other tests)

An EMC is defined as a medical condition manifesting itself with acute symptoms of sufficient severity such that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy and result in serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part. To stabilize an EMC is defined as providing medical treatment of the EMC to assure, within reasonable medical probability, that no material deterioration of the individual is likely to result from the EMC or the EMC has been resolved.

A MSE is defined as the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Initial triage is not considered a MSE. The MSE represents a spectrum ranging from a brief history and physical examination to complex processes that also involve performing ancillary studies and procedures.

The Orders for Patient Care policy read, the purpose of the policy was to define who may give and receive patient care orders. Orders may be generated from physician-approved Pre-Printed Order Sets (PPO) and Protocols.

Protocols designated to protect critical patients from treatment delays or gaps in medical care may be initiated without prior approval from physicians and/or qualified licensed independent practitioners (LIP) when applied in a very limited and focused manner. ED Protocols may be initiated without the prior approval or notification of a physician/LIP. ED Protocols orders will be authenticated by the ED physician/LIP responsible for the care of the patient. When conditions are met for the use of protocols, nurses will open the Protocol in the EHR and select the applicable orders as directed by the protocol and enter them into the EHR. Protocols give nursing specific parameters for the management of a patient's condition based on objective, measurable criteria.

The Stroke Alert policy read, the evaluation and treatment of patients with stroke symptoms is a priority. A Stroke Alert expedites the evaluation and treatment process for acute stroke patients. The rapid diagnosis and differentiation between a hemorrhagic and ischemic stroke is needed to expedite timely and appropriate treatment for the patient. Signs and symptoms of both an ischemic and hemorrhagic stroke may include the sudden onset of a severe headache with no known cause.

References and National Guidelines:

The Critical Care Tech (CCT) Job Description read, the CCT performs direct and indirect patient care in collaboration with the registered nurse (RN) or Physician. The CCT assumes responsibility and accountability for facilitating, communicating and collaborating with the team to meet the physical and emotional needs of the patient. The CCT orders, receives and stocks supplies for the ED department/unit. The CCT assists support staff with filing, medical records and daily tasks as assigned.

The job responsibilities (essential functions) of the CCT are: Communicating with RNs and Physicians regarding patient/family observations in an ongoing fashion to assist in treating patients. Communicates concerns regarding hazards or errors related to patients to the health care team. Demonstrates effective use of clinical strategies to ensure patient and associate safety. Uses Situation, Background, Assessment, and Recommendation (SBAR) communication techniques. Communicates with colleagues and allied personnel regarding patient care to maintain continuity of care between departments and care providers. Uses standards of care, hospital policies/procedures and regulatory guidelines to guide work.

The Licensed Practical Nurse (LPN) job description read, the LPN performs patient observations, data collection and the administration of medication, treatments and procedures. The LPN implements the plan of nursing care and communicates patient findings to the supervising RN. The LPN will use the nursing process in accordance with patient care standards, and the State Nurse Practice Act. The job responsibilities (essential functions) of the LPN are: Reassessment of the patient's physical, psychosocial, cultural and spiritual needs through observation, interview, medical record review and clinical data collection. The LPN evaluates patient response and will intervene when needed to ensure optimal patient outcomes. The LPN will report patient findings to the supervising RN.

The Triage: The Emergency Severity Index (ESI) read, triage determines the severity of illness or injury for each patient and determines the patient's priority of care based on physical, developmental, and psychosocial needs. The purpose of emergency department triage is to prioritize incoming patients and to identify those patients who cannot wait to be seen and based on the patient assessment, the RN will assign an ESI score to the patient. Patient triage identifies patients who require immediate care and determines the appropriate area of treatment needed for the patient. Triage is legally an RN's responsibility. Triage should start the moment a patient enters the ED. All patients in the waiting room need to be reassessed every hour.

As defined per the Triage: ESI: Patients with an extreme illness or injury who might die or deteriorate if not treated immediately or who require immediate, aggressive interventions and are assigned an ESI score of 1. Patients who present with a serious illness, injury or medical conditions which pose a potential threat to life, limb, or function and who may deteriorate or suffer long-term problems without urgent attention and require rapid medical intervention or treatment are assigned an ESI score of 2. Patients with medical conditions that could progress to a serious problem requiring emergency intervention and/or experiencing an illness or injury which is not immediately life-threatening yet needs to be treated fairly urgently are assigned an ESI score of 3. Situations and symptoms which are considered high risk for patients are: active chest pain, signs of a stroke, and symptoms related to airway, breathing and circulation (ABC). Patients with symptoms of chest pain such as crushing, constant pain or pressure, diaphoresis and shortness of breath require the following immediate interventions: Urgent electrocardiogram (a medical procedure performed to quickly detect heart problems and monitor the heart), the goal is door-to-doctor of 10 minutes. Defer triage and transport the patient to the electrocardiogram (EKG) room immediately and notify ED Charge RN and physician of the patient's symptoms.

The ESI, Version 4 Implantation Handbook read, the ESI is the rapid identification of patients that need immediate attention. The RN determines patient acuity (a measure of a patient's illness severity and medical condition) based on a brief triage assessment and will rapidly and accurately triage patients. Once an ESI triage score is assigned, the patient can be directed to a more complete patient assessment, registration, initial treatment, or waiting based on their acuity and their presumed resource needs.

1. The facility failed to ensure a qualified nursing staff performed patient triage assessments (a rapid clinical assessment performed to determine the severity and immediacy) and assigned ESI scores. Furthermore, the facility failed to ensure repeat vital signs and pain assessments were performed for patients waiting to be seen by a medical provider to determine if an EMC existed.

A. Patients received triage assessment and ESI scores by other ED staff who were not RNs.

a. Record review for Patient #1, Patient #4 and Patient #17 revealed the triage assessment was not performed by a RN but instead by a LPN.

Examples include:

i. On 7/5/22 at 5:30 p.m., Patient #4 presented to the ED with a chief complaint of shortness of breath and muscle pain. According to facility protocol, the patient should have received an electrocardiogram (EKG) within 10 minutes of arrival.

At 5:34 p.m. LPN #4 performed Patient #4's ED triage assessment and later assigned Patient #4 an ESI score of 3. At 9:14 p.m., three hours and 40 minutes after Patient #4 was triaged, an EKG was performed and it was determined the patient had a myocardial infarct (heart attack).

ii. On 5/22/22 at 9:07 a.m., Patient #1 presented to the ED. According to the ED Care Timeline at 9:16 a.m., the triage assessment was performed at 9:18 a.m., an ESI score of 2 was assigned to Patient #1 by an LPN.

This was in contrast to facility processes which required patient triage to be performed by a RN.

iii. On 3/15/22 at 3:57 p.m., Patient #17 presented to the ED. At 4:03 p.m., an LPN performed the triage assessment and assigned Patient #17 an ESI score of 3.

This was in contrast to facility processes which required patient triage to be performed by a RN.

iv. On 7/21/22 at 12:33 p.m., an interview was conducted with Clinical Nurse Manager (CNM) #1 of the ED. CNM #1 stated the ED Triage Nurse performed the triage assessment for patients who present to the ED. CNM #1 stated an LPN performed initial patient triage assessments and assigned ESI scores to patients based on the patients presenting signs and symptoms. CNM #1 stated there was no nursing oversight or supervision review for triage assessments and ESI scoring conducted by an LPN. CNM #1 stated the job description for LPNs did not require nursing supervision for the LPN. Furthermore, CNM #1 stated the triage assessment and ESI scoring performed followed the recommended guidelines from the ESI, Version 4 Implantation Handbook.

This was in contrast to the Triage: ESI process, the ESI, Version 4 Implantation Handbook and the LPN job description as outlined above.

B. Patients did not have repeat vital signs and pain assessments hourly while waiting to be seen by a medical provider to determine if an EMC existed.

a. Medical record reviews for Patient #7, #8 and #16 revealed patients waited greater than 60 minutes for a MSE with no evidence of patient reassessments as required per protocol.

Examples include:

i. On 5/11/22 at 7:25 p.m., Patient #16 presented to the ED. At 9:55 p.m., two hours and 20 minutes after Patient #16 arrived, Patient #16 left without being seen (LWBS).

On review of the medical record there was no evidence Patient #16's had an initial set of vital signs or reassessment of the vital signs or pain performed hourly as required.

ii. On 6/15/22 at 2:42 p.m., Patient #8 presented to the ED with complaints of shortness of breath, blurry vision, sweating, confusion/forgetfulness. On review of the medical record, there was no evidence nursing staff performed a reassessment of vital signs or pain while in the waiting room.

iii. Review of Patient #7's medical record revealed at 11:17 a.m., RN #5 assessed Patient #7's vital signs, pain level and acuity level. The ED Care Timeline for Patient #7 revealed Patient #7's blood pressure (BP) was elevated and Patient #7 was in extreme pain. Subsequently, Patient #7 was assigned an ESI score of 2 by RN #5.

At 1:57 p.m., four hours and 25 minutes after Patient #7 arrived in the ED, RN #5 documented multiple attempts were made to locate Patient #7 within the ED waiting room and in the area located outside the ED, but Patient #7 was unable to be located.

Further review of Patient #7's medical record revealed a lack of ongoing patient assessments and monitoring after the initial triage assessment was performed.

These were in contrast to the facility EMTALA policy and the Triage: The ESI process.

According to the EMTALA policy, the patient's medical record would reflect continued ongoing assessments. Monitoring of the patient will be performed until the patient has been stabilized. There should be evidence of patient assessments and monitoring in the medical record in addition to any medically indicated screenings and tests.

According to the Triage: The ESI reference, patients with serious illness, injury or medical conditions which threaten life, limb, or organ function and require urgent and rapid medical attention and intervention were assigned an ESI score of 2.

b. Interviews were conducted with staff and revealed an initial vital sign and pain assessment were performed for the patient during triage and staff were unaware additional vital sign and pain assessments needed to be performed for patients waiting greater than 60 minutes.

i. On 7/20/22 at 5:12 p.m. an interview was conducted with RN #6. RN #6 stated the RN was expected to perform the triage assessment while the CCT checked the patient's vital signs. RN #6 stated the RN would record the vital signs and pain assessment in the patient's electronic health record (EHR). RN #6 stated after the RN performed the triage assessment the patient would be placed in an ER room or placed in the waiting room. RN #6 stated patients placed in the waiting room had vitals and pain assessments performed every two hours by the CCT. RN #6 stated the RN would "lay eyes on" (perform a visual observation) triaged patients waiting to be seen by a QMP.

ii. On 7/19/22 at 5:10 p.m., an interview was conducted with CCT #7. CCT #7 stated patient vital signs were performed by the CCT. CCT #7 stated the RN instructed the CCT on when to perform repeat vitals for patients. CCT #7 stated the CCT would not perform repeat vital sign checks unless instructed to.

These interviews were in contrast to the Triage: ESI process which read, vital signs and pain assessments would be performed every hour for patients in the waiting room.