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Based on review of clinical records, review of policies and procedures/documentation and staff interviews, it was determined the hospital failed to enforce compliance with all requirements of CFR 489.24 including the responsibilities to provide an appropriate medical screening examination within the capability of their emergency department.

Tag A2406: The hospital personnel
1. failed to follow their policies and procedures that require patients be rapidly assessed and triaged to determine patient acuity, need for immediate physical or psychosocial needs, and the order in which they would be provided with a Medical Screening Examination (MSE) by a physician or qualified medical practitioner (Patients #2, 19, and 23); and

2. failed to follow their policies and procedures that require patients receive a MSE after they were triaged. The hospital personnel allowed the patients to leave ED, after the hospital was aware the patients were there seeking emergency services, without the hospital explaining the risks of leaving the ED prior to receiving the examination (Patients #18).

For a total of 4 out of 23 patient records reviewed who went to the hospital's Emergency Department seeking care (Patients #2, 18, 19, and 23).

The cumulative effect of this systemic problem has the potential for adverse outcomes for patients who presented with what the patient's felt were signs and symptoms that may need emergency care to ensure health and safety.

Based on reviews of hospital policies and procedures, patient record reviews, and staff interviews, it was determined for 4 of 23 patients who presented to the hospital's Emergency Department seeking emergency services (Patients #2, 18, 19, and 23), the hospital:

1. failed to follow their policies and procedures that require patients be rapidly assessed and triaged to determine patient acuity, need for immediate physical or psychosocial needs, and the order in which they would be provided with a Medical Screening Examination (MSE) by a physician or qualified medical practitioner (Patients #2, 19, and 23); and

2. failed to follow their policies and procedures that require patients receive a MSE after they were triaged. The hospital personnel allowed the patients to leave ED, after the hospital was aware the patients were there seeking emergency services, without the hospital explaining the risks of leaving the ED prior to receiving the examination (Patient #18).

Findings include:

The Hospital's policy titled Emergency Medical Treatment and Active Labor Act (EMTALA) and Direct Admission Procedure included: "III. DEFINITIONS...Medical Screening Examination (MSE): is a non-discriminatory process required to determine within reasonable confidence whether an Emergency Medical Condition (EMC) does or does not exist and whether a woman having contractions is in need of immediate medical attention...Emergency Medical Condition (EMC): means a medical condition manifesting itself by acute symptoms of sufficient severity...Triage: Is a sorting process to determine the order in which individuals are provided a Medical Screening Examination by a physician or QMP. Triage is NOT the equivalent of a Medical Screening Examination and does not determine the presence or absence of an Emergency Medical Condition...IV. PROCESS: Medical Screening Examination (MSE): The hospital provides an MSE to any person who 'comes to the hospital', regardless of person's financial status or ability to pay. The MSE is an ongoing process and must be done within the facility's capabilities (e.g., equipment and other technical resources) and the availability of QMP (Qualified Medical Person)...If the individual refuses the examination or treatment, the physician or QMP advises the individual or legally responsible person of the risks of refusal. Document the refusal and risks in the medical record."

The Hospital's policy titled Triage, Assessment and Reassessment in the Emergency Services Setting, included: "'Quick Look' and comprehensive triage are assessments that include a rapid and systematic collection of data relevant to each patient's chief complaint, age, cognitive level, and social situation. The assessment is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychosocial needs...Triage facilitates the flow of patients through the emergency care system, ensuring a timely evaluation and plan of care based on the health care needs of the patient...Triage Acuity Levels are assigned to all patients presenting to the Emergency Department according to the guidelines outlined in this policy. Periodic reassessments are performed on all ED patients...Patients presenting to the Emergency Services setting are rapidly assessed and triaged to deliver appropriate medical and nursing care based on the patient's chief complaint and acuity level. Reassessments are based on the seriousness of the injury or illness. Patients are assigned an acuity level based on assessment findings...Based on EMTALA policy, all patients who come to the ED/EC seeking health care will be: Offered a Medical Screening Exam...Emergency Severity Index, Version 4 (ESI): Triage tool used for triage acuity assessment, shown to be reproductive, utilizing five category levels for patient acuity being (1) immediate life-saving intervention required-resuscitation, (2) High risk situation-emergent, (3) Urgent, acknowledging needed resources and danger zone vital signs, (4) Non-urgent needing one resource, (5) Non-urgent needing no resources/referable...ESI Level 1: Immediately place into a patient room. ESI Level 2: Contact the Patient Placement Registered Nurse or Charge RN for bed placement assignment. If no bed is available, the patient may be placed in an alternative department holding area where he/she can be observed, reassessed, triage protocols initiated if applicable and medical screening examination performed as indicated by patient's condition. ESI Level 3: Patient may be placed in the waiting room and periodically reassessed while waiting for room placement and medical screening examination...Reassessment refers to patients' who have been previously assessed and will receive periodic reassessments while in waiting areas or treatment areas based on chief complaint, presenting signs and symptoms, pain level and interventions initiated according to protocols...." Patients presenting to the Emergency Services setting are rapidly assessed and triaged to deliver appropriate medical and nursing care based on the patient's chief complaint and acuity level. Reassessments are based on the seriousness of the injury or illness. Patients are assigned an acuity level based on assessment findings...Based on EMTALA policy, all patients who come to the ED/EC seeking health care will be: Offered a Medical Screening Exam...."

A tour of the hospital's Emergency Department was conducted on 8/01/2011 with the Interim Director of the ED. The Interim Director reported that patients coming into the main ED Entrance went to the reception area and completed an ED Patient Sign-In Form that included the date and time of arrival, mode of transportation, and reason for visit. The form was then given to a Registered Nurse whose responsibility was to triage the patient and assign an acuity level.

1. Patient #2 went to the ED on 4/19/2011 at 4:53 p.m., and documented on the ED Patient Sign-In Form in the section Reason for Visit: "Im almost 6 months pregnant and I'm having really bad pains in my abdomen." Documentation on the bottom of the form revealed the first time the patient was called from the waiting room to be triaged was at 5:50 p.m., almost one hour after she arrived and there was no response. The patient had left. The patient was called again at 6:05 p.m., and there was still no response. There was no documentation that the patient was assessed to determine the triage category. There was no documentation of the patient's vital signs or assessment of the status of the unborn child. There was no documented evidence that the patient's chief complaint was evaluated "rapidly" as stated in the hospital policy and procedure.

The Interim Director of the ED reported during an interview on 8/3/2011, that it was the Hospital's practice and expectation that triage assessments be completed within 15 minutes of a patient's arrival to the ED and was not aware of a reason for the delay.

-Patient #19 went to the ED on 7/29/2011 at 2:10 p.m., and documented on the ED Patient Sign-In Form in the section for Reason for Visit: "severe pain on right abdomen and lower back, possible kidney stones." Documentation on the bottom of the form revealed the patient was not called from the waiting room to be triaged until 3:20 p.m., over one hour later at which time she had left. The patient was called a second time at 3:43 p.m., and again there was no response. There was no documentation that the patient was assessed to determine the triage category. There was no documentation of the patient's vital signs and/or pain level. There was no documented evidence that the patient's chief complaint was evaluated "rapidly" as stated in the hospital policy and procedure.

The Interim Director of the ED stated during an interview on 8/03/2011, that there was no documentation in the clinical record that the patient was triaged or received a medical screening examination. She reported she was not aware of the reason why the patient was not called for triage for over one hour.

-Patient #23, a pediatric patient, was taken to the ED on 6/25/2011 at 6:53 p.m. Documentation on the ED Patient Sign-In Form in the section for Reason for Visit included: "complaining of chest pain & fever she says it feels like something is poking her in her chest. father has S.V.T." Documentation at the bottom of the form revealed the patient was not called from the waiting room to be triaged until 8:40 p.m., almost two hours later. The patient was called again at 10:05 p.m. with no response. There was no documentation that the patient was assessed to determine the triage category. There was no documentation of the patient's vital signs to include fever and/or pain level. There was no documented evidence that the patient's chief complaint was evaluated "rapidly" as stated in the hospital policy and procedure.

The Interim Director of the ED acknowledged during an interview on 8/4/2011, that the patient was not triaged and did not receive a MSE.

These patients presented to the emergency department requesting emergency services by signing in as required by the hospital, were not triaged as a hospital required procedure and we not assessed to determine if there was an emergency medical condition.

2. Patient #18 went to the ED on 7/30/2011 at 2:55 a.m. Documentation in the ED record revealed the patient was triaged at 3:16 a.m. by a Registered Nurse (RN). The RN documented the patient's chief complaint was: "I'm scared pt vauge (sic) not wanting to answer questions restless falling refusing to answer states he will come back denies ETOH (alcohol) denies SI or HI (suicidal ideation/homicidal ideation)...." The patient's vital signs were documented to be as follows: Blood Pressure: 174/116; Heart Rate: 109 beats per minute; and Respiratory Rate: 22 breaths per minute. The patient's temperature was not recorded. The patient was assigned an Emergency Severity Index (ESI) Acuity of "2-Emergent" and sent back to the waiting room. The RN documented at 4:46 a.m., one and one-half hours later: "pt notanswering (sic) when called then pt's partner brings pt to window states pt took 50 tablets of bendryl (sic) at 0300 (3 a.m.)." The patient was then taken back to a treatment room. The documentation revealed an ED physician was assigned to the patient at 5:23 a.m. whose Emergency Documentation included: "Shortly after the patient's chart had been placed into the rack, I went to see him in room 35. Upon coming into the room, the room was empty, it appeared that the patient had eloped from the room. Earlier, his nurse had determined that he had no SI or HI and that there have been grounds to hold him against his will or have security standby...."

There was no documentation in the ED record that the patient's vital signs were rechecked after the first set was obtained at 3:16 a.m. and were abnormal, and this ESI 2-Emergent patient was sent back to the waiting room for one and one-half hours before being called again. The hospital policy and procedure requires the patient be taken to the treatment area with and ESI of 2 or contact be made with the team to obtain a bed for the patient so that care can be initiated. Although the triage RN documented at 3:16 a.m. that the patient "denies SI or HI," she documented at 4:46 a.m. that the patient's partner reported the patient had taken 50 tablets of Benadryl at 3 a.m.

The Interim Director of the ED acknowledged in an interview on 8/03/2011, there was no documentation that the ESI 2-emergent patient's vital signs were rechecked.

The patient was not seen by a physician to complete the medical screening examination on a patient whose companion had reported the patient took 50 Benadryl tablets while waiting in the hospital emergency department. The outcome of the patient is unknown at this time.