HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure the triage nurse categorized the ESI level as per the hospital's P&P for two of 20 sampled patients (Patients 2 and 3). This failure had the potential to result in poor clinical outcomes and serious adverse events for the patients in the ED.

Findings:

Review of the hospital's P&P titled Triage dated December 2016 showed the following:

* The Emergency Severity Index 5-tier Triage System categorizes Emergency Department patients by acuity and expected resources needed. Acuity is determined by using the patient's vital signs and potential for life, limb or organ threat. Resources are defined as the number of resources or interventions a patient is expected to need to reach a disposition.

* Triage Level One (Emergent) requires immediate life-saving intervention (such as cardiac arrest, respiratory arrest, overdose, critically injured trauma patient).

* Triage Level Two (Urgent): High Risk Situation (such as unstable patient, severe pain or distress, behavioral emergency, ALOC).

* Triage Level Three (Potentially Unstable): Requires 2 or more resources and VS may not be in "Danger Zone." If VS are in the "Danger Zone," then this patient should be upgraded to an ESI level of Two as per the ESI algorithm. (An example of ESI Level Three may be a patient with acute abdominal pain or frank pain indicating kidney stones).

1. Review of the hospital's P&P titled Stroke Management dated September 2021 showed the activation of Code Stroke occurs when any patient exhibits signs or symptoms of a stroke or TIA. The P&P also showed Code Stroke is the emergent process for recognition and treatment of acute stroke patients who either present to the hospital within 6 hours of onset of symptoms.

On 5/13/25, Patient 2's closed medical record was reviewed.

Patient 2's closed medical record showed Patient 2 arrived at the ED on 5/12/25 at 0308 hours and was admitted to the hospital on 5/12/25 at 2029 hours.

Review of the Patient Care Timeline dated 5/12/25, showed the following:

* At 0321 hours, the code stroke was activated.
* At 0322 hours, Patient 2 was moved to CT.
* At 0332 hours, Patient 2's ESI level was 3.

On 5/13/25 at 0933 hours, an interview and concurrent medical record review was conducted with the ED Director. When asked, the ED Director stated Patient 2's ESI level should have been at least 2.

2. On 5/12/25 at 0820 hours, the ED Triage area was toured with RN 1. When asked, RN 1 stated that RN 1 was assigned to be a triage nurse today. When asked, RN 1 stated the ESI level would be determined based on ESI Algorithm posted on the wall in the triage area.

Review of the ESI Algorithm showed the following:

* ESI level 1 requires immediate life-saving intervention.
* ESI level 2 would be for patients who were in a high-risk situation, confused/lethargic/disoriented, or in severe pain/distress.
* ESI level 3 would be for patients needing many different resources. If patients with ESI level 3 had danger zone vitals (for example, HR >100 beats per minute or RR >20 breaths per minute, SaO2 <92% for patient's older than 8-year-old), then an ESI level 2 would be considered.

On 5/12/25 at 0840 hours, Patient 3 was observed arriving at the ambulance bay. RN 1 was observed receiving a report from the EMT.

On 5/13/25, Patient 3's medical record was reviewed.

Patient 3's medical record showed Patient 3 arrived at the ED on 5/12/25 at 0854 hours and was admitted to the hospital on 5/12/25 at 2310 hours.

Review of the Patient Care Timeline dated 5/12/25 showed the following:

* At 0854 hours, Patient 3's arrival complaint was shortness of breath.
* At 0855 hours, Patient 3's heart rate was 127 beats per minute and the respiration rate was 30 breaths per minute.
* At 0859 hours, RN 1 documented Patient 3 needed "Many" different resources. RN 1 documented Patient 3 did not have danger zone vitals. RN 1 documented Patient 3's ESI level was 3.

On 5/13/25 at 0933 hours, an interview and concurrent medical record review was conducted with the ED Director. When asked, the ED Director stated Patient 3's ESI level should have been at least 2 because Patient 3's vitals were in the danger zone.

Based on observation, interview, and record review, the hospital failed to ensure the signage for EMTALA rights with respect to the examination and treatment for EMC and women in labor were posted conspicuously in the ED areas as evidenced by:

* Failure to ensure the EMTALA signage was posted in the ED's triage area.

* Failure to ensure the EMTALA signage was posted in the ED's treatment rooms/bays.

* Failure to ensure the EMTALA signage was posted in the ED's obstetric treatment room.

These failures had the potential to result in individuals not being aware of their rights to the examination and treatment in the event of an EMC.

Findings:

Review of the hospital's P&P titled EMTALA Transfer Policy reviewed May 2024 showed under Signage, Hospital shall post signs conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by CMS that specifies the rights of individuals to examination and treatment for emergency medical conditions. Signs shall be posted in the Emergency Department, Labor and Delivery, ambulatory clinics and other locations where patients may present for emergency services.

On 5/13/25 at 0910 hours, the hospital's ED was toured with the ED Director. There was no EMTALA signage posted in the ED triage area, treatment rooms/bays 3,4,5,6,7, and 11, and the obstetric treatment room (room 10).

In a concurrent interview, the ED Director verified and acknowledged the findings.

On 5/13/25 at 1210 hours, a conference was held with the Chief Executive Officer, Chief Nursing Officer, and the ED Director. They were notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the ED central log included all the items as per the hospital's P&P. This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED for treatment for an emergency medical condition.

Findings:

Review of the hospital's P&P titled EMTALA Compliance: Emergency Medical Treatment and Active Labor Act dated December 2024 showed each department of the hospital that provides medical screening examination shall maintain a central log recording the following:

a. Patient's name
b. DOB
c. Sex
d. Chief complaint
e. Arrival time
f. Triage time
g. Registration time
h. MSE time
i. Medical record/Account number
j. Mode of arrival
k. Name of LIP who provided MSE
l. If admitted Name of admitting LIP
m. Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged.

On 5/12/25 at 1027 hours, an interview and concurrent record review was conducted with the ED Director. Review of the hospital's ED central log showed the patient's name, MRN, admission date and time, physician's name if admitted, and point of origin. However, the log did not show the DOB, sex, chief complaint, arrival time, triage time, registration time, MSE time, and name of LIP who provided MSE.

On 5/13/25 at 1210 hours, the CNO and ED Director verified the above findings.