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Based on review of medical records, video recording, facility protocol review, policy and procedure review and staff interviews it was determined the facility failed to inform the individuals of the risks and benefits to the individual of the examination and treatment, but the individual does not consent to the examination to the examination or treatment; and failed to ensure the medical record contained a description of the examination, treatment or both that was refused by the individual for 2 (#3 and #10) for 10 patients presenting to the emergency department with complaint of chest pain out of a total sample of 20 sampled medical records. Refer to findings in Tag A-2407.

Based on review of medical records, video recording, facility protocol review, policy and procedure review and staff interviews it was determined the facility failed to inform the individuals of the risks and benefits to the individual of the examination and treatment, but the individual does not consent to the examination to the examination or treatment; and failed to ensure the medical record contained a description of the examination, treatment or both that was refused by the individual for 2 (#3 and #10) for 10 patients presenting to the emergency department with complaint of chest pain out of a total sample of 20 sampled medical records.

The findings were:


1. Video recording patient #3
Review of the facility's video recording dated 08/14/18 revealed the following:
--9:11:00 Thirteen (13) people were observed sitting in the ED waiting room (WR) and a Registration Clerk (#3) is sitting at the front desk.
--9:11:06 Two (2) people leave the ED WR.
--9:11:19 A Security Officer (SO) enters and sits at the front desk and a female enters the ED. The female and three (3) people in the WR go and speak with the SO.
--9:11:46 Another female enters and stands at the front desk.
--9:11:55 Patient (#3) enters the ED, goes to the front desk, and speaks with the Registration Clerk (#3).
--9:12:44 The four (4) people speaking with the SO go into the Main ED and the female that was standing at the desk moves to speak with the SO.
--9:13:28 A bald male enters and goes to the desk with the patient (#3). A male nurse (#2) is observed in the ED triage room.
--9:13:36 Registration Clerk (#3) goes to speak with the nurse in triage (#2) right as the triage nurse steps out to call a patient from the WR.
--9:13:45 The patient (#3) and bald male go and sit down in the WR.
--9:14:00 The Registration Clerk (#3) and the triage nurse (#2) can be seen in the triage room.
--9:14:28 The triage nurse (#2) takes an adult and a child into the triage room.
--9:15:20 The bald male is observed on a cell phone, he then gets up and goes to speak with the Registration Clerk (#3).
--9:15:40 The bald male goes and sits back beside the patient (#3).
--9:15:52 The nurse (#1) goes and speaks with the triage nurse (#2).
--9:18:40 The patient (#3) and bald male go back to the nurse (#1). The nurse is observed checking the patient's pulse rate and talking to the patient (#3).
--9:20:01 The patient (#3) and bald male turn and leave the ED.

2. Medical Record Review Patient #3:
Review of the facility's EMTALA Log and the patient's medical record (#3) revealed the patient presented to the ED on 08/14/18 at 9:12 p.m. with complaints of tachycardic episode (rapid heart rate) and difficulty breathing. The medical record indicated that the patient's chief complaint was filed and triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting complaints and symptoms) was started at 9:14 p.m. by Registered Nurse (RN) #13. The patient was assigned a level three (3) acuity by RN #13 (review of the facility's video recording revealed RN #13 never physically laid eyes on the patient). RN #1 noted that the patient left without being seen (LWBS) and departed from the ED at 9:20 p.m. RN #1 also noted that the patient stated, "This is ridiculous, I shouldn't have to wait." There was no documented evidence that the nurse notified the ED physician, took a full set of vital signs (temperature [normal 97.8-99.1], pulse [normal 60-100], respirations [normal 12-18] , blood pressure (normal 90/60-120/80), and oxygen saturation [normal 95-100 is the amount of oxygen in the blood]), or that the nurse informed the patient of his/her risks of leaving prior to completing the MSE.


3. Medical Record Review Patient #10:
--Patient #10 presented to the ED on 03/07/18 at 8:39 p.m. with complaints of chest pain. There was no documentation of allergies or medical history, but the patient did have a history of knee reconstruction. At 9:06 p.m. the patient's disposition was listed as LWBS before triage. There was no documented evidence of the Chest Pain Protocol being entered into the facility's computer system or being initiated, of the patient's vital signs being taken, of the patient being triaged, of the physician being notified, or of the patient being informed of the risks of leaving without completing the MSE.

4. The following facility Protocols were reviewed:
A. --ED CHEST PAIN less than 35 YEARS OLD TRIAGE PROTOCOL (16000001), no date, revealed the following were to be performed STAT (immediate): EKG (electrocardiogram diagnostic test used to evaluate the heart rate and rhythm) to be shown to the ED physician upon completion, chest x-ray, BMP (basic metabolic panel - a blood test used to evaluate the kidneys, blood glucose level, electrolytes and acid/base balance), and Troponin T (blood test to evaluate for heart damage).
--ED CHEST PAIN greater than 35 YEARS OLD TRIAGE PROTOCOL (1605100013), no date, revealed the following were to be performed STAT: insertion of an IV (intravenous line), EKG to be shown to the ED physician upon completion, routine placement of the patient on cardiac (heart) monitor, oxygen at two (2) liters by nasal cannula, chest x-ray, BMP (basic metabolic panel - a blood test used to evaluate the kidneys, blood glucose level, electrolytes and acid/base balance), CBC with differential (complete blood cell count), Troponin T (blood test to evaluate for heart damage), and four (4) Aspirin 81 milligrams (mg) chewable tablets if the patient is not allergic to Aspirin, is not on a blood thinner or was administered an Aspirin prior to arrival, has active bleeding or a history of a bleeding disorder, or refuses the Aspirin.
--ED ABDOMINAL/FLANK PAIN TRIAGE PROTOCOL (16000010), no date revealed the following were to be performed STAT: insertion of an IV line, place the patient on strict NPO (nothing by mouth), notify the ED physician for IV fluids, anti-nausea, and pain medication orders, CBC and differential, urinalysis and if patient is unable to void within 30 minutes perform and in and out catherization to obtain the urine, urine pregnancy test on females over 8 years old and less than 60 years old unless the female has had a hysterectomy, and order blood pregnancy test if unable to obtain urine specimen. In addition, CMP (comprehensive metabolic panel - evaluates the kidneys and liver, electrolyte and acid/base balance as well as levels of blood glucose and blood proteins) and Lipase (perform essential roles in digestion, transport and processing of dietary lipids) were to be ordered for Upper Abdominal Pain, and CMP and Chem 8 (similar to BMP) were to be ordered for Lower Abdominal Pain.


5. The following facility Policies and Procedures were reviewed:

A. PATIENT LEAVING AGAINST MEDICAL ADVICE (AMA) POLICY, no number, effective date 06/05/01, last review/revision date December 2015, revealed it is the facility's policy to ensure that all patients indicating the desire to leave prior to the provider ' s final disposition will be asked to sign a form stating such; Against Medical Advice (AMA).

PURPOSE:
Establish criteria for documentation of patients leaving AMA.

PROCEDURE:
The nurse and/or provider shall discuss, with the patient and/or family the potential complications that may occur if the patient leaves prior to the provider discharging, admitting, or transferring the patient. If after explanation of potential consequences, the patient still wishes to leave AMA, request the patient or responsible party to sign the AMA form. The patient and/or responsible party are to be informed to follow up with their primary care provider or return to the ED if the condition worsens. Document in the electronic medical record the patient ' s desire to leave AMA, communication regarding potential complications, and the patient ' s condition prior to leaving the Emergency Department. In the event the patient leaves without notifying any staff member of leaving; the nurse shall disposition the patient as one of the following: LWBS: if the patient left before triage; LWOT: if the patient left after triage and before the MSE; Eloped: if the patient left after the MSE but prior to completion of treatment

C. EMTALA POLICY, no number, origination date and effective date 10/20/14, revealed the policy applies to the Hospital.
Purpose: The purpose of this policy is to set forth policies and procedures for Hospital ' s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). ..F. F. Refusal of Treatment
If the Hospital offers further examination and treatment and informs the individual or the person acting on the individual ' s behalf of the risks and benefits of the examination and treatment, but the individual or person acting on the individual ' s behalf does not consent to the examination and treatment, the Hospital must take all reasonable steps to have the individual or the person acting on the individual ' s behalf acknowledge their refusal of further examination and treatment in writing. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and/or treatment; the reasons for refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. Hospital personnel involved with the individual ' s care or witnessing the individual refusing consent must document the patient ' s refusal in the medical record.

Staff Interviews:

During an interview on 08/20/18 at 9:30 a.m. with the Registration Supervisor (#4). The Supervisor stated he/she has been at the facility for 15 years and has worked in the ED for two (2) of those years. The Supervisor explained that registration begins when the patient's social security number is entered into the electronic system. The Supervisor said that the system populates return patients' name, date of birth, and address into the system. The Supervisor said that if it is a patient's first visit, the Registrar has to enter the patient's name, date of birth, and address. The Supervisor stated patients' chief complaint is also entered into the system and that if the chief complaint is cardiac (heart) related the Registrar hands the triage nurse the patient's stickers (name, date of birth, and medical record number) and the nurse starts the cardiac protocol process. When asked what he/she would do for a patient complaining of "SVT" (supraventricular tachycardia - an abnormally fast heart rate arising from improper electrical activity in the upper part of the heart), the Supervisor stated that SVT sounded like something to do with the heart and that he/she would get the information to the nurse so that the nurse could start the cardiac protocol. The Supervisor said that not all staff would know that the acronym "SVT" is cardiac related. The Supervisor said that if a patient stated the chief complaint was supraventricular tachycardia 98% of the registration staff would know to notify the nurse so that the cardiac protocol could be initiated. The Supervisor stated all registration staff just completed EMTALA training. The Supervisor explained that the registration staff had until 08/04/18 to complete their annual EMTALA training and that he/she had checked to be sure that everyone had completed their training as required by the facility.

During an interview on 08/20/18 at 6:05 p.m. in the Conference Room, RN #1 explained that the patient (#3) was sitting across from the nurses' station with a gentleman. RN #1 said that the patient came to the desk and stated he/she needed to get into a room immediately and I (RN #1) asked the patient's name so I could look the patient up in the system. RN #1 said that the patient gave his/her name and I (RN#1) looked at the computer and saw that the chief complaint was tachycardia and shortness of breath. RN #1 explained that the pulse oximeter (measures the amount of oxygen in the blood and the heart rate) in triage was not working and was reading an error so I (RN #1) manually checked the patient's pulse. RN #1 said that he/she could not be sure but that he/she believes that the patient's pulse was 187 (normal 60-100). RN #1 said that he/she explained that the patient needed to go into the triage room for a full set of vital signs (temperature, pulse, respirations, blood pressure, and pulse oximetry) and an electrocardiogram (EKG - diagnostic test used to determine the heart rate and rhythm) and to let the mid-level provider or physician evaluate the patient. RN #1 said that the patient (#3) again asked for a room, and that he/she explained that there were no rooms available at the time. RN #1 said that he/she repeated the offer to get the patient into triage for an EKG, vital signs, and evaluation by the mid-level provider or physician. RN #1 said that the patient (#3) said that he/she wanted to go to another nearby facility. RN #1 said that he/she informed the patient (#3) that the patient did not need to leave the ED with an elevated heart rate and travel to the other hospital. RN #1 said that he/she offered the patient the option of continuing the MSE and the patient (#3) said he/she was leaving. RN #1 explained that during this time the ED was full and there was a patient in the hallway that had just been brought in by ambulance who was in severe respiratory distress. RN #1 said that he/she was covering the front desk and assisting an EMT (Emergency Medical Technician), Paramedic, and Charge Nurse (#13) with the patient in the hall, because the Respiratory Therapist who was assigned to the ED was busy with a c-section. RN #1 stated that the Paramedic had to get their BiPAP (bilevel positive airway pressure is used to help maintain the airway) off the ambulance. RN #1 said that night (08/14/18) was very busy and that there were a lot of high acuity patients in the ED. When questioned why he/she did not document the patient's pulse rate or that the patient was informed of the risks and benefits of leaving before completing the MSE, the nurse replied that he/she was busy and forgot to document on the patient. RN #1 added that later he/she was unable to document on the patient (#3) because he/she could not recall the patient's name. RN #1 stated that the facility's chest pain protocol is new and started March 2018 and that the facility's Epic (electronic system) started 02/28/18.

During an interview on 08/21/18 at 8:05 a.m. in the Conference Room, RN #2 explained that nurse (#1) was the first-tier triage and that nurse eyeballs the patient and obtains a pulse oximetry, and that he/she was the second-tier triage nurse that completes the triage process. RN #2 explained that the second-tier triage assessment includes obtaining: a complete set of vital signs, height, weight, asking the patient what their chief complaint is and if the patient can describe any signs and symptoms, and then to assign the patient to an ED bed. RN #2 said that on 08/14/18 the Registration Clerk (#3) let him/her know there was a patient that needed to be seen. RN #2 said that when he/she is informed that a patient has a cardiac issue, he/she completes the patient's triage and does an EKG. RN #2 explained that a patient with tachycardic could be assigned a higher acuity level and be seen ahead of other patients. RN #2 explained that there is no tachycardia protocol but if the patient had chest pain the patient would fall under the chest pain protocol. RN #2 said that he/she had no interaction with the patient (#3). RN #2 confirmed that he/she has had EMTALA training but was unsure of the training date. RN #2 said that if a patient decides to leave the nurse should document that the patient is leaving. RN #2 said that if he/she sees a patient leaving he/she would document whether the patient was steady or not or whether the patient appeared to be in any distress. RN #2 went on to say that if given the opportunity he/she would talk to the patient. RN #2 said that this happened last night (08/20/18). RN #2 explained that there was a fellow (patient #17) that came in with chest pain and after the EKG he said he was going to leave. RN #2 said that he/she asked the patient (#17) if he was sure because he still had the complaint and needed to be seen by the doctor. RN #2 said he/she didn't think the risk and benefits of leaving without completing the MSE were explained to the patient. RN #2 stated that the night shift is usually busy. RN #2 said that last night at the beginning of his/her shift there were three (3) patients in the ED with a couple of empty ED beds and within 1.5 to 2 hours the ED was full and there were 15 patients in the waiting room. RN #2 said that the ED is often understaffed on the night shift. RN #2 said that he/she did remember that the first-tier triage nurse (#1) was working with a patient in the hall and that they ended up intubating (tube inserted into the airway for mechanical ventilation) the patient. RN #2 said that he/she has worked at the facility in the ED for 14 years and that usually there are three (3) Respiratory Therapists covering the hospital on the night shift.

During an interview on 08/21/18 at 9:10 a.m. in the Respiratory Department, the Director of Respiratory Services (#14) explained that the facility is staffed with four (4) Respiratory Therapists on days and three (3) on nights. The Director explained that in the winter when there are more respiratory issues the staffing is increased to five (5) therapists on days and four (4) on nights and adjusted as needed. The Director confirmed that the therapists are scheduled on days from 7:00 a.m. to 7:00 p.m. and then on the night shift from 7:00 p.m. to 7:00 a.m.

During an interview on 08/21/18 at 11:10 a.m. in the Conference Room, Registration Clerk (#3) reviewed the facility's video dated 08/14/18. The Registration Clerk (#3) said that the patient (#3) knew his/her diagnosis and said that it was a heart issue. The Registration Clerk said that the triage nurse (#2) had someone in triage when the patient (#2) arrived. The Registration Clerk (#3) said that usually the triage nurses will speed up when informed that a patient has arrived with chest pain. The Registration Clerk said that the bald male came up and said that the patient was having chest pain and that he/she let the nurse know. The Registration Clerk said that the patient cursed and said "kiss my a** and left because the patient didn't think we were moving fast enough. The Registration Clerk said that he/she did not recall anyone explaining the risk and benefits of leaving without completing the MSE to the patient. The Registration Clerk confirmed that he/she has had EMTALA training, and that he/she has worked at the facility for 12 years and the EMTALA training is provided annually.