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Based on record reviews and interviews, the hospital failed to include each patient on the emergency log who came to the emergency department (ED) seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, received stabilizing treatment and transferred, or discharged for 4 of 8 patients reviewed who were listed on a hand-written log of patients who presented to the ED for a medical screening examination (MSE) but did not receive a MSE from a total of 24 patients (#3, #22, #23, #24). Findings:

Review of the hospital policy titled "Log Book, ED Patient Log", presented as the current policy by S1CEO (Chief Executive Officer), revealed that the ED Log was the responsibility of the ED Clerk. Further review revealed for LWBS (left without being seen), AMA (against medical advice), or Desertion patients only information from the chart should be typed in the corresponding fields, and typing information such as "AMA" should not be added.

Review of the computerized ED log of patients who presented to the ED revealed no documented evidence of the names and logged information for Patients #3, #22, #23, and #24.

Review of the form titled "Emergency Department Log Book), presented by S3ED Manager as the list of patients who present to the ED for a MSE but leave before the registration process occurs, revealed the following information:
1) Patient #22 presented on 10/25/12 at 9:15 a.m. with complaints of stomach pain. He had a pulse of 85, respirations 22, oxygen saturation 96% (per cent), and a steady gait. Further review revealed when Patient #22 was told who the ED doctor was, Patient #22 pulled off his blood pressure cuff, said he was not staying, and refused to sign a consent for refusal of treatment. There was no documented evidence of a nursing record completed by the triage nurse.
2) Patient #23 presented to the ED on 05/31/13 at 6:50 p.m. with complaints of abdominal pain for 21 days and unable to eat. Her blood pressure was 140/102, pulse 72, respirations 20, temperature 97.7 degrees Fahrenheit, and oxygen saturation 100%. She rated her pain as 10 out of 10, and her skin was warm, pink, and dry. She was in no acute distress and was awake, alert, and oriented times 3. Further review revealed when she was called to register, Patient #23 was no longer in the lobby or on the ED ramp. There was no documented evidence of a nursing record completed by the triage nurse.
3) Patient #24 presented to the ED on 09/15/13 at 7:13 p.m. with complaints of a lip laceration. Further review revealed Patient #24 had no active bleeding, her skin was warm and dry, and her respirations were even and unlabored. Further review revealed when she was called to register, Patient #24 was no longer in the lobby or on the ED ramp. There was no documented evidence of a nursing record completed by the triage nurse.
4) Patient #3 presented to the ED on 09/19/13 at 6:52 a.m. by ambulance. Further review of documentation by S5ED RN (registered nurse) revealed he was a 59 year old male who was struck by a vehicle while riding his bike and initially had a loss of consciousness. Further review revealed his Glasgow Coma Score (GCS) was 15, blood pressure 156/63, pulse 92, and respiration 16. Further review revealed "immediately after hanging up LERN (Louisiana Emergency Response Network) called with accepting physician @ (at) Hospital A ED... (physician at Hospital A's ED) was then called to get an idea of any specific interventions needing to be performed prior to transfer, Reports if GCS 15 (with) stable vitals & (and) clear, equal BS (breath sounds) OK to transfer pt (patient) (with) large bore PIV (peripheral intravenous line). While on phone (with) MD (medical doctor) pt. entered ED on stretcher AAOx4 (awake, alert, oriented times 4), no complaints, lungs clear & equal bilaterally, GCS 15, vitals stable. S8Chief of Staff (ED physician but not physician on duty) and (physician at Hospital A's ED) reports OK to send pt. to Hospital A @ this time..." There was no documented evidence of a nursing record completed by the triage nurse or a MSE performed by an ED physician.

In a face-to-face interview on 09/25/13 at 4:05 p.m., S3ED Manager indicated that every patient who comes to the ED and requests to see a physician is logged on the computerized ED log. She further indicated if a patient requested to leave while being triaged before the registration process began, the patient was not logged, and the patient would sign a refusal of treatment form. When asked the difference between this scenario and a patient who is triaged, taken to a room, and leave before seeing the physician but is logged on the computerized ED log, S3ED Manager answered that in the first example the patient was not registered. She indicated that patients brought by ambulance come to the hospital with the intent for the patient to be seen by the physician and should go through the same process. When given the example of Patient #3, S3ED Manager indicated the ambulance brought the patient to the ED, because the patient wanted to come, and he should have been seen by the physician.

In a face-to-face interview on 09/26/13 at 11:25 a.m., S3ED Manager indicated that the hand-written "Emergency Department Log Book" was used to document patients who came to the ED and triaged and then left before being seen by the physician. She further indicated the hospital had been using a computerized ED log for about 8 years. S3ED Manager confirmed that Patient #22 presented to the ED to be seen by the physician. She confirmed that Patients #23 and #24 were triaged by the nurse, and no nursing record of the triage assessment was completed by the nurse.

Based on record reviews and interviews, the hospital failed to: 1) provide a medical screening examination (MSE) for 1 of 1 patient reviewed who presented by ambulance and was taken into the ED prior to being transferred to another acute care hospital from a total of 24 sampled patients (#3) and 2) implement its policy for triaging patients for 7 of 10 patients who were triaged at a Level II from a sample of 24 patients (#8, #9, #11, #14, #15, #16, #19). Findings:

1) Provide a medical screening examination for a patient reviewed who presented by ambulance and was taken into the ED prior to being transferred to another acute care hospital:
Review of the hospital's policy titled "Medical Screening Examination", revised 04/16/09 and presented as a current policy by S1CEO (Chief Executive Officer), revealed that all patients who present to the ED will have a medical screening performed by the ED physician. Further review revealed that if a patient presents to the ED requesting treatment and decides to leave before a MSE by the ED physician is performed, the ED nurse will inform the patient of his/her right to have a MSE and that they may return at any time for this examination, and a "Refusal for Medical Screening Examination" form must be completed and signed by the patient or representative. Non-registered patients who sign the refusal must have a brief description of events documented on the refusal, and the refusal form is placed in the assigned folder in the filing cabinet. If the patient has been registered as an ED patient, the nurse is to document the events leading to the patient choosing to leave in the patient's ED chart with the refusal form attached to the chart.

Review of the hospital's hand-written "Emergency Department Log Book", presented by S3ED Manager as the list of patients who present to the ED for a MSE but leave before the registration process occurs, revealed Patient #3 presented to the ED on 09/19/13 at 6:52 a.m. by ambulance. Further review of documentation by S5ED RN (registered nurse) revealed he was a 59 year old male who was struck by a vehicle while riding his bike and initially had a loss of consciousness. Further review revealed his Glasgow Coma Score (GCS) was 15, blood pressure 156/63, pulse 92, and respiration 16. Further review revealed "immediately after hanging up LERN (Louisiana Emergency Response Network) called with accepting physician @ (at) Hospital A ED... (physician at Hospital A's ED) was then called to get an idea of any specific interventions needing to be performed prior to transfer, Reports if GCS 15 (with) stable vitals & (and) clear, equal BS (breath sounds) OK to transfer pt (patient) (with) large bore PIV (peripheral intravenous line). While on phone (with) MD (medical doctor) pt. entered ED on stretcher AAOx4 (awake, alert, oriented times 4), no complaints, lungs clear & equal bilaterally, GCS 15, vitals stable. S8Chief of Staff (ED physician but not physician on duty) and (physician at Hospital A's ED) reports OK to send pt. to Hospital A @ this time..." There was no documented evidence of a nursing record completed by the triage nurse or a MSE performed by an ED physician.

Review of the run report from Ambulance Company A revealed the ambulance arrived at Lady of the Sea General Hospital on 09/19/13 at 8:17 a.m. Review of the narrative documented by S10EMT (Emergency Medical Tech) with Company A revealed "due to miscommunication with EMT partner while caring for pt, we transported straight to LOSGH-ER (Lady of the Sea General Hospital-Emergency Room), Upon arrival we were advised to take pt. straight to Hospital A. Loaded pt. into unit without LOSGH-ER staff making pt. contact..."

Review of documentation by S11EMT with Company A, provided during an interview with S9Operations Manager with Company A on 09/25/13 at 1:00 p.m., revealed that he was one of the EMTs dispatched on 09/19/13 following Patient #3's injury. Further review revealed Patient #3 was brought into Lady of the Sea General Hospital, and S11EMT with Company A was told by an ED staff member to go to Room 1. While putting Patient #3 into Room 1, S11EMT and his partner (S10EMT with Company A) were told that Patient #3 was alert and oriented and accepted at Hospital A. Patient #3 was then placed in the back of the ambulance for transport to Hospital A.

Review of documentation by S10EMT with Company A, provided during an interview with S9Operations Manager with Company A on 09/25/13 at 1:00 p.m., revealed that she was dispatched to a call for a pedestrian (Patient #3) on a bicycle who was hit by a vehicle. Further review revealed she gave report to the physician at Hospital A and explained that she had made a mistake in the patient's Glasgow score when she spoke with the lady with LERN. Hospital A's physician informed her that Patient #3 met the Level I Trauma criteria and was to be taken to Hospital A. Further review revealed Patient #3 became upset and yelled that he didn't want to go to Hospital A. Approximately one minute away from Lady of the Sea General Hospital, S11EMT informed S10EMT that LERN had approved the transport of Patient #3 to LOSGH. S10EMT called report to LOSGH and spoke with S5ED RN. Upon arrival at LOSGH Patient #3 was rolled into the ED by stretcher, and someone instructed S10EMT and S11EMT to place Patient #3 in Room 1. At the same time S5ED RN was on the phone and told S10EMT that she (S5ED RN) was on the phone with Hospital A who had accepted Patient #3. S10EMT with Company A documented that Patient #3 was wheeled back to the ambulance with no one at LOSGH making physical contact with or spoke to Patient #3.

In a face-to-face interview on 09/25/13 at 4:05 p.m., S3ED Manager indicated that patients brought by ambulance come to the hospital with the intent for the patient to be seen by the physician and should go through triage and a medical screening examination.. When given the example of Patient #3, S3ED Manager indicated the ambulance brought the patient to the ED, because the patient wanted to come, and he should have been seen by the physician.

In a face-to-face interview on 09/26/13 at 9:25 a.m., S8Chief of Staff indicated he was also the Medical Director of the ED and the Medical Director of Company A. He indicated that Patient #3 was taken into the hospital's ED but was not taken into a room. He further indicated that as Medical Director he is in and out of the ED often when not on duty. He indicated that he was not on duty at the time Patient #3 was brought to the ED on 09/19/13, but he was standing at the nurse's station desk (the ED physician on duty was sleeping). S8Chief of Staff indicated when he arrived in the ED the nurse was on the phone with the ED physician from Hospital A who said that if Patient #3's vital signs were stable, LOSGH could send him to Hospital A. He further indicated that he did not speak with the ED physician from Hospital A, and Patient #3's vital signs were not assessed at LOSGH. He further indicated that Patient #3 did not receive a MSE at LOSGH. When asked what his knowledge was of the regulation for a MSE, S8Chief of Staff indicated when a patient either presents to the ED or anywhere on campus desiring a MSE or it is implied that a MSE is desired, the hospital is required to perform a MSE. He further indicated that Patient #3 presented to the LOSGH campus, and he should have had a MSE, however "it happened very fast and it was a unique situation." He further indicated that "we violated the intent of the law."

In a telephone interview on 09/26/13 at 1:30 p.m., S5ED RN indicated she received a phone call from Company A at 6:45 a.m. on 09/19/13 saying they were bringing Patient #3 to the ED. She further indicated that when she completed the phone call, she received a call from LERN who informed her that Company A was bringing Patient #3, and the ED physician at Hospital A had accepted the patient. S5ED RN indicated she then called the ED physician at Hospital A who told her he thought Patient #3 had an altered mental status. When Company A rolled Patient #3 into the ED while she was still on the phone with the ED physician at Hospital A, S5ED RN indicated she asked the physician if he wanted her to assess Patient #3 while she was on the phone, and he said yes. She indicated Patient #3 was never brought into a room, but was on the stretcher outside Room 1. She indicated that one of the other RNs had her hands on Patient #3, counted his respirations, called out vital signs taken by the EMTs, and reported the Glasgow score of 15 which she reported to the ED physician at Hospital A. She further indicated that she was told by the ED physician at Hospital A to make sure Patient #3 had a large bore intravenous line and not to register the patient. She indicated that she asked S8Chief of Staff if she was to register Patient #3, and he said not to, because Patient #3 was not supposed to come to LOSGH. She further indicated that she asked S10EMT and S11EMT with Company A if they were alright with the plan, and one of them said that they didn't think Patient #3 should have to go to Hospital A, because they had originally assessed his Glasgow score incorrectly.

2) Implement its policy for triaging patients:
Review of the hospital's policy titled "Triage", revised 12/28/10 and presented as the current triage policy by S1CEO, revealed the objective of the policy was to provide a standardized system whereby patients presenting to the ED are treated in order of priority based upon acuity utilizing the Emergency Severity Index Five-Level triage system. Level II presentation included patients at high risk and included high risk situations, new onset confusion, lethargy, or disorientation, severe pain/distress, and patients requiring two or more resources with heart rate, respiratory rate, or oxygen saturation in the danger zone. When a Level II condition is identified, the triage process stops, and the patient is taken directly to a room and immediate physician intervention is requested.

Patient #8
Review of Patient #8's ED record revealed he was a 21 year old male who presented to the ED on 09/14/13 with complaints of wanting to die and having taken 15 Lortab and consumed one beer. Further review revealed he was triaged as a Level II at 1:20 p.m. and was seen by the physician at 2:05 p.m., 35 minutes after being triaged.

Patient #9
Review of Patient #9's ED record revealed he was a 54 year old male who presented to the ED on 09/19/13 with complaints of weakness and dizziness. Further review revealed he was triaged as a Level II at 12:32 p.m. and was seen by the physician at 1:00 p.m., 28 minutes after being triaged.

Patient #11
Review of Patient #11's ED record revealed he was a 1 year old male who presented to the ED on 09/24/13 with a complaint of being burned with grease. Further review revealed he was triaged as Level II at 12:30 p.m. and was seen by the physician at 1:00 p.m., 30 minutes after being triaged.

Patient #14
Review of Patient #14's ED record revealed he was a 63 year old male who presented to the ED on 08/04/13 with complaints of chest pain. Further review revealed he was triaged as Level II at 1:41 a.m. and was seen by the physician at 2:10 a.m., 29 minutes after triage.

Patient #15
Review of Patient #15's ED record revealed she was a 78 year old female who presented to the ED on 08/10/13 with complaints of weakness and burning feet. Further review revealed she was triaged as a Level II at 12:45 p.m. and was seen by the physician at 1:25 p.m., 40 minutes after triage.

Patient #16
Review of Patient #16's ED record revealed she was a 22 year old female who presented to the ED on 08/10/13 with complaints of depression and overdose of Klonopin and Tylenol #4. Further review revealed she was triaged as a Level II at 5:30 p.m. and was seen by the physician at 7:00 p.m., 1 hour and 30 minutes after triage.

Patient #19
Review of Patient #19's ED record revealed she was a 74 year old female who presented to the ED on 08/17/13 with complaints of an ankle deformity, lumbar pain, and hip pain after being in an elevator that fell. Further review revealed she was triaged as a Level II at 11:40 a.m. and was seen by the physician at 12:07 p.m., 27 minutes after triage.

In a face-to-face interview on 09/25/13 at 4:05 p.m., S5ED RN indicated that patients who were triaged as Level II were to have the physician at the bedside in 10 minutes. When asked about the hospital's policy stating that Level II triage required the process to stop and the patient was to be taken directly to a room with immediate physician intervention requested, she indicated the "policy doesn't reflect what they (nursing staff) actually try to do."

In a face-to-face interview on 09/26/13 at 9:25 a.m., S8Chief of Staff was asked about delays in the physician seeing patients who were triaged as Level II. He indicated if a physician was in a procedure when a patient is triaged as Level II, the nurse will bring information about the patient, and he would order treatment. He further indicated that sometimes the time on the ED record doesn't reflect accurately the time that the physician started interacting with the patient.