HospitalInspections.org

Based on interview and record review, the facility failed to:

1. Ensure one of 21 sampled patients (Patient 1), received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screen exam (MSE, a medical evaluation to determine if an emergency condition exits) upon returning to the emergency department (ED, a hospital area that designed to provide immediate medical care) for a second visit.

Patient 1 visited the ED three times within 34 hours and 57 minutes:

- First visit: 5/4/2024, at 7:46 p.m.- Discharged home
- Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed
- Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility

On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac or respiratory arrest) was called, but despite resuscitation efforts, Patient 1 did not survive.

This deficient practice resulted in the facility's inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient's 1 death. (Refer to A-2406)

2. Ensure that one of 21 sampled patients (Patient 9), who was transferred to a trauma center (facility that treats critical injuries threatening life or limbs), had the required:

- "Transfer Summary Form (is a document that outlines a patient's critical medical information when they are being moved from one healthcare facility to another, ensuring the receiving facility has all necessary details about the patient's diagnosis, current condition, medications, treatment plan, and any relevant allergies to provide seamless and safe continuity of care)" and

-The "Patient Transfer Acknowledgement/Medical Transfer Consent (is a document that allows a patient to be transferred to another facility for care. The document ensures that the patient's care is continuous and appropriate to their needs)," completed, in accordance with the facility's policy and procedure titled, "Transfer of Patients From Emergency Department."

This deficient practice resulted in a lack of documented medical justification for the transfer, failure to ensure Patient 9 was informed of the risks and benefits, and absence of a required patient or witness signature. Additionally, the receiving physician's name was not documented, further compromising the appropriateness and coordination of the transfer. By failing to complete the required transfer documentation, the facility violated federal regulations designed to protect patients from being transferred in an unstable condition without proper medical oversight. This deficient practice deprived Patient 9 of their right in making informed medical decision (when a patient has made a choice about their healthcare after fully understanding their medical condition, the potential benefits and risks of different treatment options, and any available alternatives, allowing them to actively participate in the decision-making process with their healthcare provider based on their personal values and priorities), increased the risk of a breakdown in continuity of care, and created the potential for serious harm, including delays in treatment, medical deterioration enroute, and compromised Patient 9's safety upon arrival at the receiving facility. (Refer to A-2409)

Findings:

1. During a review of Patient 1's "ED Note History of Present Illness (HPMC, a description of the progression of the patient's present illness from the first sign and symptom to the present)," documented by ED provider (MD)1, dated 5/4/2024 at 8:06 p.m. (first visit), the "HPMC" indicated:

- Patient 1 was brought in by paramedics (emergency medical personnel trained to provide care and transport).
- Patient 1 initially called police due to disturbance of neighbor but told responders that he "just did not feel right."
- Patient 1 reported using methamphetamine (stimulant that speeds up body's system that is highly addictive) earlier that day.
- ER Course: Patient 1 was given 2 (unknown if this is referring to 2 milligram or 2 dose) Ativan (lorazepam, a sedative used to treat anxiety and agitation).
- Patient 1 felt improved with the above therapy ... "Stable for discharge home."
- Patient 1 was discharged at 9:21 p.m. (1 hour and 15 minutes after arrival for the first visit).


During a review of Patient 1's "ED Progress Note," documented by ED provider (MD- Medical Doctor)1, dated 5/5/2024 at 12:30 a.m. (second visit), the note indicated:

-Patient 1 stated he wanted to "go home and go to bed" and felt calmer during the previous discharge.

-Shortly after, Patient 1 was found "passed out (a temporary loss of consciousness [state of being awake and aware of one's surroundings])" outside the hospital and was brought back into the ED.
- Upon return, Patient 1 was extremely agitated (restless, unable to stay calm), raising suspicion of another episode of methamphetamine use.
- "Patient (Patient 1) was sedated with:
Ativan (lorazepam)- a medication that produce a calming effect on the brain, Benadryl (a medication used to treat allergy that have a sedative effects), and Haldol (a medication used to treat agitation and psychosis [a mental health condition characterized by a loss of contact with reality]), and psychiatric (a mental health evaluation to assess behavior and thinking), and patient is now pending sobering." The medications were administered at 12:53 a.m. MD 1 also ordered labs.

During a concurrent interview and record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), Patient 1's "ED Lab Results," dated 5/5/2024, were reviewed. The laboratory report indicated abnormal levels (test results that fall outside the normal range for a given test), as follows:

- Creatinine (a waste product in the blood that comes from muscle tissue and protein digestion):
5.39 H (high level)

Reference range (a set of values that indicates what's considered normal for a lab test result): 0.70-1.30 mg/dL (milligrams per deciliter is a unit of measurement).

- White Blood (a type of blood cell that play a crucial role in the body's system to protects the body from infections and other diseases)
30.3 H (high level)

Reference range: 3.6-10.2 K/uL (kilo per microliter, a unit of measurement).

-Estimated glomerular filtration rate (eGFR, measures kidney function):
10.7 - (End Stage kidney disease level, the final stage of chronic kidney disease, where the kidneys are no longer functioning adequately to support the body's needs, typically indicated by an estimated glomerular filtration rate (eGFR) of less than 15, requiring dialysis or a kidney transplant).

Reference range: eGFR<15mL (milliliter, a unit of measurement) indicates end-stage renal failure

During the same interview on 2/5/2025 at 11:00 a.m. with the Director of ED (DED), the DED confirmed that the lab results were abnormal but that there was no documented evidence that providers reviewed or discussed these results with Patient 1.

During a concurrent interview and record review on 2/5/2025 at 10:00 a.m. with Registered Nurse (RN) 3, Patient 1's "Vitals Flowsheet (a digital document within a patient's electronic medical record [EMR] that records and tracks a patient's vital signs [like temperature, blood pressure, heart rate, and respiratory rate] over time)," dated 5/5/2024, was reviewed. The Vitals Flowsheet indicated that at 2:00 a.m., Patient 1 was tachycardic (a condition where the heart beats abnormally fast), heart rate (HR, the number of times the heart beats per minute) was 112, and at 4:00 a.m., HR was 116. RN 3 confirmed that there was no documented evidence that this was addressed.

During a concurrent interview and electronic medical record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED confirmed the following:

-Patient 1 did not receive a triage which included assigning ESI level (a number that indicates how urgent a patient's condition is and how many resources they need), assessment, and vital signs.

-Vital signs were only recorded at 2:00 a.m. on 5/5/2024, 90 minutes after arrival (second visit).

-There was no documented evidence of a medical screening examination (MSE) from 5/5/2024 at 12:30 a.m., and through discharge on 5/5/2024 at 11:11 a.m. (10 hours and 41 minutes, the duration of the second visit).

During the same interview on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED stated this occurred because Patient 1 was not officially discharged from the electronic medical system (a digital system that stores and manages a patient's medical history). The Director of ED stated Patient 1 should have been discharged from the electronic medical record during the first encounter from 7:46 p.m. to 8:57 p.m. (1st ED visit), and Patient 1 should have been re-triaged upon arrival to the ED on 5/5/2024 at 12:30 a.m. (2nd encounter).

During a record review of Patient 1's "ED Progress Note," dated 5/5/2024 at 11:07 a.m., documented by MD 3, the ED Progress Note indicated, Patient 1 was discharged home by MD 3 (2nd discharge) at 11:11 a.m.

During an interview on 2/6/2025 at 2:00 p.m. with MD 3, MD 3 stated she (MD 3) discharged Patient 1 based on Patient 1's clinical appearance, noting that Patient 1 "looked better and was improving." MD 3 verified that she could not recall if she checked the abnormal labs nor was it was documented that she reviewed the abnormal lab results.

During a concurrent interview and record review on 2/5/2025 at 11:15 a.m. with the DED, Patient 1's electronic medical record (EMR), dated from 5/5/2024 at 12:30 a.m. (time of arrival to ED on second visit) through 5/5/2024 at 11:11 a.m. (time of discharge from second visit), was reviewed. DED confirmed that:

- There was no documented evidence that lab results were reviewed or discussed with Patient 1 before discharge.

-There was no documentation from MD 2 (who assumed care from 1:00 a.m. to 6:00 a.m.).

-There was no hand-off report (a structured communication process where one doctor transfers critical information about a patient's medical status, current treatment plan, and any necessary next steps to another doctor, typically occurring when a patient is transitioning care between different shifts) between MD 1 to MD 2, or MD 2 to MD 3.

During an interview with Security guard (SS) 1on 2/5/2025 at 3:15 p.m., SS1 confirmed that on 5/5/2024 at 6:38 p.m., Patient 1 was found lying outside the ED on the grass. SS1 stated SS1 checked on Patient 1. Patient 1 was unconscious (lacking awareness and the capacity for sensory perception as if asleep or dead and was not responding). SS1 stated SS1 informed ER staff nurses, and RN 1 responded within a minute, transporting Patient 1 into the ED on a gurney (third visit, on 5/5/2024 at 6:38 p.m.).

During an interview on 2/6/2025 at 11:44 a.m. with the Medical Director of ED (MDED), MDED stated providers rely on the triage to review the Emergency Severity Index (ESI) level to determine patient priority. Triage provides current vital signs and chief complaints (is the primary symptom or concern described by a patient that prompts them to seek medical attention) which the providers use to cross-reference with patient's reported complaint. MDED also confirmed that abnormal labs result should be reviewed and discussed with the patient prior to discharge. Additionally, MDED stated that a handoff must occur between providers to ensure continuity of care for pending labs, diagnostics, and treatment recommendations.

During an interview on 2/6/2025 at 1:00 p.m. with RN 1, RN 1 stated Patient 1 was without a pulse (the number of heart beats per minute). CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) was initiated on 5/5/2024 at 6:38 p.m. Patient 1 was taken into the ED. A Code Blue was called.

During a review of Patient 1's "Code Blue Record (documents the interventions and clinical condition of a patient during a medical emergency)," dated 5/5/2024, the record indicated, CPR was initiated on 5/5/2024 at 6:38 p.m. At 7:16 p.m., Patient 1 required CPR again. CPR was stopped at 7:24 p.m., despite resuscitation efforts, Patient 1 did not survive.

During a review of the facility's Department of Emergency Medicine Rules and Regulations, dated 11/1/2028, the record indicated, "All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists. Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner) are authorized to perform the medical Screening Examination (MSE) initiation, and must determine whether the patient has a medical condition of sufficient severity ..."

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept," dated 4/26/2023, the P&P indicated, "To establish the following guidelines:o For safe and expedient triage process, when rapidly identifying adult (> 14 years of age) and pediatric patients (S14 years of age) with urgent life-threatening conditions.o For performing Emergency Department (ED) assessments and reassessments, for initial and ongoing care, and/or observation of patients in treatment areas, or of those waiting placement for a treatment area. Triage- is the process of collecting pertinent information about patients who are seeking Emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity designation system according to the type and urgency of the patient's medical condition. (Emergency Nurses Association (2011) Emergency Nursing Scope and Standards of Practice) ... Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. The patient's physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Room Screening Registration," dated 6/23/2023, the P&P indicated, "(name of the facility's) policy to provide an emergency medical screening examination to any individual who comes to the Emergency Department, or who presents on HPMC property, to determine whether an "emergency medical condition" or active labor exists, regardless of ability to pay.

1.The patient will be entered into Paragon at time of triage, with minimal information
a. Patient Name
b. Date of Birth
c. Complaint
2.The patient will receive initial triage by an RN.
3.Upon completion of the Medical Screening Exam (MSE), the Admitting Representative will update the registration screens with updated demographic and financial information..."

2. During a review of Patient 9's "ED Note History of Present Illness (HPMC, a description of the progression of the patient's present illness from the first sign and symptom to the present)," dated 7/28/2024, the "HPMC" indicated, Patient 9 "who denies any past medical history presenting to the emergency department for evaluation after he was hit by a car. Patient (Patient 9) is unable to give any specific details regarding the incident ...multiple abrasions all over body otherwise grossly normal ...Patient (Patient 9) has moderate-to-severe soft tissue swelling to his face with left facial abrasions, trismus (also known as lockjaw, is a condition that makes it hard to open your mouth) and a left chin laceration (cut in the skin). Patient (Patient 9) placed in a C-collar (also known as a cervical collar or neck brace, is a medical device that supports and limits neck movement). Given the concern for intracranial pathology (injury that affects the brain or the structures within the skull) and the mechanism of action, patient (Patient 9) meets criteria for a 911 re-triage to a trauma center. Case was discussed by charge nurse with (name of the receiving facility) who accepts this patient (Patient 9)."

During a concurrent interview and electronic medical (EMR, a digital version of a patient's medical history, including diagnoses, medications, allergies, immunizations, and treatment plans) record review on 2/7/2025 at 11:20 a.m. with the Manager of the Emergency Department (MED), MED confirmed that there was no documented informed consent of Patient 9 or witness acknowledging the medical transfer. Additionally, there was no evidence of a completed physician certification outlining the risks and benefits of the transfer. MED confirmed that Patient 9 was transferred for a higher-level of care (a hospital capable of providing diagnostic, interventional or tertiary care beyond the capacity of the hospital from which a patient originates) to the trauma center (a specialized hospital unit equipped and staffed to treat patients with severe, life-threatening injuries sustained from car accidents, gunshot wounds, etc.). The MED also validated that a transfer form should have been completed to indicate that the risks and benefits of the transfer were discussed with Patient 9.

During a concurrent interview and record review on 2/7/2025 at 4:35 p.m. with the Director of the Emergency Department (DED), Patient 9's EMR was reviewed. The DED confirmed that there was no documented evidence of the name of the physician at the receiving facility who will resume care for Patient 9.

During a review of the facility's "(Name of the facility) Authorization for and Consent to Transfer," blank transfer form dated 8/2023, the form included the following:

Your/the patient's undersigned physician has recommended that you/the patient be transferred to ____ by ___Your/the patient's care has been accepted by____
PHYSICIAN CERTIFICATION FOR TRANSFER: the undersigned physician, have examined and evaluated this patient and hereby certify that I have discussed the transfer described in this consent form with this patient (or the patient's legal representative), Including:

1. Risk and Benefits of transfer were explained to patient;
2. All questions have been answered;
3. Any adverse effects that may reasonably be expected to occur during transfer;
4. Reasonable alternatives and the relevant risks, benefits related to transfer including not receiving care of treatment.

PHYSICIAN SUMMARY:
Receiving Facility: __________________
Accepting Physician: __________________
Time Contacted; ___________________
On call Physicians Who Failed to Appear ____________

During a concurrent interview and record review on 2/7/2025 at 4:40 p.m. with the Director of the Emergency Department (DED), the facility's policy and procedure (P&P) titled, "Transfer of Patients from Emergency Department," dated 5/22/2029, was reviewed. The P&P indicated, "It is the responsibility of the treating physician to ensure that all transfers for immediate care of an individual to another care facility are carried out in accordance with EMTALA Regulations. Once emergency evaluation and treatment have been provided, transfer may be considered if the individual is stabilized or, the individual has requested a transfer or the physician has certified that the transfer is for a higher level of care ... Informed Consent: Patient Transfer Acknowledgement/Medical Transfer Consent: Where the individual or where applicable, the individual's LRP, both orally and in writing of the recommended transfer and the reasons thereof. If an individual's physical or mental condition is such that it is not possible to notify the individual, and the individual is unaccompanied, the Hospital shall make reasonable effort to locate an LRP in order to notify that person of the intended transfer. An acknowledgement by the individual or the LRP of such notification and consent to the transfer should be included on the "Patient Transfer Acknowledgement Form/Medical Transfer Consent"... Stable Patients: Informed Request for Transfer for Non-Medical Reasons: Recommended Transfer for Medical Reasons: A Qualified Medical Person recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer. The transfer may then occur if the individual or LRP consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risks and benefits of the transfer on the "Transfer Summary Form." Discussion With Receiving Facility/Physician: A representative of the receiving facility must have confirmed that: The receiving facility has available space and qualified personnel to treat the individual. The ED RN or ED RN Case Manager will document the time, date, and name of the person they verify this information with from the receiving facility on the nurses' notes-EHR Clinical Care Station. The name of the accepting physician, room/ bed assignment and telephone number for RN-to-RN report will also be documented in EHR Clinical Care Station
b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment.
c. Where the individual has an emergency medical condition, the receiving physician must agree to accept and treat the individual. The name of the receiving physician will be documented on the transfer record..." The DED confirmed that the name of the physician at the receiving facility should be documented on transfer form.

Based on observation, interview, and record review, the facility failed to post written notice or signage informing 21 of 21 sampled patients of their right to receive a medical screening examination (the initial examination a patient receives when they go the Emergency Department), stabilizing treatment and an appropriate transfer, regardless of their ability to pay, in an area of the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) likely to be noticed by patients in the ED.

This deficient practice had the potential for patients, who were waiting in the waiting room, to not be informed of their rights when they visit the ED seeking treatment for a medical condition.

Findings:

During an observation on 2/4/2025 at 2:10 p.m. in the Emergency Department (ED), the signage informing patients of their right to a medical screening, stabilizing treatment ...regardless of their ability to pay was posted to the far-right side of the ED, in a hallway, where no patients were waiting or passing through. Patients waited in the waiting room, in front of the Registration window, located on the left side of the ED. The signage was not visible to patients waiting in the ED waiting room (Patients/Visitors have to go to the hallway where the signage was posted to be able to read the signage).

During a concurrent interview on 2/4/2025 at 2:10 p.m. with the Director of the Emergency Department (DED), DED verified that the signage was posted in a hallway and would "probably not" be noticed by patients entering the ED or waiting in the waiting room, as well as patients brought in by ambulance. The DED stated the signage notifies patients of their right to be medically screened and receive medical treatment. The DED verified there were no other signs posted in the ED.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights, Medical Screening Exam (MSE)," dated 8/24/2023, the P&P indicated the following: Posting Signs. The Hospital will post signs likely to be noticed by all individuals entering the Emergency Department as well as those individuals waiting for examination and treatment, signs in clear and simple terms in multiple languages appropriate to the community ...

Based on interview and record review, the facility failed to ensure one of 21 sampled patients (Patient 1), received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screen exam (MSE, a medical evaluation to determine if an emergency condition exits) upon returning to the emergency department (ED, a hospital area that designed to provide immediate medical care) for a second visit.

Patient 1 visited the ED three times within 34 hours and 57 minutes:

- First visit: 5/4/2024, at 7:46 p.m.- Discharged home
- Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed
- Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility

On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac or respiratory arrest) was called, but despite resuscitation efforts, Patient 1 did not survive.

This deficient practice resulted in the facility's inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient's 1 death.

On 2/7/2025 at 9:51 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Nursing Officer (CNO), Director of Quality and Risk management (DQRM), Manager of Risk Management (MRM), and Chief Information Officer (CIO).

The IJ was related to the facility's failure to ensure that Patient 1, who was brought in by paramedics to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for general malaise received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screening exam (MSE, a medical evaluation to determine if an emergency condition exits) by a provider for a second visit.

Patient 1 visited the ED three times within 34 hours and 57 minutes:
- First visit: 5/4/2024, at 7:46 p.m.- Discharged home
- Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed.
- Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility

On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac [heart stops beating] or respiratory arrest [not breathing]) was called, but despite resuscitation efforts (the medical actions taken to revive someone who has experienced cardiac arrest), Patient 1 did not survive.

This deficient practice resulted in the facility's inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient's 1 death.

On 2/07/2025 at 5:26 p.m. p.m., while onsite, the IJ was removed in the presence of the CEO, COO, CNO, VPQR, MRM, and CIO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review.

The IJ Removal Plan included the following:
Emergency Department (ED) Registration Process
o A new ED Registration Process and Procedures guide was created by the Admitting Manager as a quick reference for staff, following the Admitting (Patient Access), Registration Process, Patient" policy.

Key elements:
o Once a patient is discharged, their visit number becomes inactive.
o Nurses are responsible for discharge; the system removes the patient from the tracker. Once the patient is removed from the tracker, the encounter is no longer active and can no longer be utilized.
o If the patient needs to come back inside the ED and be seen again for treatment, the patient will need to be re-registered per the "Admitting (Patient Access), Registration Process, Patient" policy.

Training & Education:
oRegistration staff were trained in May 2024
oRe-education on policy and quick reference sheet for our staff on February 6, 2025.
oA visual aid was posted in admitting areas.
oPerson Responsible: Admitting Director

Nursing Assessment/ Re-assessment:
o Beginning February 7, 2025 to ensure "Every patient arriving to the ED is a new encounter, requiring triage, intake information, and vital signs must be done again. The provider will then provide MSE for each patient.
Person Responsible: Director, ED and ICU (Intensive Care Unit- handles severe, potentially life-threatening cases)
o ED Policy Review Attestation Education was implemented for all new ED nurses, registry, and staff, added to the mandatory onboarding, covering:

"Hand-Off (the process of transferring responsibility for a patient's care from one healthcare provider to another)/SBAR Communication (Situation, Background, Assessment, Recommendation- a communication tool that helps people structure information into a consistent format)"
"Notification to providers for critical laboratory, and any other critical diagnostic test results, or a change in patient status as appropriate"
"Shift change report, for intra-procedural changes, or change of assignment within a shift.
"The handoff will be documented and will be retained in the patient's medical record."

Assessment & Re-assessment in critical patients:
o Upon arrival to unit, patient will have chief complaint and vital signs assessed
o A registered nurse (RN) completes the initial assessment within 15 minutes of admission and documents findings in the electronic health record (EHR- digital version of paper chart).
o Reassessment is completed by RN and documented in EHR every 2 hours for: stability, complexity, predictability, vulnerability, resiliency

o Chain of Command
o All physicians and staff have the responsibility and authority to immediately intervene to protect the safety of a patient or to prevent a medical error. Person Responsible: Director, ED and ICU; Director, Education Department

Discharge Instructions Updates:
o Modified to ensure triage, MSE, labs, and diagnostics are reviewed with the patient prior to discharge.
o Patient signature required only after all items are completed; a copy of the signed Discharge Instructions will be kept as part of the EHR.

Person Responsible: Manager, Informatics systems; Director, ED & ICU
o Nurses trained on the new process; patients cannot be discharged until validation is complete.
Person Responsible: Director, ED & ICU

Physician Education:
On May 25, 2024, ED physicians received training on:
o Hand-off process: Reviewing all patients, pertinent labs/diagnostics, diagnosis, and disposition.
o Use SBAR (Situation, Background, Assessment, Recommendations) - why was this patient here? What studies/interventions have been done? What are they pending and what are your recommendations?
o Oncoming physician assesses all signed out patients.
o Document assumption of care on signed out patients.

Person Responsible: Co-Associate ED Medical Director
o New template has been provided along with attestations to ensure they are aware of the new template that must be used for each patient that is signed off.
Re-education to all ED physicians regarding the facility's Department of Emergency Medicine Rules and Regulations, "All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists" was conducted to ensure all new encounters receive a new MSE.

Person Responsible: ED Medical Director
Audit Process: 20 charts per week will be reviewed to ensure proper handoff documentation. Compliance reports will be submitted weekly to the ED Medical Director, VP of Quality and Risk, and the Chief Medical Officer will be provided weekly to review compliance.
Person Responsible: Quality Department

Findings:

During a review of Patient 1's "ED Note History of Present Illness (HPMC, a description of the progression of the patient's present illness from the first sign and symptom to the present)," documented by ED provider (MD)1, dated 5/4/2024 at 8:06 p.m. (first visit), the "HPMC" indicated:

- Patient 1 was brought in by paramedics (emergency medical personnel trained to provide care and transport).
- Patient 1 initially called police due to disturbance of neighbor but told responders that he "just did not feel right."
- Patient 1 reported using methamphetamine (stimulant that speeds up body's system that is highly addictive) earlier that day.
- ER Course: Patient 1 was given 2 (unknown if this is referring to 2 milligram or 2 dose) Ativan (lorazepam, a sedative used to treat anxiety and agitation).
- Patient 1 felt improved with the above therapy ... "Stable for discharge home."
- Patient 1 was discharged at 9:21 p.m. (1 hour and 15 minutes after arrival for the first visit).

During a review of Patient 1's "ED Progress Note," documented by ED provider (MD)1, dated 5/5/2024 at 12:30 a.m. (second visit), the note indicated:

-Patient 1 stated he wanted to "go home and go to bed" and felt calmer during the previous discharge.
-Shortly after, Patient 1 was found "passed out (a temporary loss of consciousness [state of being awake and aware of one's surroundings])" outside the hospital and was brought back into the ED.
- Upon return, Patient 1 was extremely agitated (restless, unable to stay calm), raising suspicion of another episode of methamphetamine use.
- "Patient (Patient 1) was sedated with:
Ativan (lorazepam)- a medication that produce a calming effect on the brain, Benadryl (a medication used to treat allergy that have a sedative effects), and Haldol (a medication used to treat agitation and psychosis [a mental health condition characterized by a loss of contact with reality]), and psychiatric (a mental health evaluation to assess behavior and thinking), and patient is now pending sobering." The medications were administered at 12:53 a.m. MD 1 also ordered labs (laboratory tests).

During a concurrent interview and record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), Patient 1's "ED Labs Results," dated 5/5/2024, were reviewed. The laboratory report indicated abnormal levels (test results that fall outside the normal range for a given test), as follows:

- Creatinine (a waste product in the blood that comes from muscle tissue and protein digestion):
5.39 H (high level)
Reference range (a set of values that indicates what's considered normal for a lab test result): 0.70-1.30 mg/dL (milligrams per deciliter is a unit of measurement).

- White Blood (a type of blood cell that play a crucial role in the body's system to protects the body from infections and other diseases)
30.3 H (high level)
Reference range: 3.6-10.2 K/uL (kilo per microliter, a unit of measurement).

-Estimated glomerular filtration rate (eGFR, measures kidney function):
10.7 - (End Stage kidney disease level, the final stage of chronic kidney disease, where the kidneys are no longer functioning adequately to support the body's needs, typically indicated by an estimated glomerular filtration rate (eGFR) of less than 15, requiring dialysis or a kidney transplant).

Reference range: eGFR<15mL (milliliter, a unit of measurement) indicates end-stage renal failure

During the same interview on 2/5/2025 at 11:00 a.m. with the Director of ED (DED), the DED confirmed that the lab results were abnormal but that there was no documented evidence that providers reviewed or discussed these results with Patient 1.

During a concurrent interview and record review on 2/5/2025 at 10:00 a.m. with Registered Nurse (RN) 3, Patient 1's "Vitals Flowsheet (a digital document within a patient's electronic medical record [EMR] that records and tracks a patient's vital signs [like temperature, blood pressure, heart rate, and respiratory rate] over time)," dated 5/5/2024, was reviewed. The Vitals Flowsheet indicated that at 2:00 a.m., Patient 1 was tachycardic (a condition where the heart beats abnormally fast), heart rate (HR, the number of times the heart beats per minute) was 112, and at 4:00 a.m., HR was 116. RN 3 confirmed that there was no documented evidence that this was addressed.

During a concurrent interview and electronic medical record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED confirmed the following:
-Patient 1 did not receive a triage which included assigning ESI level (a number that indicates how urgent a patient's condition is and how many resources they need), assessment, and vital signs.
-Vital signs were only recorded at 2:00 a.m., 90 minutes after arrival (second visit).
-There was no documented evidence of a medical screening examination (MSE) from 5/5/2024 at 12:30 a.m., and through discharge on 5/5/2024 at 11:11 a.m. (10 hours and 41 minutes, the duration of the second visit).

During the same interview on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED stated this occurred because Patient 1 was not officially discharged from the electronic medical system (a digital system that stores and manages a patient's medical history). The Director of ED stated Patient 1 should have been discharged from the electronic medical record during the first encounter from 7:46 p.m. to 8:57 p.m. (1st ED visit), and Patient 1 should have been re-triaged upon arrival to the ED on 5/5/2024 at 12:30 a.m. (2nd ED visit).

During a record review of Patient 1's "ED Progress Note," dated 5/5/2024 at 11:07 a.m., documented by MD 3, the ED Progress Note indicated, Patient 1 was discharged home by MD 3 (2nd discharge) at 11:11 a.m.

During an interview with MD 3, MD 3 stated she (MD 3) discharged Patient 1 based on Patient 1's clinical appearance, noting that Patient 1 "looked better and was improving." MD 3 verified that she could not recall if she checked the abnormal labs nor was it was documented that she reviewed the abnormal lab results.

During a concurrent interview and record review on 2/5/2025 at 11:15 a.m. with the DED, Patient 1's electronic medical record (EMR), dated from 5/5/2024 at 12:30 a.m. (time of arrival to ED on second visit) through 5/5/2024 at 11:11 a.m. (time of discharge from second visit), DED confirmed that:
- There was no documented evidence that lab results were reviewed or discussed with Patient 1 before discharge.
-There was no documentation (a physician progress note, a document that records a patient's condition, care plan, and treatment updates) from MD 2 (who assumed care from 1:00 a.m. to 6:00 a.m.).
-There was no hand-off report (a structured communication process where one doctor transfers critical information about a patient's medical status, current treatment plan, and any necessary next steps to another doctor, typically occurring when a patient is transitioning care between different shifts) between MD 1 to MD 2, or MD 2 to MD 3.

During an interview with Security guard (SS) 1on 2/5/2025 at 3:15 p.m., SS1 confirmed that on 5/5/2024 at 6:38 p.m., Patient 1 was found lying outside the ED on the grass. SS1 stated SS1 checked on Patient 1. Patient 1 was unconscious (lacking awareness and the capacity for sensory perception as if asleep or dead and was not responding). SS1 stated SS1 informed ER staff nurses, and RN 1 responded, transporting Patient 1 into the ED on a gurney (third visit).

During an interview on 2/6/2025 at 11:44 a.m. with the Medical Director of ED (MDED), MDED stated providers rely on the triage to review the Emergency severity Index (ESI) level to determine patient priority. Triage provides current vital signs and chief complaints (is the primary symptom or concern described by a patient that prompts them to seek medical attention) which the providers use to cross-reference with patient's reported complaint. MDED also confirmed that abnormal labs result should be reviewed and discussed with the patient prior to discharge. Additionally, MDED stated that a handoff must occur between providers to ensure continuity of care for pending labs, diagnostics, and treatment recommendations.

During an interview on 2/6/2025 at 1:00 p.m. with RN 1, RN 1 stated Patient 1 was without a pulse (the number of heart beats per minute). CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) was initiated. Patient 1 was taken into the ED. A Code Blue was called.

During a review of Patient 1's "Code Blue Record (documents the interventions and clinical condition of a patient during a medical emergency)," dated 5/5/2024, the record indicated, CPR was initiated on 5/5/2024 at 6:38 p.m. At 7:16 p.m., Patient 1 required CPR again. CPR was stopped at 7:24 p.m., despite resuscitation efforts, Patient 1 did not survive.

During a review of the facility's Department of Emergency Medicine Rules and Regulations dated 11/1/2028, the record indicated, "All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists. Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner) are authorized to perform the medical Screening Examination (MSE) initiation, and must determine whether the patient has a medical condition of sufficient severity ..."

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept," dated 4/26/2023, the P&P indicated, "To establish the following guidelines:o For safe and expedient triage process, when rapidly identifying adult (> 14 years of age) and pediatric patients (S14 years of age) with urgent life-threatening conditions.o For performing Emergency Department (ED) assessments and reassessments, for initial and ongoing care, and/or observation of patients in treatment areas, or of those waiting placement for a treatment area. Triage- is the process of collecting pertinent information about patients who are seeking Emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity designation system according to the type and urgency of the patient's medical condition. (Emergency Nurses Association (2011) Emergency Nursing Scope and Standards of Practice) ... Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. The patient's physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Room Screening Registration," dated 6/23/2023, the P&P indicated, "(name of the facility's) policy to provide an emergency medical screening examination to any individual who comes to the Emergency Department, or who presents on HPMC property, to determine whether an "emergency medical condition" or active labor exists, regardless of ability to pay.
1.The patient will be entered into Paragon at time of triage, with minimal information
a. Patient Name
b. Date of Birth
c. Complaint
2.The patient will receive initial triage by an RN.
3.Upon completion of the Medical Screening Exam (MSE), the Admitting Representative will update the registration screens with updated demographic and financial information..."

Based on interview and record review, the facility failed to ensure that one of 21 sampled patients (Patient 9), who was transferred to a trauma center (facility that treats critical injuries threatening life or limbs), had the required:

- "Transfer Summary Form (is a document that outlines a patient's critical medical information when they are being moved from one healthcare facility to another, ensuring the receiving facility has all necessary details about the patient's diagnosis, current condition, medications, treatment plan, and any relevant allergies to provide seamless and safe continuity of care)" and

-The "Patient Transfer Acknowledgement/Medical Transfer Consent (is a document that allows a patient to be transferred to another facility for care. The document ensures that the patient's care is continuous and appropriate to their needs)," completed, in accordance with the facility's policy and procedure titled, "Transfer of Patients From Emergency Department."

This deficient practice resulted in a lack of documented medical justification for the transfer, failure to ensure Patient 9 was informed of the risks and benefits, and absence of a required patient or witness signature. Additionally, the receiving physician's name was not documented, further compromising the appropriateness and coordination of the transfer. By failing to complete the required transfer documentation, the facility violated federal regulations designed to protect patients from being transferred in an unstable condition without proper medical oversight. This deficient practice deprived Patient 9 of their right in making informed medical decision-making, increased the risk of a breakdown in continuity of care, and created the potential for serious harm, including delays in treatment, medical deterioration enroute, and compromised Patient 9's safety upon arrival at the receiving facility.

Findings:

During a review of Patient 9's "ED Note History of Present Illness (HPMC, a description of the progression of the patient's present illness from the first sign and symptom to the present)," dated 7/28/2024, the "HPMC" indicated, Patient 9 "who denies any past medical history presenting to the emergency department for evaluation after he was hit by a car. Patient (Patient 9) is unable to give any specific details regarding the incident ...multiple abrasions all over body otherwise grossly normal ...Patient (Patient 9) has moderate-to-severe soft tissue swelling to his face with left facial abrasions, trismus (also known as lockjaw, is a condition that makes it hard to open your mouth) and a left chin laceration (cut in the skin). Patient (Patient 9) placed in a C-collar (also known as a cervical collar or neck brace, is a medical device that supports and limits neck movement). Given the concern for intracranial pathology (injury that affects the brain or the structures within the skull) and the mechanism of action, patient (Patient 9) meets criteria for a 911 re-triage to a trauma center. Case was discussed by charge nurse with (name of the receiving facility) who accepts this patient (Patient 9)."

During a concurrent interview and electronic medical (EMR, a digital version of a patient's medical history, including diagnoses, medications, allergies, immunizations, and treatment plans) record review on 2/7/2025 at 11:20 a.m. with the Manager of the Emergency Department (MED), MED confirmed that there was no documented informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) of Patient 9 or witness acknowledging the medical transfer. Additionally, there was no evidence of a completed physician certification outlining the risks and benefits of the transfer. MED confirmed that Patient 9 was transferred for a higher-level of care (a hospital capable of providing diagnostic, interventional or tertiary care beyond the capacity of the hospital from which a patient originates) to the trauma center (a specialized hospital unit equipped and staffed to treat patients with severe, life-threatening injuries sustained from car accidents, gunshot wounds, etc.). The MED also validated that a transfer form should have been completed to indicate that the risk and benefit of the transfer were discussed with Patient 9.

During a concurrent interview and record review on 2/7/2025 at 4:35 p.m. with the Director of the Emergency Department (DED), Patient 9' EMR was reviewed. The DED confirmed that there was no documented evidence of the name of the physician at the receiving facility that will resume care for Patient 9.

During a review of the facility's "(Name of the facility) Authorization for and Consent to Transfer," blank transfer form dated 8/2023, the form included the following:

Your/the patient's undersigned physician has recommended that you/the patient be transferred to ____ by ___Your/the patient's care has been accepted by____
PHYSICIAN CERTIFICATION FOR TRANSFER: the undersigned physician, have examined and evaluated this patient and hereby certify that I have discussed the transfer described in this consent form with this patient (or the patient's legal representative), Including:
1. Risk and Benefits of transfer were explained to patient;
2. All questions have been answered;
3. Any adverse effects that may reasonably be expected to occur during transfer;
4.Reasonable alternatives and the relevant risks, benefits related to transfer including not receiving care of treatment.
PHYSICIAN SUMMARY:
Receiving Facility: __________________
Accepting Physician: __________________
Time Contacted; ___________________
On call Physicians Who Failed to Appear ____________

During a concurrent interview and record review on 2/7/2025 at 4:40 p.m. with the Director of the Emergency Department (DED), the facility's policy and procedure (P&P) titled, "Transfer of Patients from Emergency Department," dated 5/22/2029, was reviewed. The P&P indicated, "It is the responsibility of the treating physician to ensure that all transfers for immediate care of an individual to another care facility are carried out in accordance with EMTALA Regulations. Once emergency evaluation and treatment have been provided, transfer may be considered if the individual is stabilized or, the individual has requested a transfer or the physician has certified that the transfer is for a higher level of care... Informed Consent: Patient Transfer Acknowledgement/Medical Transfer Consent: Where the individual or where applicable, the individual's LRP, both orally and in writing of the recommended transfer and the reasons thereof. If an individual's physical or mental condition is such that it is not possible to notify the individual, and the individual is unaccompanied, the Hospital shall make reasonable effort to locate an LRP in order to notify that person of the intended transfer. An acknowledgement by the individual or the LRP of such notification and consent to the transfer should be included on the "Patient Transfer Acknowledgement Form/Medical Transfer Consent"... Stable Patients: Informed Request for Transfer for Non-Medical Reasons: Recommended Transfer for Medical Reasons: A Qualified Medical Person recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer. The transfer may then occur if the individual or LRP consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risks and benefits of the transfer on the "Transfer Summary Form." Discussion With Receiving Facility/Physician: A representative of the receiving facility must have confirmed that: The receiving facility has available space and qualified personnel to treat the individual. The ED RN or ED RN Case Manager will document the time, date, and name of the person they verify this information with from the receiving facility on the nurses' notes-EHR Clinical Care Station. The name of the accepting physician, room/ bed assignment and telephone number for RN-to-RN report will also be documented in EHR Clinical Care Station
b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment.
c. Where the individual has an emergency medical condition, the receiving physician must agree to accept and treat the individual. The name of the receiving physician will be documented on the transfer record..." The DED confirmed that the name of the physician at the receiving facility should be documented on transfer form.