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Based on observation, interview, and record review, the facility failed to comply with CFR 489.24 by failing:

1. To ensure a thorough medical screening exam (MSE) was completed to determine the emergency treatment and services needed for Patients 1, 8, and 11.

Patients 1 and 8 presented with signs and symptoms that required immediate treatment and/or examination from a qualified medical personnel (QMP), but instead the patients were sent back to the waiting area.

Patient 11 was not reassessed after laboratory results indicated the patient's white blood count was elevated.

This failure resulted in an inappropriate MSE for Patient 1 which was a direct proximate cause for the patient to seek treatment from another acute hospital. Subsequently, the patient was diagnosed, cared, and treated for an acute stroke (a new onset of cerebrovascular accident - CVA).

For Patients 8 and 11, these failures resulted in an inappropriate MSE, and a delay in determining if an EMC existed.

Based on observation, interview, and record review, the facility failed to ensure a thorough medical screening exam (MSE) was completed to determine whether an emergency medical condition (EMC) existed; and failed to determine whether emergency treatment and services were needed for Patients 1, 8, and 11.

Patients 1 and 8 presented with signs and symptoms that required immediate treatment and/or examination from a qualified medical personnel (QMP), but instead the patients were sent back to the waiting area.

Patient 11 was not reassessed after laboratory results indicated the patient's white blood count was elevated.

For Patient 1, this failure resulted in an inappropriate MSE, which was a direct proximate cause for the patient to seek treatment from another acute hospital. Subsequently, the patient was diagnosed, cared, and treated for an acute stroke (a new onset of cerebrovascular accident - CVA).

For Patients 8 and 11, these failures resulted in an inappropriate MSE, and a delay in determining if an EMC existed.

Findings:

1. On November 5, 2013, Patient 1's record was reviewed. Patient 1 was a 54-year old female, who presented to the Emergency Department (ED) on August 26, 2013, at 8:49 p.m.

The "Emergency Patient Sign-in Sheet" dated August 25, 2013, (the date was actually August 26), 2013, at 8:49 p.m., indicated, "Reason for Visit: Half Body Numb, Feel Paralized [sic] weak..."

The "Triage Note" dated August 26, 2013, at 8:56 p.m., indicated:

"Chief Complaint/Mechanism of Injury: left sided weakness x 7 hours with numbness also;

Demonstrated Signs, Symptoms of Condition: None.

Vital Signs: Temperature - 98.6 DegF (degrees Fahrenheit); Apical Heart Rate - 64 bpm (beats per minute); Respiratory Rate - 18 br/min (breathes per minute); BP - 204/91 mmHg (millimeter mercury) (HI [high]) [normal BP is less than 120/80]...

Problems (Active): Diabetes mellitus type 2 and hypertension;

Diagnoses (Active): Paraesthesia (an abnormal or inappropriate sensation in an organ, part, or area of the skin, as of burning, prickling, and/or tingling) and weakness or fatigue;

ESI (Emergency Severity Index; a five level standardized system that designates the order of priority based upon the acuity of the patient's condition, one being the highest priority and five being the least priority): 3."

The record did not contain documented evidence of further assessment of the patient's chief complaint, including the patient's normal blood pressure range and the extent of her weakness.

The record indicated the patient was sent back to the waiting area. The record indicated laboratory tests were ordered at 10:52 p.m. (2 hours and 3 minutes after the triage assessment), but indicated, "Discontinued" due to "Patient left without being seen."

On August 29, 2013, at 8:30 a.m., during a phone conversation with Patient 1, she stated she asked a friend to bring her to the facility's ED due to left sided weakness and numbness. The patient stated she was unable to steadily ambulate when she went to the ED. The patient stated she worked as a cook in a skilled nursing facility (SNF). Earlier that day (August 26, 2013), while at work, she started feeling the numbness on her left side. At the end of her shift, she decided to seek medical attention at the facility. Patient 1 stated, when she got to the facility's ED, she was sent back to the waiting room and waited approximately 3 1/2 hours. She stated she decided to go home and "rest it out," because she felt "so tired." Patient 1 stated when she woke up the following morning, her left side was weaker and paralyzed. She was brought by a friend to the nearby hospital (Acute Hospital [AH] 2) and was admitted with the diagnosis of stroke (CVA).

On September 20, 2013, at 1:50 p.m., Patient 1's record was reviewed with the ED Director (EDD). The EDD stated the patient was seen only by the triage nurse and not by a QMP. The EDD was unable to find documented evidence of further evaluation/assessment of Patient 1 to determine the extent of the patient's chief complaint. The EDD was unable to find documented evidence of an evaluation/assessment determining whether the patient's BP of 204/91 was within the patient's normal range. The EDD stated the expectation was for Patient 1 to be seen by a QMP in a "shorter time frame."

On October 18, 2013, at 7:35 a.m., the triage nurse (Registered Nurse [RN] 1), who evaluated Patient 1 on August 26, 2013, was interviewed. Patient 1's record was reviewed with RN 1. RN 1 stated he "usually finds-out" the history of the patient's vital signs, which included the patient's normal vital sign ranges. He was unable to find documentation that he assessed Patient 1's normal BP range. RN 1 stated, if a patient had "true signs and symptoms" of stroke, he would immediately notify the physician, get the patient bedded, obtain an order for a Computerized Tomography (CT) of the head, and seek further intervention and treatment. RN 1 stated, with Patient 1's "left sided weakness for 7 hours," along with the elevated BP, he would get the patient bedded, notify the physician, and seek further intervention. When asked why RN 1 did not get Patient 1 bedded with these symptoms, RN 1 stated the only explanation about sending the patient back to the waiting room was, the patient did not present "true signs and symptoms" of stroke.

On October 18, 2013, at 8:40 a.m., one of the ED Physician (EDP 1) was interviewed regarding the process of evaluating and examining patients that present in the ED. Patient 1's record was discussed with EDP 1. He stated the "standard of practice" would be to bring the patient back (bedded) and get the patient evaluated by a physician as soon as possible.

On September 20, 2013, Patient 1's record from Acute Hospital (AH) 2 was reviewed. Patient 1 arrived and was triaged on August 27, 2013, at 7:58 a.m.

The "Patient Registration Form (no date)" indicated, "Severe Paralysis/can't move."

The "Triage Report" dated August 27, 2013, at 7:58 a.m., indicated:

"Patient Narrative: Left sided weakness since last night at 1900 (7 p.m.), a/o (alert and oriented) x 4, no slurred speech; BP 197/117 mmHg..."

The "Emergency Room Report (by the ED Physician)" dated August 27, 2013, indicated, "History of Present Illness: The patient...is having left-sided weakness since last night. She is alert and oriented, but she said her left arm is completely weak and she is having a hard time walking...She stated that she went to Loma Linda Murrieta where they examined her and then subsequently sent her home without any further testing..."

The "History and Physical Exam (by the Primary Physician - PMD)" dated August 27, 2013, indicated, "History of Present Illness: This is a 54 year-old...who was apparently noted by her coworkers to have droopy left upper extremity and dragging her feet all of a sudden at work. She was then advised to go to the hospital. She went to the Loma Linda Hospital in Murrieta, stayed there for 5 hours, apparently nothing was done as per the patient. She went home, slept it over and went to the ER (Emergency Room) this morning and was admitted for left-sided weakness, possible stroke..."

The "MRI (Magnetic Resonance Imaging) - Brain without Contrast" dated August 28, 2013, indicated, "Impression: There is a 2 cm (centimeter) area of acute infarction involving the posterior limb of the right internal capsule and extending toward the immediate right ventricular surface with associated minimal wedge edema. It encroaches toward, but does not directly invade the right putamen (a large structure located within the brain). No associated hemorrhage."

The "Discharge Summary (by the PMD)" dictated September 27, 2013, indicated Patient 1 was discharged on September 3, 2013, to an Acute Rehabilitation Hospital. The record indicated, "Discharge Diagnoses: Status post stroke with right cerebrovascular accident with left hemiparesis, stabilized..."

2. On November 5, 2013, Patient 8's record was reviewed. Patient 8, a 53-year old female, presented to the ED on August 23, 2013.

The "Triage Note" dated August 23, 2013, at 11:55 a.m., indicated:

"Chief Complaint/Mechanism of Injury: weakness starting this morning, with heaviness in chest and neck constant, does not increase with inspiration 3/10;

Demonstrated Signs, Symptoms of Condition: None;

Vital Signs: Temperature - 98.6 DegF (degrees Fahrenheit); Apical Heart Rate - 117 bpm (normal is 60 to 100 bpm); Respiratory Rate - 16 br/min; BP - 172/96 mmHg (HI) [normal BP is less than 120/80]...

Diagnoses (Active): SOB - Shortness of breath and weakness or fatigue;

ESI: 3."

The "EKG (Electrocardiogram - a test that indicates heart rhythm)" dated August 23, 2013, at 11:58 a.m., indicated, "Sinus tachycardia (heart rhythm with elevated rate of impulses)."

The record indicated the patient was sent back to the waiting area after triage.

The record indicated, "Discharge Disposition: Patient left after triage."

The record did not provide documented evidence that further assessment of the patient's chief complaint was completed, which included establishing the patient's normal blood pressure range, normal heart rate, and the extent of her weakness. There was no documented evidence that the abnormal EKG result was relayed and/or seen by a physician. The record did not indicate when the patient was discovered leaving the ED.

On November 6, 2013, at, 10:40 a.m., Patient 8's record was reviewed with the EDD. The EDD stated the record did not indicate if the abnormal EKG result was relayed to the physician. The EDD was unable to find documentation at what time the patient left the ED and what the patient's condition was prior to leaving the ED. In addition, the EDD was unable to find documentation that the physician was notified of the increased blood pressure and heart rate. The EDD was unable to find documented evidence that a QMP examined or evaluated Patient 8. The EDD stated the facility's policy indicated that if a patient's heart rate was over 100 bpm, the expectation was to notify the physician.


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3. A review of Patient 11's ED record was conducted on November 5, 2013. Patient 11 presented to the facility's ED, on September 4, 2013, at 5:30 p.m., and indicated on his "Emergency Patient Sign-in Sheet," his reason for his visit was "CLL."

The American Cancer Society identifies Chronic lymphocytic leukemia (CLL) as a type of cancer that starts from white blood cells (called lymphocytes) in the bone marrow. It then invades the blood. White blood cells help the body fight infections. Lymphocytes are one type of white blood cell. The other types of white blood cells are granulocytes (such as neutrophils, basophils, and eosinophils) and monocytes.
The "Emergency Documentation," for Patient 11 indicated the patient was triaged on September 4, 2013, at 6:25 p.m. Patient 11's "Mechanism of Injury," was documented as "PT [patient] states has leukemia and fills (sic) like he needs a blood transfusion with weakness. Last transfusion was about six weeks ago." Patient 11 was identified as an ESI (Emergency Severity Index) 3 (urgent).

The record indicated orders for a complete blood count (CBC), and basic metabolic panel (BMP) were received at 6:31 p.m., and an order for a "manual differential," was received at 7 p.m.

A review of the CBC result completed at 7:22 p.m., indicated the following:

White blood count (WBC) - 64.15 "H" - [Reference Range 4.80-11.80];

Red Blood Count (RBC) - 3.07 "L" - [Reference range 3.80-5.30];

Hemoglobin (Hgb) - 8.6 "L" - [Reference range 11.0-16.0];

Hematocrit (Hct) - 27.4 "L" - [Reference Range 33.5-47.0];

Platelets -73 "L" - [Reference range 140-340];

Lymph Man - 97 % "H" [Reference range 7-40];

WBC estimate - Marked Increase "@" [Reference range Normal]; and

Platelet estimate - Decreased "@" [Reference range Normal].

The legend at the bottom of the laboratory report indicated: "@" = abnormal, "H" = High, and "L" = Low.

White blood cells are a major component of the body's immune system. Indications for a WBC count include infectious and inflammatory diseases; leukemia and lymphoma; and bone marrow disorders.

A high WBC count associated with other symptoms, including fatigue and anemia, may indicate a need to treat.

According to documentation in the record, Patient 11 returned to the lobby after the triage process. Patient 11 remained in the lobby until 9:54 p.m., when it was documented "pt stated not wanting to wait any longer, ambulatory gait steady. nad [no acute distress] noted." There was no evidence in the record that the patient was educated about the risks and benefits of leaving. There was no documented evidence the patient's abnormal WBC was relayed and/or seen by a QMP.

On November 5, 2013, at 11:40 a.m., Patient 11's record was reviewed with the ED Director. Patient 11 presented to the facility at 5:35 p.m., was triaged at 6:25 p.m., lab work was ordered at 7 p.m., blood collected at 7:17 p.m., and results were available at 7:22 p.m. Patient 11 left the facility, at 9:45 p.m., two and half hours after his laboratory results were available. Patient 11 left without undergoing a complete Medical Screening Examination (MSE).

In a concurrent interview with the ED Director, the ED Director stated lab results were "posted," when complete. The ED Director stated an icon would show up on the patient tracking board to indicate lab results were available. A yellow star icon would indicate the patient had abnormal labs, and a red star icon would indicate a lab result with a critical value.

The ED Director stated a lab result with a critical value would also be communicated to the department by telephone. A review of Patient 11's WBC indicated the result was "High," but was not a critical value. The ED Director stated a patient that left without being seen would not be notified about abnormal lab results.

A review of the policy, "Critical Values, Reporting and Communication," with a last reviewed date of November 1, 2012, was conducted. The policy indicated there was no critical value for high levels of WBCs in the blood.

On November 5, 2013, at 1:45 p.m., in an interview with the ED Director, the Director stated it looked like the "Quickview," nurse wrote the note about Patient 11 leaving at 9:55 p.m.

On November 6, 2013, at 12 p.m., the registration desk was observed. A registration clerk and the Quickview Nurse were sitting at the desk. A computer screen, with the ED tracking board was noted. The Quickview Nurse could easily see the number of registered patients and could see the yellow and red star icons associated with different patients currently in the ED.

In an interview with Registered Nurse (RN) 5, on November 6, 2013, at 12:10 p.m., RN 5 stated she could review lab results, but could not disclose the results to the patient. When asked what she would do, if a patient with abnormal lab results told her they were leaving, RN 5 stated she would attempt to get the patient to stay.

A review of the ED policy, "Five Level Triage #1356," with an approval date of April 15, 2011, was conducted. The policy indicated: "To provide a standardized system whereby patients presenting to the Emergency Department are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) Five Level Triage system ...The sickest patients (Level 1) will be seen first and (Level 5) patients will be seen last..."

The facility policy titled, "Compliance with EMTALA (Emergency Medical Treatment and Active Labor Act), dated May 14, 2013" was reviewed and indicated:

"Emergency services and care are defined as a medical screening examination and evaluation within the capability of the facility, including ancillary services routinely available to the emergency department, by an emergency physician or a practitioner under the supervision of a physician who is qualified to determine whether the patient has an emergency medical condition and what further medical examination and treatment is necessary to stabilize the emergency medical condition...

...A medical screening examination shall be provided to any person who comes to the LLUMC-Murrieta Emergency Department (ED)...and requests services and care, or for whom services and care are requested..."

The facility policy titled, "Five Level Triage (dated April 8, 2011)" was reviewed and indicated:

"Purpose: To provide a standardized system whereby patients presenting to the Emergency Department are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) Five Level Triage System...The sickest patients (LEVEL 1) will be seen first and (LEVEL 5) patients will be seen last...

...Patients who are triaged but leave before being seen by a Physician must have documentation in their medical record that they were called three times, prior to documenting they were a left without being seen...

...ESI Level 2: High-risk situations; new onset confusion, lethargy or disorientation...Unstable vital signs (HR, RR or O2 Sat in danger zone). When Level 2 condition is identified, the triage process stops, the patient is taken directly to a bed and immediate physician intervention requested...

...Danger Zone Vital Signs...greater than 8 yrs (old) HR greater than 100..."

The facility policy titled, "Assessment and Reassessment (dated April 15, 2011)" was reviewed and indicated:

"Purpose: To establish assessment criteria for all Emergency Department patients.

Policy...All patients who present for emergency care will receive a medical screening exam by a licensed independent practitioner...

...Vital signs are to be assessed upon arrival...from the ED. Vital signs are to include pain score, BP, HR...(when indicated)...Notify the ED physician promptly of abnormal vital signs so that interventions can be initiated in a timely manner..."