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A. Based on document review, review of facility policy and procedure, review of three (3) of three (3) medical records, and staff interviews, it was determined that the facility failed to ensure that its policy on the triage of obstetric patients is implemented.

Findings include:

Reference: Facility policy, Care of a Patient in Obstetric Triage states, "... 1. Patients will be triaged into the following levels: 1. Emergent: needs immediate assessment by a provider... 2. Urgent: needs to be seen by a provider within 15 minutes... 3. Stable: needs to be re-evaluated within 30 minutes by the RN, and seen by the provider after emergent and urgent cases are seen. ... ."

1. Review of Medical Records #1, #8, and #10 lacked evidence of the patient's assigned triage level.

2. Upon interview, Staff #7 confirmed that obstetric triage patients are not assigned triage levels, as indicated in the facility policy.

3. Staff #2, Staff #3, and Staff #4 confirmed the above findings.


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B. Based on document review, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that policies and procedures for education and training are implemented.

Findings include:

Reference #1: Facility policy, New Employee Orientation states, " ... Policy Guidance: 1. Newly hired employees must attend the general orientation within 30 days of their start date. ...
3. Orientation will be for all employees, including, but not limited to: full time, part time, temporary, per diem, contract, and agency employees. ...4. Department Orientation 1. Department Directors will be required to have a department orientation for all new employees within that department within the first week. ... ."

Reference #2: Facility policy, Emergency Department Staff Education and Training states, " ... Policy Guidance: ... 2. After successful completion of general orientation, staff will then be assigned to the Emergency Department, to completed departmental specific orientation. Staff in the ED (Clerks, Technician and Nurses) will receive education and training specific to their service, of different categories of staff on all work shifts. ... ."

Reference #3: Vendor contract, Master Services Agreement states, " ... 3.5 Hiring and Orientation of Other Staff. ...Vendor will provide orientation specific to [licensing contracted agency] and the applicable Facilities to all the Vendor Personnel as appropriate, including providing them with information of [licensing contracted agency] and the applicable Facilities' policies and procedures... ."

1. During the entrance conference on 11/21/18, Staff #3 stated that all Emergency Department (ED) staff receive EMTALA education and training upon orientation.

2. During a tour of the ED on 11/21/18, employees were asked to explain the Emergency Medical Treatment and Labor Act (EMTALA) law. The following was determined:

a. Staff #10 was not versed in EMTALA law and language.

b. Staff #12 was not versed in EMTALA law and language.

3. Upon interview, Staff #14 stated after two weeks of training, a new Patient Access Representative and the Patient Access Supervisor will have a face to face evaluation with the staff member to determine if they are able to work independently.

a. Review of personnel records for Staff #11 lacked evidence of a face to face evaluation having been completed.

4. Staff #2, Staff #3 and Staff #14 confirmed the above findings.

5. During a tour of the Labor and Delivery Unit (L&D) on 11/21/18, employees were asked to explain the Emergency Medical Treatment and Labor Act (EMTALA) law. The following was determined:

a. Staff #13 was not versed in EMTALA law and language.

6. Staff #2 and Staff #3 confirmed the above findings.

C. Based on document review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that policies and procedures for the Emergency Severity Index (ESI) triage system are implemented.

Findings include:

Reference #1: Facility policy, Triage of Patients Presenting to the Emergency Department states, "... Policy Statements: 1. ... An initial triage will be conducted by the nurse, who will determine the priority of care necessary and the appropriate area for further evaluation and treatment. ...Policy Guidance: ... 1. The Emergency Severity Index (ESI) triage system will be used to categorize patients, based on acuity and resource needs. ... Emergency care will be initiated according to the patient's Urgency Level Rating, as defined by ESI. ... 3. Level 2, Emergent- High risk situation, signs of a time -critical problem, sever{sic} pain/distress, or acute confusion. Such as lethargy/disorientation, cardiac-related chest pain, asthma attack. ... ."

Reference #2: Facility policy, ED Patient Processing states, " ... Triage classification is indicated in patient's electronic medical record. ...4. The Triage Nurse will make the determination of the order of Triage for patients."

Reference #3: Facility document, ESI Triage Research Team, 2004 states, " ... ESI level 2, high risk situation or confused/lethargic/disoriented, or severe pain/distress ...Notes: ...Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. ... ."

1. Review of Medical Record #3 on 11/23/18 revealed the following:

a. The patient arrived to the Emergency Department (ED) on 10/25/18 at 9:50 AM with complaints of chest pain. The patient reported mid sternal chest pain and tightness, rated 5 out of 10, on the numeric pain scale. The pain radiated into his/her throat. He/she also reported feeling clammy and nauseous.

i. The patient was triaged at 10:02 AM and assigned an ESI acuity level of 3.

ii. The patient had an abnormal EKG and was transferred to another facility via helicopter at 1:15 PM with a diagnosis of a STEMI (ST elevated myocardial infarction).

b. Upon interview, Staff #8 confirmed that the patient presented with symptoms that should be assigned an ESI acuity level of 2.

2. Review of Medical Record #5 on 11/23/18 revealed the following:

a. The patient arrived to the ED on 7/3/18 at 6:36 PM with complaints of abdominal pain and a hematoma. The patient is sixteen (16) weeks pregnant. The patient reported pain of 10 out of 10 on the numeric pain scale.

b. The patient was triaged at 6:58 PM and assigned an ESI acuity level of 3.

c. Upon interview, Staff #8 confirmed that patients who present with severe pain, 10 out of 10 on the numeric pain scale, should be assigned an ESI acuity level of 2.

3. Review of Medical Record #14 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 4/4/18 at 9:46 AM with complaints of stroke symptoms. The patient reported that he/she could not feel the left side of his/her face and had pain rated an 8 out of 10 on the numeric pain scale.

i. The patient was triaged at 10:00 AM and assigned an ESI acuity level of 3.

b. Upon interview, Staff #8 confirmed that the patient presented with symptoms that should have been assigned an ESI acuity level of 2.

4. Review of Medical Record #19 on 11/26/18 revealed the following:

a. The patient presented to the ED on 9/23/18 at 10:42 PM with complaints of progressively worsening chest pain radiating to his/her left arm. The patient reported pain rated 8 out of 10 on the numeric pain scale.

b. The patient was triaged at 11:06 PM. There was no ESI acuity level assigned to the patient.

5. Review of Medical Record #20 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 9/23/18 at 9:00 AM with complaints of abdominal pain and colitis. He/she reported pain 10 out of 10 on the numeric pain scale.

b. The patient was triaged at 9:13 AM and assigned an ESI acuity level of 3.

c. Upon interview, Staff #8 confirmed that patients who present with severe pain, 10 out of 10 on the numeric pain scale, should be assigned an ESI acuity level of 2.

6. Review of Medical Record #23 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 6/20/18 at 8:23 PM with complaints of chest pain. He/she reported pain 7 out of 10 on the numeric pain scale.

b. The patient was triaged at 8:35 PM and assigned an ESI acuity level of 4.

c. The patient was not assigned an appropriate ESI acuity level according to facility policy.

7. Review of Medical Record #24 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 10/25/18 at 1:10 PM with complaints of vaginal bleeding and lower abdominal pain. The patient reported pain 10 out of 10 on the numeric pain scale.

b. The patient was triaged at 1:51 PM and assigned an ESI acuity level of 3.

c. Upon interview, Staff #8 confirmed that patients who present with severe pain, 10 out of 10 on the numeric pain scale, should be assigned an ESI acuity level of 2.

8. Review of Medical Record #28 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 6/20/18 at 1:25 PM with complaints of abdominal pain that radiated to his/her chest. The patient reported pain 8 out of 10 on the numeric pain scale.

i. The patient was triaged at 1:32 PM and assigned an ESI acuity level of 3.

b. Upon interview, Staff #8 confirmed that the patient presented with symptoms that should be assigned an ESI acuity level of 2.

9. Review of Medical Record #30 on 11/26/18 revealed the following:

a. The patient arrived to the ED on 7/4/18 at 11:14 PM with complaints of shortness of breath.

b. The patient was triaged at 11:27 PM. There was no ESI acuity level assigned to the patient.

10. Staff #2, Staff #3, Staff #4, and Staff #8 confirmed the above findings.


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D. Based on a review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to follow its policy regarding pain management.

Findings include:

Reference: Facility policy, Pain Management Standard states, "... When pain is identified, appropriate interventions or referrals are utilized and follow up evaluations and documentation ensues to assess outcomes. ... 1. Pain is assessed on all patients. ... Once an intervention is instituted to address pain needs, appropriate follow-up assessment is required. ... 5. Documentation... Pain reassessment is completed within a maximum of one hour following pain medication administration and is documented. ... ."

1. Review of Medical Record #5 on 11/23/18 revealed the following:

a. The patient presented to the Emergency Department (ED) on 7/3/18 at 6:36 PM with complaints of abdominal pain. The patient rated his/her pain 10 out of 10 on the numeric pain scale.

b. Review of the Medication Administration Record (MAR) indicated that Morphine 2 MG IV was administered at 7:30PM.

c. There was no evidence that the patient's pain level was reassessed one (1) hour after pain medication was administered.

2. Review of Medical Record #18 on 11/26/18 revealed the following:

a. The patient presented to the ED on 5/12/18 at 9:15 AM with complaints of falling down stairs. The patient was twenty-three (23) weeks pregnant.

b. There was no evidence that a pain assessment was performed, as indicated in the facility's policy.

c. The patient was discharged on 5/12/18 at 11:14 AM in improved condition.

3. Review of Medical Record #20 on 11/26/18 revealed the following:

a. The patient presented to the ED on 9/23/18 at 9:00 AM with complaints of diarrhea and abdominal pain.

b. The patient complained of pain 10 out of 10 at 11:03 AM. Hydromorphone 1MG IV was administered at 11:03 AM.

i. There was no evidence that the pain was reassessed within one (1) hour.

c. The patient complained of pain 7 out of 10 at 3:20 PM. Hydromorphone 1MG IV was administered at 3:21 PM.

i. There was no evidence that the pain was reassessed within one (1) hour.

4. Review of Medical Record #21 on 11/26/18 revealed the following:

a. The patient presented to the ED on 8/18/18 at 5:50 PM with complaints of a head injury.

b. There was no evidence in the medical record of a pain assessment.

5. Review of Medical Record #23 on 11/26/18 revealed the following:

a. The patient presented to the ED on 6/20/18 at 8:23 PM with complaints of chest pain. The patient rated the pain 7 out of 10 on the numeric pain scale.

b. The patient was administered 10 ML of Lidocaine HCL 2% viscous solution for pain at 9:43 PM.

c. There was no evidence that the pain was reassessed within one (1) hour.

6. Review of Medical Record #24 on 11/26/18 revealed the following:

a. The patient presented to the ED on 10/25/18 at 1:10 PM with complaints of vaginal bleeding. The patient was twelve (12) weeks pregnant.

b. Upon arrival to the ED, the patient complained of pain 10 out of 10 on the numeric pain scale.

c. There was no evidence that pain interventions were implemented.

7. Staff #3 and Staff #8 confirmed the above findings.

Based on observation, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to conspicuously post signage in areas of the facility where patients may come to seek emergency treatment.

Findings include:

Reference: Facility policy, EMTALA Compliance-Signage states, " ... Policy Statements: The Emergency Department and other areas of the Hospital where patients may come to the Hospital seeking emergency treatment must post appropriate signage notifying patients of their right to a medical screening examination and stabilizing treatment as specified under EMTALA. Policy Guidance: 1. Locate one or more signs conspicuously and in a place or places likely to be noticed by all individuals entering the emergency department as well as those individuals waiting for examination and treatment. 1. NOTE: Departments other than the traditional emergency department where patients may come to the Hospital must also post appropriate signage. These areas may include the entrance, admitting areas, waiting rooms, and treatment areas. ..."

1. Upon interview on 11/21/18, Staff #3 confirmed that patients from the ED who are placed in observation status are kept on 3 West, a medical surgical unit.

2. During a tour of 3 West on 11/21/18, the following was observed:

a. There was no evidence of EMTALA signage on the unit.

b. Patient #12 was an ED patient placed in observation status. There was no evidence of EMTALA signage in Patient 12's room.

3. Upon interview, Staff #3 and Staff #16 confirmed that EMTALA signage is not posted on the various units that house ED patients in observation status.

Based on document review and staff interviews, it was determined that the facility failed to ensure that all records related to an individuals transfer to or from the hospital, are maintained for a period of 5 years.

Findings include:

1. A request was made to Staff #8 on 11/26/18 for the ED ambulance trip reports.

2. Staff #8 stated that the facility does not keep ambulance trip reports or an ambulance log for patients transferred into or out of the hospital. He/she stated, "The ambulance company does not give us any papers. We just sign a paper that says we accept the patient. They take the paper with them."

3. Staff #2, Staff #3, and Staff #4 confirmed the above findings.

Based on document review and staff interviews, it was determined that the facility failed to ensure that its on-call list of physicians identifies on-call physicians by individual names.

Findings include:

1. On 11/26/18, the Emergency Department's on-call physicians schedule for November 2018 was reviewed.

a. From November 1, 2018 to November 24, 2018, under the specialty labeled "Dermatology", the name of a physician group was indicated.

b. From November 1, 2018 to November 24, 2018, under the specialty labeled "Pediatrics", there was no physician name identified.

2. Staff #3 and Staff #7 confirmed the above findings.

A. Based on document review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that a central log is provided on each individual who comes to the hospital seeking care for an emergency medical condition.

Findings include:

Reference: Facility policy, Medical Screening Exam for Labor Status states, "... 2. Unscheduled OB (obstetric) Patient: Any obstetric patient who presents to the hospital (Emergency Department or Labor & Delivery) unannounced, unplanned, or unanticipated. ... By registering the patient as an Obstetric triage patient, the patient's name will be placed in the Triage Log Book. 3. Scheduled OB Patient: An obstetric patient who is prescheduled... These patients are registered as inpatients, clinical patients, or outpatients as appropriate, and will also be listed in the Admission log in Labor & Delivery. The scheduled OB patient is not a triage patient... ."

1. A request was made to Staff #1 on 11/21/18 for the OB Triage Logs for the following dates: 4/4/18, 5/12/18, 6/20/18, 7/4/18, 8/18/18, 9/23/18, 10/25/18, 10/26/18, and 10/27/18. The logs provided were titled "Labor & Delivery Outpatient Log."

2. Review of the logs on 11/23/18 revealed that all patients admitted to the Labor & Delivery unit were listed in the Labor & Delivery Outpatient Log.

3. Upon interview, Staff #7 confirmed that the Labor & Delivery department does not have a Triage Log for obstetric triage patients. He/she confirmed that triage patients are listed in the Outpatient Log with scheduled obstetric patients.

4. Staff #2, Staff #3, and Staff #4 confirmed the above findings.


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B. Based on document review and staff interviews, it was determined that the facility failed to ensure that the Emergency Department (ED) maintains an accurate central log.

Findings include:

1. Patient #12 arrived to the ED on 11/20/18. The ED central log listed the patient's disposition status as admitted.

a. Upon interview, Staff #3 confirmed that the patient was placed in observation status and was not admitted to the hospital.

2. Patient #27 arrived to the ED on 9/23/18. The ED central log listed the patient's disposition status as admitted.

a. Upon interview, Staff #3 confirmed that the patient was placed in observation status and was not admitted to the hospital.

3. Staff #1 and Staff #3 confirmed the above findings.

Based on document review, review of medical records, and staff interviews, it was determined that the facility failed to ensure that reasonable registration processes may not unduly discourage individuals from remaining for further evaluation.

Findings include:

1. Review of Medical Record #8 on 11/23/18 revealed the following:

a. The patient arrived to the ED on 8/19/18 at 6:38 PM with complaints of bilateral lower extremity edema. The patient was thirty-seven (37) weeks pregnant.

b. The patient was triaged at 7:12 PM and received an MSE (medical screening examination) at 8:49 PM.

c. Registration documentation revealed that the patient received a full registration, including insurance information, at 6:38 PM.

d. The patient received a full registration prior to being triaged.

2. Review of Medical Record #10 on 11/23/18 revealed the following:

a. The patient arrived to the ED on 11/18/18 at 9:43 AM with complaints of spotting. The patient was thirty-four (34) weeks pregnant.

b. The patient was triaged at 9:43 AM and received an MSE at 9:51 AM.

c. Registration documentation revealed that the patient received a full registration, including insurance information, at 9:25 AM.

d. The patient received a full registration prior to being triaged.

3. Staff #2, Staff #3, and Staff #4 confirmed the above findings.

A. Based on document review, review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that the transfer of patients out of the ED utilizes appropriate personnel, appropriate equipment, and appropriate life support measures during the transfer.

Findings include:

Reference: Facility policy, InterFacility Transfer of Patients states, "... 10. The transfer must occur utilizing appropriate personnel as indicated by the treating physician and transported with appropriate equipment as required, including the use of necessary and medically appropriate life support measures during the transfer. ... ."

1. Review of Medical Record #30 on 11/23/18 revealed the following:

a. The patient arrived to the ED on 7/4/18 at 11:14 PM with complaints of shortness of breath and dizziness.

i. A CT angiogram of the chest revealed that the patient had multiple pulmonary emboli. A decision was made to transfer the patient to another facility for a higher level of care.

b. Review of the physician's orders indicated that an order was placed on 7/5/18 at 4:23 AM to transfer the patient to "[Name of facility] ICU."

c. A request was made on the Ambulance Transport: Medical Certification Form, for the patient to be transferred via ambulance with ACLS (advanced cardiac life support) care, IV fluids, and EKG monitoring. This form was signed by an RN and not the treating physician.

d. There was no evidence in the medical record that the patient was transported with ACLS care, IV fluids, or EKG monitoring.

e. There was no evidence in the medical record that the treating physician indicated the appropriate equipment and personnel required to transfer this patient.

2. Staff #2, Staff #3, and Staff #4 confirmed the above findings.



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B. Based on document review, review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that transfer documents are complete for all patients transferred out of the ED.

Findings include:

Reference #1: Facility policy, Universal Transfer Form and Instructions states, "... Policy Statements: 1. A Universal Transfer Form must be completed for transfer of a patient to any acute facility... Instructions... COMPLETE ALL BOXES #1-29... ."

Reference #2: Facility policy, INTER Facility Transfer of Patients states, "... Policy Guidance... 4. An informed consent from the patient regarding transfer request must be obtained, including risks and benefits of transfer... 12. A copy of the patient's medical records related to their emergency conditions, ambulance transfer form, consent to transfer and universal transfer form must be sent to the receiving hospital at time of transfer. ... ."

1. Upon interview on 11/23/18, Staff #8 confirmed that the facility uses the Universal Transfer Form when transferring patients out of the ED.

2. Review of Medical Record #3 on 11/23/18 revealed the following:

a. The following boxes on the Universal Transfer form were incomplete:

i. Box #2: Time of Transfer

ii. Box #5: Physician Phone Number

iii. Box #10: Restraints

iv. Box #12: Isolation Precautions

v. Box #15: Skin Condition

vi. Box #16: Diet

vii. Box #18: Personal Items Sent With Patient

viii. Box #19: Attached Documents

ix. Box #24: Immunizations/Screening

x. Box #27: Receiving Facility Contact, Title, Unit, Phone

xi. Box #29: Form Completed By - Title, Phone

3. Review of Medical Record #16 on 11/26/18 revealed the following:

a. The Consent To Transfer form failed to include the following:

i. The physicians name

ii. If the transfer was/was not medically necessary and appropriate

iii. The name of the receiving facility

iv. The explanation of the transfer and the benefits that outweigh the risks

v. The estimated transport time

b. The following boxes on the Universal Transfer Form were incomplete:

i. Box #6: Code Status

ii. Box #8: Pain

iii. Box #24: Immunizations/Screening

iv. Box #27: Receiving Facility Contact: Phone

v. Box #29: Form Completed by: Name, Title, Phone

4. Review of Medical Record #30 on 11/26/18 revealed the following:

a. The Consent to Transfer form failed to include the following:

i. If the transfer was/was not medically necessary and appropriate.

b. The following boxes on the Universal Transfer form were incomplete:

i. Box #2: Time of Transfer

ii. Box #5: Physician Name, Phone Number

iii. Box #7: Contact Person, Relationship, Phone Number

iv. Box #18: Personal Items Sent With Patient

v. Box #20: Weight Bearing Status

vi. Box #24: Immunizations/Screening

vii. Box #27: Receiving Facility Contact, Title, Unit, Phone

viii. Box #29: Form Completed By - Title, Phone



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5. Review of Medical Record #19 on 11/26 revealed the following:

a. The following boxes on the Universal Transfer form were incomplete:

i. Box #2: Date and Time of Transfer

ii. Box #4: Language

iii. Box #8: Pain

iv. Box #14: Sensory

v. Box #18: Personal Items Sent With Patient

vi. Box #20: Weight Bearing Status

vii. Box #24: Immunization Screening

viii. Box #29: Form Completed By - Title, Phone

c. The Consent to Transfer form failed to include the following:

i. Name of the accepting/receiving provider

ii. Estimated transport time

iii. The patient's medical condition

2. Staff #3 and Staff #8 confirmed the above findings.