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Based on interviews, review of surveillance video and document review, it was determined the facility failed to provide medical screening examinations, including ED triage assessments, in order to assess for the presence of an emergency medical condition for ten (10) out of twenty-seven (27) patients reviewed (Patient # 1, 10, 14, 15, 18, 22, 23, 24, 25, 27).

The findings include:

06/16/22 at 10:15 am-The surveyor collected a sample of twenty-seven (27) patients (including Patient #1) who presented to the facility ED throughout the week of 05/12/22. All patient information was acquired from the ED logs, which were provided by Staff Member #6. The medical record review of all twenty-seven (27) patients were initiated at this time with Staff Member #6.

The surveyor identified the following concerns regarding a lack of triage assessments in the ED:

Patient #1-Presented to ED on 05/12/22 with a chief complaint of "Shortness of Breath". There was no evidence of vital signs, triage assessment, including pain or an Emergency Severity Index (ESI) rating. There was no evidence from the medical record that Patient #1 was ever assessed, including being triaged with an Emergency Severity Index (ESI) or vital signs prior to coding and going into cardiac arrest.

06/16/22 at 1:45 pm-The surveyor reviewed the video footage maintained by the facility with Staff Member #27 (Vice President of Operations) and Staff Member #6 regarding the encounter with Patient #1. From the footage, the surveyor observed the following details:

05/12/22 at 1:03:59: Patient #1 was parked in front of main entrance to ED. The patient can be seen briefly getting out of car and looking around.

05/12/22 at 1:04:54: Patient #1 quickly drives to ambulance/EMS bay entrance.

05/12/22 at 1:04:56: The Charge Nurse/Clinical Coordinator (Staff Member #17) appears to notice patient outside, and can be seen getting a law enforcement officer for assistance. Both the nurse and officer briefly speak with the patient. No assessment, vital signs or other treatment interventions were seen during the interaction.

05/12/22 at 1:06:19: The PCT (Staff Member #18) leaves the nurse's station to get a wheelchair.

05/12/22 at 1:06:33: The patient can be seen parking in the adjacent parking lot.

05/12/22 at 1:07:02: The patient can be seen collapsing onto the mulch area of parking lot.

05/12/22 at 1:07:42: Staff Member #18 arrives to the Patient #1 with a wheelchair, and immediately calls for help on radio. Staff Member #17 is seen running out to patient with the officer.

05/12/22 at 1:09:56: Additional nurses as well as the ED physician run out to assist the patient onto a stretcher.

05/12/22 at 1:11:20: Cardiopulmonary Resuscitation (CPR) is initiated while the patient is being transported by stretcher to the ED.

05/12/22 at 1:12:09: Patient #1 arrives to the trauma room of ED.

06/17/22 at 9:10 am-The surveyor conducted an interview with Staff Member #17. Staff Member #17 stated on phone "we were busy" that night. "I was at nurse's station looking at footage, and saw the patient at the main entrance when the patient then drove to the side ambulance bay entrance". Staff Member #17 stated that the EMS ambulance bay entrance is secured and locked at all time, and is only able to be opened with an approved security badge. Staff Member #17 stated that for safety, they requested that the police officer go out with them to talk to the patient. Staff Member #17 stated that they could recall the patient calling for help but that they informed the patient with the officer that they had to move car out of the ambulance entrance area.

Staff Member #17 stated that they received notification from the dispatcher that the patient was coming "at the same time" the patient presented to the facility. Staff Member #17 stated when they and the officer met the patient outside in front of ambulance bay entrance; the patient was noticeably " short of breath " . When the surveyor questioned Staff Member #17 if they could change anything about the event, and what they would do if a similar event arose, Staff Member #17 stated they would immediately bring back the patient for an immediately triage assessment, and request for a family member or security to move the vehicle, if needed.

06/14/22 at 9:14 am-The surveyor interviewed Staff Member #6 who provided additional information regarding Patient #1 ' s encounter. Staff Member #6 confirmed that the self-reported incident was considered a sentinel event, and that the facility conducted an internal investigation to inquire about the event. At the time of survey, many of the non-clinical ED staff had not received any education or other intervention by the facility related to this incident, and the action plan was not formally addressed or approved by the Medical Staff or Governing Body.

Staff Member #6 informed surveyor the patient had reportedly called 911, and was directed to the main visitor entrance of ED, and briefly got out of car to look around. Staff Member #6 stated that the patient immediately got back into running car to drive up to the ambulance entrance. Staff Member #6 stated that the patient was reportedly directed by the 911 emergency dispatcher to drive directly to the EMS bay entrance area of the ED for assistance. Staff Member #6 added that the emergency dispatcher had contacted the facility ED, and communicated with Staff Member #17 to notify that a patient would be arriving in need of emergent medical care. Staff Member #6 stated that the ED Charge Nurse (Staff Member #17) then noticed a patient was present, and outside of EMS entrance, in which Staff Member #17 requested to being accompanied by the law enforcement officer in meeting with the patient. Staff Member #6 informed surveyor that when interviewing Staff Member #17, the nurse advised that the patient was yelling for help, anxious mood with " escalated " demeanor, and stated they were short of breath.

Staff Member #6 stated that the nurse informed the patient they had to immediately relocate car before receiving medical care. The patient then attempted to offer car keys to nurse before the officer reiterated instructions to the patient that the patient was responsible in moving private vehicle. Staff Member #6 stated that Patient #1 complied with the request of the officer and nurse to move car. The ED patient care tech (PCT) (Staff Member #18) was instructed by nurse to get a wheelchair for patient. While bringing out wheelchair for Patient #1, Staff Member #18 observed that Patient #1 had collapsed and was non-responsive in the mulch area of the parking lot. Staff Member #18 then communicated with the ED team for immediate additional assistance by radio. Staff Member #6 stated that the ED staff brought out a stretcher for transporting the patient into the ED but that there was further treatment delay as the ED team had difficulty lifting the patient onto the stretcher due to the patient ' s size. Staff Member #6 then stated that the patient ultimately coded and died despite the team ' s best resuscitation efforts.


[Note: Although the following patients ultimately left the ED voluntarily, many of the patients presented with medical complaints without ever having been triaged or assessed, often with prolonged wait times].

Patient #10- Presented to ED on 06/14/22 with a chief complaint of "sore throat". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 49 minutes later.

Patient #14- Presented to ED on 06/11/22 with a chief complaint of "Mental Health Evaluation". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 6 hours and 29 minutes later.

Patient #15- Presented to ED on 06/10/22 with a chief complaint of "High Heart Rate". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 41 minutes later.

Patient #18- Presented to ED on 06/06/22 with a chief complaint of "Alcohol Intoxication". No evidence of triage assessment, including pain, vital signs or an Emergency Severity Index (ESI) rating. Patient left 20 minutes later.

Patient #22- Presented to ED on 06/12/22 with a chief complaint of "New onset trembling back of neck and legs". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 1 hour and 57 minutes later.

Patient #23- Presented to ED on 06/11/22 with a chief complaint of "Elevated Blood Pressure". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 3 hours and 57 minutes later.

Patient #24- Presented to ED on 06/11/22 with a chief complaint of "Migraine Headache". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 4 hours and 25 minutes later.

Patient #25- Presented to ED on 05/09/22 with a chief complaint of "Mental Health Crisis" No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 2 hours and 52 minutes later.

Patient #25- Returned to ED on 05/10/22 with a chief complaint of "Wants Mental Help/Psych" No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 29 minutes later.

Patient #27- Presented to ED on 05/11/22 with a chief complaint of "Kidney Stone". No evidence of triage assessment, including pain or an Emergency Severity Index (ESI) rating. Patient left 1 hour and 31 minutes later.

The surveyor requested the ED triage and assessment policy from Staff Member #6 in the afternoon of 06/16/22. The surveyor acquired the facility policy titled, "Assessment and Reassessment of Patients "(with effective date of 01/2021). On page ten (10) of policy reads, "All patients entering the Emergency Department will be triaged upon arrival. The five-level triage assessment differentiates the severity of patient problems and prioritizes care, designating appropriate [ESI] levels. The assessment is initiated upon patient arrival, regardless of entry point (triage or immediately to treatment area). " The policy then goes on to say that triage should entail classifying the patient based on severity, known as the ESI scale, and ranges from " Resuscitation " and " Emergent " to " Less Urgent " and " Non-urgent " . The same policy continues to read, "Upon arrival, all patients who arrive by private vehicle will sign on an arrival sheet and the nurse will triage the patient.

The policy stated, "If the initial rapid survey [reported chief complaint] upon patient arrival reveals a resuscitative or emergent condition, triage will be done at the bedside. Otherwise, bedside triage may be performed in situations when there is an available nurse and available treatment area. An Emergency Department physician assesses all patients presenting for treatment in the Emergency Department.

The policy continued to say:

"An assessment is performed by a licensed nurse for each patient and is recorded on the Emergency Department system form and includes, but is not limited to: a. airway, breathing, and circulation status b. chief complaint c. Focused systems assessment based on the chief complaint/triage d. allergies e. current medications f. vital signs g. tetanus and immunization status h. last menstrual period for females as it relates to the chief complaint i. past medical and surgical history as appropriate to the chief complaint i. past medical and surgical history as appropriate to the chief complaint j. history of, and recent exposure to, communicable disease of a respiratory nature k. previous hospitalizations and surgeries l. psychosocial/emotional status m. pain assessment n. skin assessment ."
The surveyor conducted an interview with Staff Member #6 regarding the policy. Staff Member #6 confirmed that any patient arriving to ED should be immediately triaged by nursing, and that the triage should include at least an ESI rating, vital signs, and a brief assessment."

Staff Member #6 also provided the surveyor with the facility policy titled, "Virginia EMTALA-Medical Screening Examination and Stabilization Policy "(with effective date of 06/2021). The policy reads, "An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED " ) and: 1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition." The policy continues to say, " If a prudent layperson observer would believe that the individual is experiencing an EMC [emergency medical condition], then an appropriate MSE [Medical Screening Examination] ...shall be performed ".

06/16/22 at 3:46 pm-The surveyor interviewed Staff Member #9 (ED Director). The surveyor questioned Staff Member #9 regarding the triage and assessment of patients by ED staff, as well as how patients are screened upon entering ED. Staff Member #9 stated that the expectation is for all patients to be immediately assessed and triaged, including the acquisition of pain rating, ESI, and vital signs. Staff Member #9 added that "ideally " , all patients arriving to ED would be assessed by a triage nurse upon entrance. Staff Member #9 added that the nurse triage assessment is component of the MSE but that a provider, such as the ED physician, can replace the need for a triage and ESI rating if an MSE is made instead. Staff Member #9 advised the surveyor during interview that the ED has been struggling with staffing issues, and only has a PCT available up front to greet and recept patients, and possibly take vital signs. Staff Member #9 added that PCTs cannot provide triage assessments. Staff Member #9 advised the surveyor that since a PCT cannot perform triage assessments, and since the ED nurses are not usually available up front, many patients do not always get triaged and assessed upon entrance. When the surveyor questioned Staff Member #9 if it was common for some patients to not get a triage assessment or a MSE, Staff Member #9 added that it " does occur " , especially throughout the night when staffing is limited.

The surveyor made Staff Member #9 aware during interview that there was no documentation that Patient # 1, Patient #10, Patient #14, Patient #15, Patient # 18, Patient # 22, Patient #23, Patient #24, Patient #25, and Patient #27 were triaged or assessed by nursing despite presenting with seemingly urgent needs, and waiting prolonged periods. Staff Member #9 expressed concern and stated that staffing in the ED currently at that time was, and still is, limited. Staff Member #9 stated that although the patients in the ED are seen by acuity, all patients arriving should be at least screened and triaged by nursing upon arrival.