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Based on interviews and record review it was determined the facility failed to comply with 489.24 as evidenced by a failure to maintain a centralized Emergency Room Log for each individual and specifically patient #11, who sought treatment, and failed to provide appropriate Emergency Medical Screening for patient #11 who presented with an arterial bleed of the hand.

Refer to A 2406

Based on interview and record review it was determined the facility failed to maintain a central log on each individual who came to the Emergency Department (ED) seeking assistance and specifically patient #11. Patient 11 presented to the ED on August 30, 2010 at 6:30 PM, verbally requested emergency service, and eventually left the ED prior to completing the facility's patient information sheet and prior to being triaged or treated .

The findings include:

Interview on 09/16/10 at 9:34 AM, with Patient #11 revealed he/she presented to the ED on 08/30/10 at approximately 6:30 PM and requested treatment of a bleeding injury to the hand. The patient stated after waiting about ten (10) minutes to be seen he/she left the ED without completing the patient information worksheet. Patient #11 stated he/she returned the ED room at approximately 7:30 PM on 08/30/10. The facility was unable to control Patient #11's bleeding and the patient was air lifted to another hospital for treatment by a vascular hand specialist.

Interview on 09/16/10 at 2:10 PM, with Registration Clerk #5 revealed that a Registration Log was maintained for all patients seeking treatment in the ED. She explained the Registration Log was not initiated until the patient information sheet was completed.

Interview on 009/16/10 at 1:51 PM, with ED Clerk #6 revealed she also maintained the ED Registration Log. She explained the ED Log was not completed until she received the patient information sheet or registration sheet.

Review of the Registration Log revealed no documented evidence that Resident #11 had sought treatment at approximately 6:30 PM on 08/30/10, when he initially presented to the ED.

During interview on 09/16/10 at 2:53 PM, the Chief Nursing Officer stated the facility did not maintain a sign-in log at the ED admission desk because she thought it was a Health Insurance Portability and Accountability Act (HIPAA) violation.

Review of the facility's policy "Management of Patients Presenting with Emergency Medical Conditions", revised June 2006, revealed the policy detailed the information to obtain for the ED central log but did not detail how the facility would ensure all persons seeking services were included on the log, (i.e. did not address when and how the log would be initiated).

Based on interview and record review it was determined the facility's emergency department (ED) failed to ensure that a Medical Screening Examination was provided for an individual when requested. Patient #11 initially presented to the ED on August 30, 2010 at 6:30 PM with an arterial bleed ( major bleeding may be a life threatening condition requiring immediate attention ) of the left hand to the facility who had the capability to determine whether or not an Emergency Medical Condition existed.

The findings include:

Interview conducted on 09/16/10 at 9:34 AM, with Patient #11 revealed he/she sought emergency treatment for a bleeding hand at approximately 6:30 PM on 08/30/10. The patient stated he/she was informed by the registration clerk there were no beds available and was asked to complete registration paperwork while waiting to be seen. Patient #11 stated he/she requested several times to have the doctor evaluate the extent of his/her injury, with no success. The patient stated after waiting approximately 10 minutes he/she felt they would get faster treatment at a nearby ED (approximately twenty (20) miles away) and left the facility.

Interview on 9/16/10 at 1:19 PM, with the person who initially transported Patient #11 to the facility's ED on August 30, 2010, revealed the patient presented to the ED and asked several times to have a doctor look at the injured hand. This person stated after about ten (10) minutes he and the patient decided the patient would get faster treatment at a nearby ED and they left the facility.

Interview, on 09/15/10 at 2:26 PM, with Registration Clerk #2 revealed she was on duty at 6:30 PM when Patient #11 sought treatment for the injured hand. The registration clerk stated the patient did not stay long enough for her to get the nurse.

Review of the facility's Emergency Room Registration Log found no documented evidence of Patient #11's visit, on 08/30/10 at 6:30 PM. (Cross reference A2405).

An additional interview, with Patient #11, on 09/16/10 at 9:34 AM revealed when he/she arrived home from the 6:30 PM Emergency Department visit, his/her son insisted they return to the facility and not go to the next closest ED. The patient stated upon return to the facility at approximately 7:30 PM, the facility again asked that the registration paperwork be completed and was told someone would be with him/her in a few minutes. The patient stated he/she was there for about twenty (20) minutes and no one checked on him/her. Patient #11 stated he/she went to the registration desk and asked to be seen, when a woman (RN#5) came from the back, saw the bloody hand and took the patient for treatment.

Interview, on 09/15/10 at 3:28 PM, with Registration Clerk #2 revealed Patient #11 presented for treatment the second time, and she asked the patient to complete a registration sheet and informed the triage nurse the patient was in the lobby. The registration clerk stated she had no medical training, but saw nothing that indicated she needed to get the triage nurse immediately. Additionally Registration Clerk #2 stated arrival time is not documented until after the patient registration sheet has been completed and returned to the registration clerk.

Interview, on 09/15/10 at 3:36 PM, with Registered Nurse #6, the triage nurse on duty on 08/30/10, revealed she was informed of Patient #11's initial presence in the ED, but did not remember details. She stated she was busy and did not triage the patient. RN #6 explained when she went to get the patient he/she was no longer in the waiting room. Per interview with Registration Clerk #2, it was learned that she did not notify the triage nurse of Patient #11's presence until the second, 7:30 PM visit.

An interview, on 09/15/10 at 2:54 PM, with RN #5 revealed she identified Patient #11 as needing immediate medical attention, when she saw him on the second visit. The RN explained she had entered the ED lobby area to call another patient back for treatment. She stated when she saw Patient #11's hand wrapped in a bloody towel, she had Patient #11 remove the towel and saw pulsating blood coming from the wound. RN #5 stated she took Patient #11 to the treatment area and began efforts to stop the bleeding. Review of the ED Nursing Record revealed RN #5 began triage of Patient #11 at 7:44 PM. The RN stated the registration clerk should have recognized Patient #11 needed immediate medical attention.

Review of the ED Nursing Record revealed the facility was unable to stop Patients #11's bleeding and the patient was transferred to another hospital at 9:18 PM. Review of the "Interfacility Transfer Form" revealed the transfer to the other hospital was necessary for Patient #11 to be seen by a vascular/hand specialist. Per the transfer form, Patient #11 was sent via helicopter.

Review of Patient #11's ED Medical Record, Nursing Documentation, revealed that Patient #11 arrived at 7:30PM and was triaged at 7:44 PM. Patient #11 was in the facility waiting for treatment of an arterial bleed for more than fourteen minutes after his/her second attempt to obtain emergency medical treatment at this facility. The Medical Record review and Registration Clerk #2's interview that arrival time is not documented until after the registration form is completed, validates Patient #11's statement he waited about twenty (20) minutes when he/she sought treatment at 7:30 PM.

Review of the facility's policy for registration and emergency triage revealed no procedure regarding which patients, the registration staff should refer immediately to the triage nurse. However, a sign was posted at the registration desk stated the triage nurse should be notified immediately for the following: chest discomfort, difficulty breathing, weakness, sweating, nausea, lightheadedness, cardiac history, patients 18 to 80 and older with pain navel to neck. The sign did not address bleeding injuries.

Review of the facility's policy "Triage" which was not dated, revealed ED patients were treated based on acuity utilizing the Emergency Severity Index Five Level triage system (Gilboy, Tanabe, Travers, Eitel, and Werz, 2003). Based on this system the five levels are:
Critical - conditions that require immediate and aggressive intervention
Emergent - conditions that represent initial loss of life or limb if interventions not done promptly
Urgent - Interventions need in the ED for timely return to health, heart rate and respiratory rate within normal limits
Non-Urgent-conditions that will benefit from being seen in the ED, but may wait to be seen, and
Minor- conditions that may be seen in clinic setting and/or have no expectation of deterioration.

Review of Patient #11's ED nursing record revealed the patient was classified as needing urgent care even though he was bleeding excessively from his hand, which under the defined Emergency Severity Index should have been classified as an Emergent condition. Review of facility's policy and procedure entitled "Triage", revealed that "bedside registration shall occur for patients critical or emergent." This policy also indicates that the following steps should occur when making triage decisions:
Determine chief complaint; Conduct an "across the room assessment; conduct an objective assessment and a subjective assessment. The policy does not indicate who is completing these tasks or how soon after patients arrival, these tasks should be accomplished. The facility failed to ensure that the patient was triaged accurately according to their policy .