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Based on observation, interview, and record review, the hospital failed to ensure to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for one of 20 sampled patients (Patient 13) and failed to ensure the OB physician and MHA 1 had completed the EMTALA training annually. Cross reference to A2406.

2. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for 11 of 20 sampled patients (Patients 1, 2, 5, 8, 9, 10, 12, 16, 17, 18, and 20). Cross reference to A2407.

3. The hospital failed to ensure the ED staff appropriately transferred four of 20 sampled patients (Patients 5, 8, 11, and 20) when the Patient Transfer Summary forms were not completed for Patients 5, 8, 11, and 20 as per the hospital's P&P. Cross reference to A2409.

Based on observation, interview, and record review, the hospital failed to ensure the signages for EMTALA rights with respect to the examination and treatment for emergency medical conditions (EMC) and women in labor were posted conspicuously in the ED areas where the signages would likely be noticed by the individuals visiting the ED area as evidenced by:

1. The EMTALA signage in the Main ED, Triage Tent, and Ambulance Bay were not clearly visible from a distance as per the hospital's P&P.

2. The EMTALA signage was not posed in the ED procedure room.

These failures had the potential to result in the individuals to not be aware of their rights to the examination and treatment in the event of an emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA dated 10/15/21, showed signage refers to the requirement that the hospital post conspicuous signs in the ED and L&D Department and other places in which patients may present. The signs must specify the rights of unstable individuals with emergency conditions and women in labor who come to the ED and L&D Department. The letters within the sign must be clearly readable at a distance of 20 feet from the vantage point of persons in the ED and L&D department.

1. On 7/3/2024 at 0950 hours, a tour of the Main ED, Triage Tent, and Ambulance Bay was conducted with the ED Director.

The posted EMTALA signage was noted conspicuously. However, the font of the letter was too small and could not be read from a distance of 20 feet.

On 7/3/2024 at 1050 hours, the above findings were shared with the ED Director and CNO.


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2. On 7/3/24 at 1128 hours, a tour of the ED was conducted with the Sr. Director of Critical Care. In the hospital lobby, it was observed a space which was divided by the plastic partition panels. According to the Sr. Director of Critical Care, this area was an ED procedure room where the minor procedures would be performed. The Sr. Director of Critical Care confirmed there was no EMTALA signage posted in this area.

Based on interview and record review, the hospital failed to maintain a central ED log for two of 20 sampled patients (Patients 13 and 14) to show an ED disposition to the OB Triage. This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED and L&D Department for the treatments of their emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA dated 10/15/21, showed the Central Log will indicate whether individuals refused treatment; were denied treatment; were treated, admitted, stabilized; and/or transferred or discharged.

On 7/3/24, review of the ED log was conducted with the Sr. Director of Critical Care and the Director of Quality.

a. Review of the ED log showed Patient 13 arrived to the ED on 4/19/24 at 1256 hours with abdominal pain after a MVA trauma during pregnancy. The disposition section of the ED log was left blank. The discharge time documented on the ED log was on 4/19/24 at 1649 hours.

Review of Patient 13's Encounter Location History Viewer showed the patient was in the LDRP on 4/19/24 at 1335 hours for an OB Triage.

b. Review of the ED log showed Patient 14 arrived to the ED on 4/29/24 at 1345 hours with MVA, back pain, and abdominal pain. The patient was pregnant. The disposition section of the ED log showed "Discharged to Home or Self Care". The discharge time documented on the ED log was on 4/29/24 at 1419 hours.

Review of Patient 14's Encounter Location History Viewer showed the patient was in the LDRP on 4/29/24 at 1419 hours for an OB Triage.

On 7/3/24 at 1342 hours, an interview and concurrent review of the ED logs and EHR was conducted with the Sr. Director of Critical Care and Director of Quality. The Sr. Director of Critical Care stated there was a possible error in the EHR when transferring over the correct disposition for ED patients who went to the LDRP for following-up of an OB related complaint. The above findings were shared and verified by the Sr. Director of Critical Care and Director of Quality.

Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for one of 20 sampled patients (Patient 13) and failed to ensure the OB physician and MHA 1 had completed the EMTALA training annually as evidenced by:

1. For Patient 13, the L&D Attending Physician and L&D nursing staff did not evaluate the patient who was pregnant, in the ED as per the hospital's P&P.

2. There was no documented evidence showing the OB physician and MHA 1 had completed the EMTALA training annually.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Assessment of the Obstetric Patient in the Emergency dated 8/23/21, showed pregnant patients with non-pregnancy related emergency cases with obstetrical implications will be treated by the ED physician for emergent medical problems and the OB provider on-call will be notified. The L&D Attending Physician will be called to evaluate the patient in the ED. The L&D nursing staff will also be called to monitor the fetus in the ED.

On 7/5/2024 at 1130 hours, an interview and concurrent review of Patient 13's medical record was conducted with the Director of Perinatal Services and Sr. Director of Critical Care.

Patient 13's medical record showed Patient 13 presented to the ED on 4/19/2024 at 1256 hours.

Review of the Tier 2 Triage dated 4/19/24 at 1305 hours, showed Patient 13 presented with lower abdominal plan and s/p MVA today. Patient 13 was 36 weeks pregnant and reported having lower abdominal pain after the incident.

Review of the ED Note - Physician dated 4/19/2024 at 1318 hours, showed Patient 13 received an MSE to rule out an EMC for the non-pregnancy related concern of abdominal pain. The medical decision making was that Patient 13 was experiencing abdominal pain in pregnancy after blunt trauma. Patient 13 was recommended to be admitted to OB/GYN for further workup and treatment and tocometry.

Review of the Encounter Location History Viewer showed Patient 13 arrived in the LDRP on 4/19/24 at 1335 hours.

Review of the History and Physical examination dated 4/19/2024 at 1750 hours, showed OB DO 1 consulted with Patient 13 in the LDRP.

The Director of Perinatal Services confirmed OB DO 1 and L&D nursing staff did not evaluate Patient 13 in the ED. The Director of Perinatal Services stated OB DO 1 should have seen the patient before 1750 hours. The Director of Perinatal Services stated if the patient had an abdominal injury, then the L&D physician would come down to see the patient.

2. Review of the hospital's P&P titled EMTALA dated 10/15/21, showed the hospital establishes the P&P to ensure the compliance with EMTALA requirement. The Dedicated Emergency Department (DED) includes the main ED and L&D Department. The EMC means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

a. On 7/5/24 at 1328 hours, OB DO 1's credential file was reviewed with the Medical Staff Administrator. When asked for the document for the EMTALA training or in-service for OB DO 1, the Medical Staff Administrator stated there was none. The Medical Staff Administrator stated MD 2 said it was not necessary for the OB physician to have the EMTALA training. The hospital's medical staff did not include the EMTALA training in their credentialing requirement.

On 7/5/24 at 1328 hours, the CNO stated the hospital required the hospital staff to have the EMTALA training annually. The CNO stated the physician should have the same requirement.

b. On 7/8/2024 at 1437 hours, an interview and concurrent review of training files of MHA 1 was conducted with the Director of Education and Professional Development.

Review of MHA 1's training file showed MHA 1's last EMTALA training was completed on 12/21/21.

The Director of Education and Professional Development acknowledged the findings and stated MHA 1 was contacted to complete the EMTALA training which was an annual training requirement.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for 11 of 20 sampled patients (Patients 1, 2, 5, 8, 9, 10, 12, 16, 17, 18, and 20) as evidenced by:

1. The ED staff did not ensure the pain management for Patients 5, 8, 9, 10, 12, 17, and 18 as per the hospital's P&P.

2. The ED staff did not assess the vital signs every two hours for Patients 2, 5, 8, 16, 18, and 20 as per the hospital's P&P.

3. The ED staff did not assess the orthostatic vital signs for Patients 1 and 2 as per the physician's orders.

4. The ED staff did not ensure the discharge instructions for Patient 1 was completed as per the hospital's P&P.

5. The ED staff did not perform the focused assessment related to the chief complaint for Patient 17 as per the hospital's P&P.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Pain Assessment and Reassessment Management dated 2/16/22, showed the following:

* Screening patients for the presence of pain will be done according to the requirements in the care setting they are in as the 5th vital sign.

* The hospital has adopted and consistently used the following Pain Assessment Scales to identify the patient's level/intensity of plan, based on the patient's condition, age, and ability to self-report.

- The FACES Pain Scale is used in children ages 4-12 who are able to point to various degrees of pain expression faces for a total score of up to 10. On the scale from zero to 10, zero indicates the patient has no pain and ten indicates the patient has the worst possible pain.

- The Numerical Rating Scale (NRS) is also known the Verbal Numerical Scale (VNS) is used for self-reporting of pain on a scale of zero to 10. Zero indicates the patient has no pain and ten indicates the patient has the worst possible pain.

* ED patients shall receive treatment for acute pain related to their chief complaint or presenting condition when intensity exceeds their acceptable level of pain, or pain goal.

* Pain screening and admission pain assessment for patient admitted to any care setting. The staff nurse is to complete and document the following upon a patient admission to any care setting within the hospital.

- Perform an initial pain screen at the time of admission to identify the presence of pain.

- If the pain screen is positive, the "Yes" option will open up into a complete and more in depth "Admission Pain Assessment" to gather sufficient information to identify the pain as follows: pain demographics and pain characteristics, including the pain location, laterality, quality, time variation. onset, duration, alleviating factors.

* In the ED, the post treatment assessment includes to reassess pain within one hour following treatment/intervention or at the time of discharge or transfer, whichever comes first. All reassessments are documented in the EHR.

Review of the hospital's P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the following:

- For the patients in the waiting room, the patient is reassessed all abnormal vital signs according to the ESI level. For patients with ESI level 3, the lobby manager and/or co-charge RN will ensure that a reassessment of systems related to the patient's primary complaint is completed along with vital signs (BP, HR, RR, temperature, SpO2, and pain score) at least every two hours or more frequently based on patient condition or changes.

- The primary RN responsibilities include to assure subsequent vital signs and reassessments are completed at least every two hours for ESI level 3 patients or more frequently based on the patient conditions and/or changes.

Review of the hospital's P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed STAT order are defined as patient care, treatment, and service orders issued verbally, by telephone or entered in EHR for life threatening, and/or emergency situations. The implementation of STAT orders will be initiated immediately.

a. On 7/8/24 at 1100 hours, Patient 5's medical record review was conducted with the Sr. Director of Critical Care.

Patient 5's medical record showed Patient 5 came to ED on 3/21/24 at 1432 hours and transferred to other hospital on 3/22/24 at 1145 hours.

Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed Patient 5 had left side lower jaw swelling for a month. The Pain Assessment ED section showed "Pain Present: Yes actual or suspected pain." There was no documented evidence to show the nursing staff assessed the patient's pain characteristics as per the hospital's P&P.

Review of the physician's order dated 3/21/24 at 1509 hours, showed to administer morphine (a pain medication) 4mg, IVP, once to the patient.

Review of the MAR showed the morphine 4mg was administered to Patient 5 on 3/21/24 at 1609 hours (or one hour after the medication was ordered). There was no documented evidence to show Patient 5 was reassessed after the morphine was administered to the patient. There was no documented evidence to show the reason for the medication ordered as "once" was given one hour later.

There was no documented evidence to show the pain reassessment was completed prior to the patient's discharge on 3/22/24 at 1145 hours.

On 7/8/24 at 1110 hours, the Sr. Director of Critical Care confirmed the findings.

b. On 7/8/24 at 0932 hours, Patient 8's medical record review was conducted with the Sr. Director of Critical Care.

Patient 8's medical record showed Patient 8 came to the ED on 5/10/24 and transferred to the HLOC on 5/11/24 at 0821 hours.

Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient's ESI level was "3."

Review of the Pain flowsheet showed the following:

* On 5/10/24 at 2345 hours, the patient's pain score was four.

* On 5/11/24 at 0147 hours, the patient's pain score was zero.

* On 5/11/24 at 0533 hours, the patient's was four.

* On 5/11/24 at 0637 hours, the patient's pain score was zero.

Review of the physician's order dated 5/11/24 at 0002 hours, showed to administer ibuprofen (a pain medication) 336 mg once, STAT to the patient.

Review of the MAR showed the ibuprofen was administered to the patient on 5/11/24 at 0117 hours (one hour and 15 minutes later).

Review of the physician's order dated 5/11/24 at 0522 hours, showed to administer fentanyl (a pain medication) 25 mcg, IVP, once, STAT to the patient.

Review of the MAR showed the fentanyl was administered to the patient on 5/11/24 at 0632 hours (one hours and 10 minutes later); and the RN documented the late reason to be given the medication to the patient was "wanted to wait patient asked for it."

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed Patient 8's medical record did not show the pain assessment was done every two hours for the patient as per the hospital's P&P. There was no pain assessment documented on 5/11/24 from 0147 to 0533 hours (or approximately 3 hours). The Sr. Director of Critical Care confirmed the findings.

c. On 7/8/24 at 0933 hours, Patient 10's medical record review was conducted with the Sr. Director of Critical Care. Patient 10's medical record showed the patient came to the ED on 5/27/24.

Review of the Tier 2 Triage - Text dated 5/27/24 at 0532 hours, showed Patient 10 complained of back and bilateral leg pain. The patient's ESI level was 3. The patient's pain level was 10. The pain location was the back and low leg. The patient's pain quality was aching, sharp, and throbbing.

Review of the Pain flowsheets showed the following:

* On 5/27/24 at 0532 hours, the patient's pain score was 10 (severe pain).

* On 5/27/24 at 0800 hours, the patient's pain score was "8" (severe pain).

* On 5/27/24 at 0908 hours, the patient's pain score was " 8." The patient's acceptable pain score was zero.

* On 5/27/24 at 1025 hours, the patient's pain score was "8."

Review of the physician's order dated 5/27/24 at 0549 hours, showed to administer hydromorphone (a pain medication) 3 mg, IVP, once, STAT to the patient.

Review of the MAR showed the hydromorphone was given to the patient on 5/27/24 at 0903 hours.

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed Dilaudid (same as hydromorphone) was given to the patient approximately three hours later, after the patient was assessed having severe pain on 5/27/24 at 0532 and 0800 hours. The Sr. Director of Critical Care confirmed there was no document evidence to show the justification why the hydromorphone was not administered immediately.

d. Patient 9's medical record review was initiated on 7/5/24. Patient 9's medical record showed the patient came to the ED on 7/1/24.

Review of the Tier 2 Triage - Text dated 7/1/24 at 1705 hours, showed Patient 9's chief complaint was facial pain after falling. The patient had a numeric pain scale of "7 = Severe."

Review of Patient 9's MAR showed the patient was administered acetaminophen (a pain medication) 650 mg by mouth on 7/1/24 at 1758 hours.

Review of the Pain flowsheet showed Patient 9's numeric pain scale was "8 = Severe" on 7/1/24 at 1911 hours. The pain location was the head with an aching quality and sudden onset.

Review of Patient 9's Discharge Information dated 7/1/24 at 1920 hours, showed Patient 9 was discharged from the ED.

However, further record review failed to show any further interventions were performed or the ED provider was notified of Patient 9's severe pain.

On 7/8/2024 at 1205 hours, the above findings were shared and acknowledged with the Sr. Director of Critical Care and Quality Coordinator for ED. The Quality Coordinator for ED stated the physician should have been notified of Patient 9's severe pain.

e. Patient 12's medical record review was initiated on 7/5/2024. Patient 12's medical record showed the patient came to the ED on 2/15/24.

Review of the Tier 2 Triage - Text dated 2/15/24 at 0247 hours, showed Patient 12 complained of abdominal pain, coughing, and vomiting. The patient's numeric pain scale was "6 = Moderate." The pain location was the left upper abdomen which was constant and sharp.

Review of the physician's order dated 2/15/24 at 0256 hours, showed to administer to Patient 12 ketorolac (a pain medication) 30 mg, IVP, STAT.

However, review of the MAR showed Patient 12 did not receive the ketorolac 30 mg IVP until 0350 hours. Additionally, there was no reassessment of Patient 12's pain level after the administration of the pain medication.

Review of the Discharge Information showed Patient 12 was discharged from the ED on 2/15/2024 at 0452 hours.

On 7/8/2024 at 1225 hours, the above findings were shared and acknowledged with the Sr. Director of Critical Care and Quality Coordinator for ED. The Sr. Director of Critical Care stated the RN should have reassessed Patient 12's pain within one hour of administering the pain medication.

f. Patient 17's medical record review was initiated on 7/5/24. Patient 17's medical record showed the patient came to the ED on 6/24/24.

Review of the Tier 2 Triage - Text dated 6/24/24 at 1033 hours, showed Patient 17 complained of rectal pain with headache. Patient 17's numeric pain scale was "10 = Severe." However, further review of the document failed to show a comprehensive assessment including the pain characteristics for Patient 17.

Review of the MAR showed on 6/24/24, Patient 17 received morphine 4 mg IM at 1132 hours and 2 mg IVP at 1423 hours. There was no documentation to show Patient 17 was reassesed for pain within one hour of administration of pain medications as per the hospital's P&P.

On 7/8/24 at 1228 hours, the above findings were shared and acknowledged by the Director of Quality and Sr. Director of Critical Care. The Director of Quality stated the expectation was to reassess a patient's pain within one hours after a pharmacological intervention.

g. Patient 18's medical record review was initiated on 7/5/24. Patient 18's medical record showed the patient came to the ED on 6/24/24.

Review of the Tier 2 Triage - Text dated 6/24/24 at 1112 hours, showed Patient 18's chief complaint was shortness of breath with mid-sternal chest pain and cough. The patient's numeric pain scale was "10 = Severe."

Review of the Pain flowsheet showed on 6/24/24 at 1157 hours, Patient 18 had a numeric pain score of "10" in the left chest which had an aching quality.

Review of the MAR showed Patient 18 was administered pain medications without a timely reassessment within one hour of medication administration. For example:

- Patient 18 was administered morphine 4 mg IVP on 6/24/24 at 2229 hours. However, review of the pain assessment failed to show Patient 18's pain was reassessed until 0040 hours with the numeric pain scale of "7= Severe."

- Patient 18 was administered Norco (a pain medication) 325/5 mg tablet on 6/25/24 at 0035 hours, and tramadol (a pain medication) 50 mg tablet on 6/25/24 at 0259 hours. However, there was no documentation to show Patient 18's pain was reassessed within one hour of administering the pain medication as per the hospital's P&P.

- Patient 18 was administered Norco 325/5 mg tablet by mouth on 6/25/24 at 0753 hours. However, there was no documented evidence to show Patient 18's pain was reassessed within one hour of administering the pain medication as per the hospital's P&P. The next pain assessment was conducted on 6/25/24 at 1200 hours, which Patient 18 stated the patient's numeric pain scale was "9 = Severe.".

On 7/8/24 at 1246 hours, the above findings were shared and verified by the Sr. Director of Critical Care, who stated the patient's pain reassessment should have been performed within one hour of pain medication intervention.

2. Review of the hospital's P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the ED Primary RN responsibilities include to assure subsequent vital signs and reassessment are completed at least every two hours for the ESI Levels 2 and 3 patients or more frequently based on patient's condition and changes.

a. Patient 2's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0927 hours.

Patient 2's medical record showed the patient came to the ED on 1/1/24 at 1412 hours.

Review of the Tier 2 Triage - Text dated 1/1/24 at 1421 hours, showed Patient 2's chief complaint included headache, dizziness, and nausea. The patient's ESI level was 3.

Review of the Vital Signs flowsheet showed Patient 2 was assessed for the vital signs on 1/1/24 at 1421, 1700, 1830, and 1954 hours. The patient's vital signs were not access every two hours on 1/1/24 from 1421 hours to 1700 hours.

On 7/8/24 at 0927 hours, the Sr. Director of Critical Care confirmed the above findings.

b. Patient 5's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1110 hours.

Patient 5's medical record showed Patient 5 came to the ED on 3/21/24 at 1432 hours and transferred to other hospital on 3/22/24 at 1145 hours.

Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed the patient had left side lower jaw swelling for a month. The patient's ESI level was 3.

Review of the Vital Signs flowsheet showed Patient 5 was assessed for the vital signs on 3/21/24 at 1451 and 2100; on 3/22/24 at 0036, 0335, 0649, and 1041 hours. The patient's vital signs were not access every two hours as per the hospital's P&P.

During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 5's vital signs were not assessed as per the hospital's P&P.

c. Patient 8's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0932 hours.

Patient 8's medical record showed the patient came to the ED on 5/10/24.

Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient's ESI level was "3."

Review of the Vital Signs flowsheet showed Patient 8 was assessed for the vital signs on 5/11/24 at 0221, 0533, and 0800 hours. The patient's vital signs were not access every two hours as per the hospital's P&P.

During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 8's vital signs were not assessed as per the hospital's P&P.

d. Patient 16's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1050 hours.

Patient 16's medical record showed the patient came to the ED on 6/24/24 at 1232 hours.

Review of the Tier 2 Triage - Text dated 6/24/24 at 1237 hours, showed Patient 16 was bought in by ambulance for dizziness and had a history of anemia. The patient's ESI level was 3. The patient's pulse was 120 bpm (a normal resting heart rate or pulse ranges from 60 to 100 bpm).

Review of the Vital Signs flowsheet showed Patient 16 was assessed for the vital signs on 6/24/24 at 1240 and 1502 hours. The patient's vital signs were not assessed every two hours as per the hospital's P&P.

During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 16's vital signs was assessed more than two hours.

e. Patient 18's medical record review was initiated on 7/5/24. Patient 18's medical record showed the patient came to the on 6/24/24 and transferred to the HLOC on 6/25/24 at 1619 hours.

Review of the Tier 2 Triage -Text dated 6/24/24 at 1108 hours, showed Patient 18 complained of mid-sternal pain and shortness of breath. The patient's ESI level was 3.

However, review of Patient 18's vital signs failed to show the patient's vital signs were documented at a minimum of every two hours. For example:

- Patient 18's vital signs were documented on 6/24/24 at 1500 hours. However, another vital signs were not documented until 1931 hours.

- Patient 18's vital signs were documented on 6/25/24 at 0800 hours. However, vital signs were not checked again until 1200 hours. Additionally, the next subsequent vital signs were not taken until 1607 hours.

On 7/8/2024 at 1246 hours, the above concerns were shared and verified by the Quality Coordinator for ED and Sr. Director of Critical Care. The Quality Coordinator for ED stated Patient 18's vital signs should have been documented every two hours.

f. Patient 20's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1056 hours.

Patient 20's medical record showed the patient came to the ED on 6/24/24 at 0015 hours.

Review of the Tier 2 Triage - Text dated 6/24/24 at 0020 hours, showed the chief complaint was that Patient 20 was bought in by ambulance, complained of hearing voice for four days. The patient's ESI level was 3.

Review of the Vital Signs flowsheet showed on 6/25/24, Patient 20 was assessed for the vital signs at 0000 and 0400 hours. At 0600 hours, the patient's temperature, pulse, blood pressure, and SpO2 were not documented. The patient's vital signs were not access every two hours as per the hospital's P&P.

During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 20's vital signs were not assessed every two hours as per the hospital's P&P.

3. Review of the hospital's P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed the physician's orders shall be carried out until the physician discontinues them.

a. On 7/3/23, Patient 1's medical record review was initiated. Patient 1's medical record showed the patient arrived to the ED via ambulance on 6/24/24, with a chief complaint of weakness and a near syncopal event.

Review of the physician's order dated 6/24/24 at 1521 hours, showed MD 1 ordered to perform orthostatic vital signs.

However, review of Patient 1's medical record failed to show the orthostatic vital signs were performed.

During an interview with MD 1 on 7/3/24 at 1448 hours, MD 1 stated MD 1 ordered the orthostatic vital signs for Patient 1 since the patient reported feeling like the patient was going to pass out. MD 1 stated the orthostatic vital signs were usually ordered for patients who clinically presented with light headedness. MD 1 stated if the order was not discontinued by MD 1, the orthostatic vital signs should have been done.

On 7/3/2024 at 1448, the Sr. Director of Critical Care was informed of and acknowledged the above findings.

b. Patient 2's medical record review was conducted with the Director of Critical Care on 7/8/24 at 0927 hours.

Patient 2's medical record showed the patient came to the ED on 1/1/24 at 1412 hours.

Review of the Tier 2 Triage - Text dated 1/1/24 at 1421 hours, showed Patient 2's chief complaint included headache, dizziness, and nausea. The patient's ESI level was 3.

Review of the physician's order dated 1/1/24 at 1501 hours, showed to assess the orthostatic vital signs for the patient.

Review of the Orthostatic Vital Signs flowsheet showed on 1/1/24 at 1700 hours, Patient 2 was assessed for SBP and DBP with the sitting and standing positions and was assessed for the pulse with the sitting position. At 1830 hours, the patient was assessed for SBP, DBP, and pulse with the sitting position; and there was no documented evidence to show the patient was assessed for the SBP and DPB with the standing position.

An interview and concurrent review of Patient 2's medical record was conducted with the Director of Quality on 7/8/24 at 1231 hours. The Director of Quality was not able to locate documents to show a completed set of orthostatic vital signs was done for Patient 2 during the ED visit. There was no additional document to show the reason why the physician's order was not carried or if it was reported to the ordering physician that the orthostatic vital signs were not completed for the patient.


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4. Review of the hospital's P&P titled Communicating with the Primary Care Provider and Discharge Instructions dated 4/19/23, showed it is the responsibility of the RN to assure the patient or legal guardian verbally states understanding of discharge instructions, allow time for questions, and when full understanding it achieved, have the patient or legal guardian sign the last page of the discharge instructions; this indicates the understanding of medications, follow up, specific aftercare, and patient educational materials. The responsibility of the RN also includes to provide the last executed signature age of the discharge instructions to the unit secretary for scanning of the signature into the EHR.

On 7/3/23, Patient 1's medical record review was initiated. Patient 1's medical record showed the patient arrived to the ED via ambulance on 6/24/2024, with a chief complaint of weakness and a near syncopal event.

Review of the ED Patient Summary dated 6/24/24 at 1705 hours, showed a summary of the patient's discharge diagnosis, name of provider, follow up instructions, and aftercare instructions. However, the last page of the instructions to sign in acknowledgement of Patient 1 receiving written medication orders, follow up instructions, aftercare instructions, and receipt and understanding of education material was left blank.

On 7/5/2024 at 0930 hours, the above findings were shared and verified by the Director of Quality. The Director of Quality stated the signed discharge instructions were not found in Patient 1's medical record.

5. Review of the hospital's P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed a physical assessment of systems related to the primary complaint will be done as a primary responsibility of the RN.

Patient 17's medical record review was initiated on 7/5/2024. Patient 17's medical record showed the patient came to the ED on 6/24/24.

Review of the ED Physician Note dated 6/24/2024 at 1051 hours, showed Patient 17 presented with abdominal pain. Associated symptoms were decreased oral intake and constipation. Patient 17 reported having no bowel movements for several days. Patient 17 reported having a diverting left colostomy placed.

However, further review of Patient 17's medical record failed to show an assessment of Patient 17's colostomy.

On 7/8/2024 at 1228 hours, the Sr. Director of Critical Care was informed of and acknowledged the above findings. The Sr. Director of Critical Care stated it should be expected to assess the patient's colostomy if the patient also presented with abdominal pain.

Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred four of 20 sampled patients (Patients 5, 8, 11, and 20) when the Patient Transfer Summary forms were not completed for Patients 5, 8, 11, and 20 as per the hospital's P&P. These failures had the potential to result in poor clinical outcomes and serious adverse event for patients receiving ED services in the hospital.

Findings:

Review of the hospital's P&P titled EMTALA dated 10/15/21, showed appropriate transfer means a transfer that complies with all the following requirements:

* The hospital provides medical treatment within its capacity to minimize risks to the individual's health and in the case of a woman in labor, the health of the unborn child, the medical record will reflect the vital signs and condition of the individual at the time of the transfer.

* The hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency medical condition of the individual, including

- Records related to the individual's emergency condition.

- The individual's information written consent to transfer or the physician certification.

* The transfer is effected using qualified personnel and transportation equipment, including the use of medically appropriate life support measures.

Review of the Patient Transfer Summary form showed the following:

* The Physician section showed there are two check boxes.

- For the first check box: if it is checked, it indicates "Emergency condition treated and stabilized....Based upon my examination and the information available to me at this time, I have concluded that with reasonable medical probability, the above referenced patient transport will create no medical hazard to the patient, or that the medical benefits reasonably expected from the transfer out weight the associated risks or that the patient and /or patient's representative has required the transfer against medical advice."

- For the second check box: if it is checked, it indicates "An emergency condition exist and the patient is not able to be stabilized prior transfer because:...the specialty service or specialty physician required is not available...Based on the reasonable risk and benefits to the patient and based upon the information available at this time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate emergency medical care at another facility outweigh the increased risk, If any, to the individual's medical condition."

* The UnitSec/Primary RN section showed the patient's record /valuables/belongings received by:... NAME _________SIGNATURE_________ that should be signed by the transport personnel who receives the patient.

On 7/8/24 at 0933 hours, when asked for process of transferring the ED patients, the Director of Quality stated the Patient Transfer Summary was used for each transfer. It was the provider's responsibility to complete the "Physician" section for evaluation of the patient's condition and discussion of the transfer risk vs. benefits to the patient or the patient's representative. The physician would document on the "Physician" section.

On 7/8/24, review of medical records for Patients 5, 8, 22, and 20 was conducted with the Sr. Director Critical Care and the Director of Quality,

1. Patient 5's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1110 hours.

Patient 5's medical record showed Patient 5 came to the ED on 3/21/24 at 1432 hours and transferred to the HLOC on 3/22/24 at 1145 hours.

Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed the patient had left side lower jaw swelling for a month. The patient's ESI level was 3.

Patient 5's medical record showed the patient received pain medication, IV antibiotic, and an incision and drainage (I&D) procedure during the ED staying.

Review of the History and Physical examination dated 3/22/24 at 0657, showed Patient 5 had osteomyelitis of jaw. The plan was to transfer the patient to HLOC for OMFS evaluation.

Review of Patient 5's Patient Transfer Summary showed the following:

* The Physician section showed the following:

- The description section was blank.

- The sections of transport personnel, the hospital personnel accompanying were blank.

- The box to indicate if the emergency condition treated and stabilized was blank.

- The box to indicate if emergency conditions exist and the patient is not able to be stabilized prior to transfer was bank.

* The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient's records/valuable/belongings were received, was blank.

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings.

2. Patient 8's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0932 hours.

Patient 8's medical record showed the patient came to the ED on 5/10/24.

Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient's ESI level was 3.

Review of the ED Clinical Summary dated 5/11/24 at 0821 hours, showed Patient 8 was transferred to other hospital. The diagnosis was acute appendicitis. The patient was transferred on 5/11/24 0821 hours.

Review of Patient 8's Patient Transfer Summary showed the following:

* The Physician section showed the following:

- The description section was blank.

- The boxes of "Stable:" or "Other;" were not checked.

- The box to indicate if the emergency condition treated and stabilized was blank.

- The box to indicate if emergency conditions exist and the patient is not able to be stabilized prior to transfer was bank.

* The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient's records/valuable/belongings were received, was blank.

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings.

3. Patient 11's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1100 hours.

Patient 11's medical record showed the patient came to ED on 2/1/24 1813 hours and transferred to other facility on 2/2/25 at 1010 hours.

Review of the Tier 2 Triage - Text dated 2/1/24 at 1825 hours, showed Patient 11's chief complaint included suicidal ideation. The patient's ESI level was 2.

Review of the Social Work Psychosocial Assessment dated 2/1/24 at 2350 hours, showed Patient 11 was placed on 5150 Hold for suicide ideation.

Review of the ED Note - Physician dated 2/2/24 at 0747 hours, showed Patient 11 was stable, medically cleared, and transfer to other psychiatric facility.

Review of Patient 11's Patient Transfer Summary showed the following:

* The Physician section showed the physician signed the form on 2/2/24 at 0930 hours. However, the Physician section was blank.

* The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient's records/valuable/belongings were received, was blank.

Review of the Patient Transfer Acknowledgement dated 2/2/24, showed the Patient Signature section showing ""72 hr involuntary hold."

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings.

4. Patient 20's medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1056 hours.

Patient 20's medical record showed the patient came to the ED on 6/24/24 at 0015 hours and transferred to other facility on 6/25/24 at 1700 hours.

Review of the Tier 2 Triage - Text dated 6/24/24 at 0020 hours, showed the chief complaint was that Patient 20 was bought in by ambulance, complained of hearing voice for four days. The patient's ESI level was 3.

Review of the Consultation Notes dated 6/24/24 at 0941 hours, showed Patient 20's chief complaint was hearing voice for four days. The patient's family member reported the patient had been sitting in the heat, talking to herself, and having outbursts. The plan was to place the patient on 5150 and transfer the patient to psychiatric facility.

Review of Patient 20's Patient Transfer Summary showed the following:

* The Care Management section showed the box of "Resource (HIGHER LEVEL OF CARE)" was checked. The Description section showed "5150."

* The Physician section showed the following:

- The Description section was blank.

- The sections of the Transport Personnel and the hospital Personnel Accompany was blank.

- The sections of "MD DISCUSSED THIS PATIENT WITH DR." and "ACCEPTING MD. DATE/TIME:" were blank.

Review of the Patient Transfer Acknowledgement dated 6/25/24, showed the section of the patient signature showing "Pt is on 5150."

During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings.