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Based on interviews and a review of the facility's Emergency Department registration logbook, medical records, the facility's policies, and video footage of the Emergency Department it was determined the facility failed to ensure a medical examination was provided for one (1) of twenty (20) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment.

Interview and review of the facility's video footage revealed Patient #1 presented to the facility (Facility #1) on 02/25/16 with a ruptured blood vessel in the patient's groin area. Patient #1 was triaged by Registered Nurse (RN) #1 and was returned to the lobby to wait for a medical screening examination. Patient #1 began bleeding again while waiting in the lobby and RN #1 was informed Patient #1 was bleeding uncontrollably. RN #1 failed to reassess Patient #1 to determine if the patient's condition had deteriorated. Patient #1 left the facility with a family friend and went to Facility #2 (31 miles away) and was treated and diagnosed with bleeding varicose veins on the scrotum (varicose veins are veins that have become enlarged and twisted).

Refer to 42 CFR 489.24 Medical Screening Exam (A2406).

Based on interviews and a review of the facility's Emergency Department registration logbook, medical records, the facility's policies, and video footage of the Emergency Department, it was determined the facility failed to ensure a medical examination was provided for one (1) of twenty (20) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment. Interview and review of the facility's video footage revealed Patient #1 presented to the facility (Facility #1) on 02/25/16 with a ruptured blood vessel in the patient's groin area. Patient #1 was triaged by Registered Nurse (RN) #1 and was returned to the lobby to wait for a medical screening examination. Patient #1 began bleeding again while waiting in the lobby and RN #1 was informed Patient #1 was bleeding uncontrollably. RN #1 failed to reassess Patient #1 to determine if the patient's condition had deteriorated. Patient #1 left the facility with a family friend and went to Facility #2 (31 miles away) and was treated and diagnosed with bleeding varicose veins on the scrotum (varicose veins are veins that have become enlarged and twisted).

The findings include:

Review of Facility #1's policy titled, "The Emergency Medical Treatment and Active Labor Act (EMTALA)," revised March 2008, revealed all patients presenting to the facility's Emergency Department seeking emergency care would be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the facility to reach a diagnosis.

Review of Facility #1's policy titled, "Emergency Severity Index Triage," revised April 1996, revealed triage will involve a rapid, directed patient assessment which provides an assignment of an acuity level for each patient arriving in the Emergency Department. A Registered Nurse would perform the patient assessments. Acuity levels and disposition would be assigned to patients based on the revised Emergency Severity Index (ESI). The acuity level and definitions and assignments were: Level One (resuscitation), the patient presents with the need for immediate upon arrival lifesaving interventions. Level Two (emergent), the patient presents with a condition posing a potential threat to life, limb, or function and requires rapid medical intervention. Level Three (urgent), the patient presents with a condition that could progress to a serious problem requiring emergency interventions. Level Four (semi-urgent), the patient presents with a condition that has a low potential for deterioration or complications. Level Five (non-urgent), the patient presents with a condition that may be acute but not urgent; the condition may be part of a chronic problem with or without evidence of deterioration.

Review of Facility #1's policy titled, "Diversion of Patients/Ambulance Diversion," revised May 2008, revealed the facility will render the best care of the medical center's capabilities to all patients who come to the facility and the medical staff determines that the patient has an emergency medical condition. Diversion status does not relieve the facility or its physicians of EMTALA responsibilities.

Review of video footage revealed Patient #1 presented to the Emergency Department on 02/25/16 at 1:22 AM with Family Friend #1. Patient #1 was observed to go into the triage room at 1:24 AM and left the triage room to return to the waiting area at 1:33 AM. Patient #1 was observed to go into the restroom at 1:34 AM and remained in the restroom until 1:40 AM. Family Friend #1 was observed to leave the facility at 1:57 AM and Patient #1 returned to the restroom. Family Friend #1 returned to the waiting area at 2:01 AM and was observed to go into the restroom with Patient #1. Family Friend #1 was observed at the triage window at 2:02 AM and Patient #1 was observed to leave the restroom and present to the triage window at approximately 2:03 AM. Patient #1 and Family Friend #1 were observed to leave the facility at 2:06 AM.

Review of Patient #1's medical record from Facility #1 revealed the facility triaged Patient #1 on 02/25/16 at 1:28 AM. Patient #1 presented with a complaint of bleeding from a popped vein on the patient's testicle. Patient #1's vital signs were: blood pressure - 189/91, pulse - 110, and respirations - 19. The facility's "discharge disposition" for Patient #1 at 2:07 AM was "left without being seen." Patient #1's ESI was listed as "urgent."

Interview with Patient #1 on 03/07/16 at 8:09 PM revealed on 02/25/16 the patient had a varicose vein rupture and started bleeding when he was at home. Patient #1 stated he managed to get the bleeding to stop, contacted a family friend, and went to the Emergency Department at Facility #1. Patient #1 stated he was triaged by RN #1 upon his arrival at the facility. Patient #1 stated that RN #1 told him that there were four patients in front of the patient and he would have to wait in the lobby. Patient #1 stated he returned to the lobby to wait but at that time he began bleeding again. Patient #1 stated he went into the restroom to try to control the bleeding but could not. Patient #1 stated his family friend informed RN #1 that he was bleeding uncontrollably but RN #1 informed Family Friend #1 that there were still four patients in front of Patient #1 and they could not "skip." Patient #1 stated he became scared and told RN #1 he was leaving the facility. Patient #1 stated Family Friend #1 took him to Facility #2 where he was immediately treated. Patient #1 stated he "got stitched up" and they observed him for "three or four hours" to make sure he did not "start bleeding again."

Interview with RN #1 on 03/07/16 at 7:10 PM revealed he was the RN working triage on the night of 02/25/16. RN #1 stated they were completely full when Patient #1 presented to the Emergency Department. RN #1 stated he triaged Patient #1 and did assess the patient's ESI as being "urgent." RN #1 stated he did not observe any blood on Patient #1 at the time of the assessment. Further interview with RN #1 revealed that he did recall Family Friend #1 coming up to the triage window and telling him Patient #1 was bleeding; however, he did not reassess Patient #1 at that time. RN #1 stated Patient #1 told him he was leaving the facility and the RN said he apologized at that time for the wait. RN #1 stated the Physician (Physician #1) who was working that night was a "slower" physician and there was nothing he could do. RN #1 stated "every single bed in the Emergency Room was full." Continued interview with RN #1 revealed that he did not contact the House Supervisor to assist him with managing the patients in the Emergency Department or with addressing the wait times. RN #1 stated "wait times" are a problem when Physician #1 works in the Emergency Department. When asked what he would have done if a patient had presented as a "Level 4 or 5" in an ambulance RN #1 stated, "I do not know; we would have found a way to treat them." RN #1 stated the facility was not on "divert" that day due to bed availability.

Interview with the Emergency Room Director on 03/08/16 at 1:00 PM revealed that he was unaware of this incident with Patient #1 until the state surveyor entered the facility. The Emergency Room Director stated the RN working in triage assessed patients and assigned the ESI or acuity level to the patient to determine the order in which patients were medically screened. The Emergency Room Director stated he had some concerns regarding Physician #1, who was working the Emergency Room on 02/25/16. The Emergency Room Director stated his concerns surrounded Physicians #1's inability to manage patients and "wait times" in the Emergency Department. The Emergency Room Director stated he had reported his concerns and all complaints to Administration. Continued interview with the Emergency Room Director revealed that there was no written Emergency Department Policy/Procedure to direct staff/triage nurse actions when the Emergency Department was at capacity and additional emergent and urgent patients arrived seeking treatment. However, the Emergency Room Director stated RN #1 should have contacted the House Supervisor on 02/25/16 regarding Patient #1 and if the issue could not have been resolved then RN #1 should have contacted him (Emergency Room Director) or the Administrator on call.

Interview with the Director of Nursing (DON) on 03/08/16 at 10:40 AM revealed usually the only reason the facility goes on "divert" status is if a piece of equipment is not operating. She stated there were "recliners" and an express room located in the Emergency Department that can be utilized if the beds were all full. The DON stated the triage RN should contact the House Supervisor to assist in the management of the Emergency Department when issues such as this incident arise. The DON stated RN #1 should have reassessed Patient #1 to determine if the patient's acuity level had changed when the family friend reported the patient was bleeding.

Review of Patient #1's medical record from Facility #2 revealed the facility admitted Patient #1 on 02/25/16 at 2:34 AM. Patient #1 presented with a bleeding varicose vein and cyst on his testicle which was bleeding profusely. Continued review of the medical record revealed Patient #1 had his wound cauterized with silver nitrate and anesthetized with 1% Lidocaine. Further review of the medical record revealed Physician #2 had sewn Patient #1's varicose vein with suture of 6-0 nylon. The record also revealed the patient had good closure and hemostasis. Facility #2 discharged Patient #1 on 02/25/16 at 5:47 AM in stable condition with no further bleeding.

Interview with Physician #2 on 03/08/16 at 3:15 PM revealed he was the physician working the Emergency Department on 02/25/16 at Facility #2. Physician #2 stated Patient #1 presented and was immediately taken into a treatment room. Physician #2 stated that Patient #1's pants were "soaked" with blood when he went into the room to evaluate the patient. Physician #2 stated he was very surprised and confused as to why Facility #1 did not treat the patient. Physician #2 stated he checked to ensure that no one in Facility #2's Emergency Department had received a transfer call from Facility #1 regarding Patient #1. Physician #2 stated that Patient #1 did present with an "emergent" medical condition and in his opinion should have been treated immediately at Facility #1.