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A. Based on a review of policy and procedure, review of the emergency department registry, review of four (4) medical records and interviews with administrative staff, it was determined that the disposition of 3 of 4 patients documented to have "Lwbs (Left without being seen) Before Triage" was inaccurate.

Findings include:

Reference: Policy and procedure titled "EMERGENCY DEPARTMENT DISPOSITION" states: ".....
IX. DEFINITIONS:
.....
2. Left prior to triage:
A patient who leaves hospital prior to a triage evaluation.
.....
XI. PROCEDURE:
.....
Left Without Being Seen (LWBS)/ Left Prior to Triage
1. This category applies only to a patient in the Emergency Department who has not had a MSE (Medical Screening Exam).
.....
4. If the patient who has not been triaged and we are aware of their name and departure, this should be made part of the record.
XIII. REGULATORY REQUIREMENT:
Yes
XIV. DOCUMENTATION:
1. Patient's EMR (Electronic Medical Record), as appropriate
2. The following dispositions will be entered by the licensed independent practitioner and will be considered an order for discharge from the Emergency Department: Admit, transfer, observation, treat and release.
3. The following are the only dispositions that can be entered by a registered nurse: Elopement, left without being seen, against medical advice, left prior to triage.
....."

1. Review of documentation regarding Patient #17:

a. Emergency department log: The disposition section for the patient's Emergency Department (ED) visit on 8/15/21 stated: "Lwbs Before Triage."

b. Medical record:

(i) The "Patient Care Timeline" section stated that the patient arrived to the ED at 12:26pm, that triage was completed at 12:29pm and the patient was discharged at 3:40pm.

(ii) The "Disposition" section of the "ED Triage Notes Filed" stated:
"Disposition: LWBS After Triage Comments: This disposition was set automatically."

2. Review of documentation regarding Patient #18:

a. Emergency department log: The disposition section for the patient's ED visit on 8/15/21 stated: "Lwbs Before Triage."

b. Medical record: The "Patient Care Timeline" section stated that the patient arrived to the ED at 12:52pm, that triage was completed at 1:01pm and the patient "dismissed" at 3:40pm.

3. Review of documentation regarding Patient #19:

a. Emergency department log: The disposition section for the patient's ED visit on 8/16/21 stated: "Lwbs Before Triage"

b. Medical record:

(i) The "Patient Care Timeline" section stated that the patient arrived to the ED at 12:37pm, that triage was completed at 12:58pm and the patient "dismissed" at 3:40pm.

(ii) The "Disposition" section of the "ED Triage Notes Filed" stated: "Disposition: LWBS After Triage"

4. Administrator #3 agreed with the findings.

B. Based on a review of policy and procedure, review of the emergency department registry, review of one medical record and interviews with administrative staff, it was determined that the disposition entry of "Or (Operating room) Emergency Medical Condition Cleared" is not an acceptable disposition per policy, nor is it an accurate disposition.

Findings include:

Reference: Policy and procedure titled "EMERGENCY DEPARTMENT DISPOSITION" states: ".....
XIV. DOCUMENTATION:
1. Patient's EMR (Electronic Medical Record), as appropriate
2. The following dispositions will be entered by the licensed independent practitioner and will be considered an order for discharge from the Emergency Department: Admit, transfer, observation, treat and release.
3. The following are the only dispositions that can be entered by a registered nurse: Elopement, left without being seen, against medical advice, left prior to triage.
....."

1. Review of documentation regarding Patient #5:

a. Emergency Department (ED) log: The disposition section for the patient's ED visit on 7/10/21 stated: "Or (Operating room) Emergency Medical Condition Cleared"

b. Medical record:

(i) At 16:33, an RN entry stated "Patient admitted To department MEMH OR (Memorial Hospital Operating Room)."

(ii) The header on each page between pages 4 and 135 states: "7/10/2021 - ED to Hosp [hospital]-Admission (Discharged) in Memorial 4 Northeast Med Surg [medical surgical] unit (continued)."

(iii) A Clinical Note entry made by a physician stated: "(7/10/21 Admitted to Inpatient ACUTE LOC for diagnosis: Ectopic pregnancy without intrauterine pregnancy, unspecified location)."

(iv) The "Disposition" section stated: "OR Emergency Medical Condition Cleared."

2. Administrator #3 agreed with the above findings.

C. Based on a review of policy and procedure, review of the emergency department registry, review of one (1) of one (1) medical record (#9) for patients who left Against Medical Advice (AMA) and interviews with administrative staff, it was determined that the disposition entry of "Left Against Medical Advice (AMA)" is inaccurate.

Findings include:

Reference: Policy and procedure titled "EMERGENCY DEPARTMENT DISPOSITION" states: ".....
IX. DEFINITIONS: ...4. Against Medical Advice (AMA) A patient who leaves the hospital prior to discharge after being advised of the risks of doing so by a staff member or physician. 5. ELOPEMENT A patient that leaves the hospital without the knowledge of staff, or an Emergency Department patient who leaves without staff knowledge after receiving a medical screening. ... XIV. DOCUMENTATION: ... 2. The following dispositions will be entered by the licensed independent practitioner and will be considered an order for discharge from the Emergency Department: Admit, transfer, observation, treat and release.
3. The following are the only dispositions that can be entered by a registered nurse: Elopement, left without being seen, against medical advice, left prior to triage. ..."

1. Review of documentation regarding Patient #9:

a. Emergency department log: The disposition section for the patient's Emergency Department (ED) visit on 6/22/21 stated: "AMA (Against Medical Advice)."

b. Medical record:

(i) The "Patient Care Timeline" section stated that the patient arrived to the ED on 6/22/21 at 1:08 PM with complaints of left sided facial droop and headache, the patient had the Medical Screening Exam and stroke evaluation at 1:09 PM, the triage was completed at 1:14 PM, patient was placed in waiting room at 1:19 PM and at 3:43 PM when patient was called to come back to an ED room the patient had left.

(ii) The "Disposition" section of the "ED Triage Notes Filed" stated: "Disposition: AMA Comments: This disposition was set automatically."

2. The above findings were confirmed by Staff #3.