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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 as evidenced by:

* Failure to ensure EMTALA signage was posted in the main ED waiting room.

* Failure to ensure EMTALA signage was posted in the NLT area.

* Failure to ensure EMTALA signage was posted in the ambulance bay/entrance to the ED.

* Failure to ensure EMTALA signage posted in the psychiatric ED area.

* Failure to ensure EMTALA signage posted in the pediatric triage/treatment room.

These failures had the potential 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 Compliance dated 9/22/22, showed the medical center will post signage conspicuously in lobbies, waiting rooms, admitting areas where examination and treatment occurs in the form required by CMS that specifies the rights of individuals to examination and treatment for emergency medical conditions and indicating the medical center participates in the Medi-Cal program. Signage will be posted in each dedicated emergency department.

1. On 7/24/23 at 1318 hours, the hospital's ED was toured with Nurse Manager 1, Medical Director 1, and the ED Associate Medical Director. It was observed there was no EMTALA signage in the main ED waiting room. Nurse Manager 1 stated the main ED waiting room was the location where the patients who were assessed withthe acuity levels of 3, 4, or 5 were waiting for further diagnostic procedures.

2. On 7/24/23 at 1015 hours, the NLT was toured with Nurse Manager 1. When asked, Nurse Manager 1 stated the NLT was the location where the patients with the acuity levels of 2 or 3 with high-risk elopement were waiting for treatment.

On 7/24/23 at 1318 hours, the NLT was toured again with Nurse Manager 1, Medical Director 1, and the ED Associate Medical Director. It was observed there was no EMTALA signage in the NLT area.

On 7/26/23 at 1316 hours, Nurse Manager 1 verified the above findings.


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3. On 7/24/23 at 0930 hours, a tour of the ED was conducted with the Assistant Hospital Administrator IV and Nurse Manager 3. There was no EMTALA signage posted in the ambulance bay/entrance to the ED.

Nurse Manager 3 verified the findings.

4. On 7/24/23 at 1100 hours, a tour of the psychiatric ED area was conducted with the Assistant Hospital Administrator IV, Nurse Manager 3, and Nurse Manager 4. There was no EMTALA signage posted in the psychiatric ED area.

Nurse Manager 4 verified the findings.

5. On 7/24/23 at 1432 hours, a subsequent tour of the ED was conducted with Manager 3. There was no EMTALA signage posted in the pediatric triage/treatment room.

Nurse Manager 3 verified the findings.

Based on interview and record review, the hospital failed to maintain the list of on-call specialty physicians included the name of the physicians who were on-call for Facial Trauma. This failure could result in the delay in the stabilizing treatments and substandard health outcomes to the patients.

Findings:

Review of the hospital's P&P titled EMTALA Compliance dated 9/22/22, showed in part:

* On-Call Coverage. The Medical Center will maintain a list of physicians who are on-call to come to the hospital to consult or provide treatment necessary to stabilize an individual with an emergency medical condition. Each dedicated emergency department will be prospectively aware of physicians who are on-call to the department.

Review of the hospital's P&P titled On-Call Specialty Consultants dated September 2021 showed in part:

* Purpose: to establish guidelines for the care of patients with illness or injuries requiring specialty consultation within the DEM.

* Policy: The DEM shall follow the guidelines established by the hospital Attending Staff Rules & Regulations for the calling of specialty consultants for the care of patients.

* Procedure: The residents and attending staff for specialty patient care within the hospital and the emergency room are designated in advance by the specialty service and the on-call schedule is available for review 24/7.

On 7/27/23 at 1128 hours, an interview and review of the on-call specialty physician list was conducted with the Assistant Nursing Director 1 (Regulatory Affairs).

Review of the on-call specialty physician list dated 7/26/23, did not show the name of the physicians who were on-call for Facial Trauma. The list showed, "ENT Resident On Call."

The Assistant Nursing Director 1 (Regulatory Affairs) confirmed and acknowledged the findings.

Based on interview and record review, the hospital failed to ensure the ED central log was maintained accurately for two of 21 sampled patients (Patients 4 and 7). 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 for treatment for an emergency medical condition.

Findings:

Review of the hospital's P&P EMTALA Compliance dated 9/22/22, showed in part:

* Purpose: to describe and comply with the Emergency Medical Treatment and Active Labor ACT (EMTALA) for the physicians and employees and its application to [name of hospital] facilities.

* Policy: It is the policy of the Medical Center to comply with the EMTALA obligations.

* Procedures: The hospital will maintain a central log recording the names of the individuals who come for emergency services and whether the person refused treatment, was refused treatment by the Medical Center or whether the individual was transferred, admitted and treated, stabilized and transferred or discharged.

1. On 7/26/23 at 0815 hours, an interview and concurrent review of the hospital's ED central log for various dates from February 2023 through July 2023 was conducted with the Assistant Nursing Director 1 (Regulatory Affairs).

Review of Patient 7's record showed Patient 7 was seen in the ED on 6/2/23, for the chief complaint of worsening foot ulcer. The ED Note-Provider dated 6/2/23 at 1720 hour, showed the physician conducted an MSE; the disposition section showed "Patient...will be transferred to outside facility." Further review of Patient 7's medical record showed the patient was discharged and was transferred to an outside acute care hospital on 6/3/23.

However, review of the hospital's ED central log showed the following was identified for Patient 7:

* The MSE column was left blank for Patient 7.

* The inconsistencies on the ED central log with the discharge and transfer date for Patient 7. The ED central log showed Patient 7 was transferred from the ED to the outside acute care hospital on 6/2/23 at 2002 hours. The ED central log also showed Patient 7 was discharged from the ED on 6/3/23 at 0928 hours.

The findings were shared and acknowledged by the Assistant Nursing Director 1 (Regulatory Affairs).


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2. On 7/24/23 at 1056 hours, the OB triage area was toured with Nurse Manager 2 and Clinical Nursing Director 2. Nurse Manager 2 stated this area would be used for the patients who were scheduled for the diagnostic tests/procedures or seek for the emergency evaluations. When asked, Nurse Manager 2 stated the patients seeking for emergency evaluations could come to the OB triage area from the main ED or could come straight from the clinic to this area. When requested the census of the unit, Nurse Manager 2 provided the census.

Review of Patient 4's medical record showed Patient 4 came to the hospital on 7/24/23 at 0737 hours, and was roomed in the OB triage area right away. The patient was triaged on 7/24/23 at 0941 hours.

On 7/25/23 at 0852 hours, Nurse Manager 2 and Clinical Nursing Director 2 were interviewed. When asked, Nurse Manager 2 stated Patient 4 directly arrived the OB triage area without going through main ED entrance.

On 7/25/23 at 0939 hours, an interview and record review was conducted with the Information Specialist in the presence of Clinical Nursing Director 1 and Assistant Nursing Director 1. When asked about Patient 4 from the ED central log on 7/24/23, the Information Specialist was not able to locate Patient 4 information from the ED central log. The Information Specialist stated the patients who went straight to the OB triage area, were not included in the ED central log.

Clinical Nursing Director 1 and Assistant Nursing Director 1 verified the above findings.

Based on interview and record review, the hospital failed to ensure an MSE was provided in a timely manner to determine whether or not an EMC existed for four of 21 sampled patients (Patients 1, 3, 5, and 20) as evidenced by:

1. The ED staff did not complete the pain assessments for Patients 1 and 3 as per the hospital's P&P.

2. The ED staff failed to call the patients for a total of three times over a four-hour period if the patient did not respond to the calls as per the hospital's P&P for Patients 1, 5, and 20.

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

Findings:

1. Review of the hospital's P&P titled Pain Management dated April 2022 showed Numerical Rating Scale (NRS) is one of the pain scales approved for use in the hospital. NRS is a numeric pain assessment tool in which patients are asked to verbally rate their current pain intensity on a scale of zero to 10 with zero being in no pain and 10 being the worst possible pain. Patients will be screened for the presence or absence of pain upon admission or initial contact in the ambulatory care setting utilizing one of the above-mentioned pain scales. If pain is present, it will be assessed and treated per the pain clinical standard.

a. Review of the Nursing Clinical Standard titled Pain Management dated May 2023 showed to assess/reassess pain characteristics as follows:

* Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, and time pattern.

Patient 1's medical record was reviewed on 7/24/23. Patient 1's medical record showed Patient 1 arrived at the ED on 6/23/23 at 1325 hours, and was triaged on 6/23/23 at 1357 hours.

Review of the ED Triage to Room dated 6/23/23 at 1357 hours, showed Patient 1 had pain to the finger with the pain level of seven out of 10.

Review of the Orders-Medications showed on 6/23/23 at 1958 hours, acetaminophen (a pain medication) 650 mg and ibuprofen (a pain medication) 400 mg were ordered for Patient 1.

Review of the Medication Administration Report showed on 6/23/23 at 2000 hours, Patient 1 received the above pain medications.

However, there was no documented evidence to show the baseline pain assessment including laterality, quality, and time pattern was completed for Patient 1.

b. Review of the Nursing Clinical Standard titled Pain Management dated June 2020 showed assessment include to

* Assess/reassess pain characteristics as follows:

- Baseline assessment (upon first complaint of pain/complaint of new type of pain): onset, character/quality, location, duration, time, and pattern.

* Assess for oversedation, hypotension, and respiratory depression (for opioids) and for effectiveness for all pain medications within 30 to 60 minutes of oral, intramuscular, subcutaneous, and rectal administration.

Patient 3's medical record was reviewed on 7/24/23. Patient 3's medical record showed Patient 3 arrived at the ED on 3/10/23 at 0827 hours and was triaged on 3/10/23 at 0828 hours.

Review of the ED Triage to Room dated 3/10/23 at 0828 hours, showed Patient 3 had pain with the pain level of eight out of 10.

Review of the Pain dated 3/10/23 at 0922 hours, showed Patient 3 had back pain with the pain level of eight out of 10.

Review of the Medication Administration Record showed on 3/10/23 at 1017 hours, Patient 3 received one tablet of hydrocodone-acetaminophen (an opioid, a pain medication) 5 mg/325 mg.

* However, there was no documented evidence to show the baseline pain assessment including onset, character/quality, duration, and pattern was completed for Patient 3.

* Review of the History and Physical Reports dated 3/10/23 at 1114 hours, showed the physician had performed the examination for Patient 3.

Review of the Pain showed on 3/10/23 at 1203 hours (one hour 46 minutes after Patient 3 received the hydrocodone-acetaminophen tablet), Patient 3's pain was reassessed as the medication administration follow-up.

On 7/25/23 at 1410 hours, Nurse Manager 1 was interviewed. When asked, Nurse Manager 1 stated the nursing staff was to reassess patient's pain within one hour after oral pain medication administration. Nurse Manager 1 verified Patient 3's pain level was not reassessed within one hour of medication administration.

On 7/25/23 at 1500 hours, Nurse Manager 1 verified the above findings.

2. Review of the hospital's P&P titled Discharge/Transfers- Discharge Guidelines dated September 2021 showed patients who leave the department either prior to or after being medically screened will be handled in the following way:

* Healthcare worker or provider calling the patient who does not respond will document in the medical record that the patient is a "no answer."

* Each patient will be called in the waiting room a total of three times over a 4-hour period.

* If after four hours and three pages the patient does not respond, the patient status will be changed to left without being seen (LWBS) or left before treatment complete (LBTC).

a. Patient 1's medical record was reviewed on 7/24/23. Patient 1's medical record showed Patient 1 arrived at the ED on 6/23/23 at 1325 hours and was triaged on 6/23/23 at 1357 hours.

Review of the ED Notes dated 6/23/23 at 1510 and 1511 hours, showed Patient 1 was called for MSE on 6/23/23 at 1510 hours, but no answer.

Review of the Orders-Medications showed on 6/23/23 at 1958 hours, acetaminophen 650 mg and ibuprofen 400 mg were ordered for Patient 1.

Review of the Medication Administration Record showed on 6/23/23 at 2000 hours (or four hours fifty minute after the patient was called on 6/23/23 at 1510 hours), Patient 1 received the above pain medications.

Review of the ED Notes dated 6/23/23 at 2001 hours, showed the Assessment MSE section showing Patient 1 was stable to wait.

Patient 1 was not called a total of three times over a 4-hour period when the patient did not respond to the call on 6/23/23 at 1520 hours.

On 7/25/23 at 1434 hours, an interview and concurrent review of Patient 1's medical record was conducted with Nurse Manager 1. When asked, Nurse Manager 1 stated verbally calling a patient's name and overhead page was "calling a patient." Nurse Manager 1 stated a patient would be called three times within four hours if the patient did not respond. Nurse Manager 1 verified Patient 1 should have been called three times by 1910 hours on 6/23/23.

b. Review of the hospital's P&P titled Leaving Against Medical Advice dated 5/26/22, showed for the patient (or surrogate for a minor) to make an informed decision about whether to leave the hospital, the physician must attempt to explain to the patient the reasons for recommending continued hospitalization and treatment; the risks and consequences of leaving; the benefits of continuing hospitalization; and any alternatives, such as transfer to another facility or outpatient treatment, if appropriate in the specific situation. If the patient still insists on leaving the hospital, the staff must attempt to have the patient sign and AMA form. The provider should carefully document the above risks and benefits discussion held with the patient. If the patient refuses to sign the AMA form, a notation should be made on the form that the patient refused to sign, and the circumstances around the patient's departure should be documented in the medical record.

Patient 5's medical record was reviewed on 7/26/23. Patient 5's medical record showed Patient 5 arrived to the ED on 6/17/23 at 0721 hours, was triaged on 6/17/23 at 0725 hours.

Review of the ED Notes dated 6/17/23 at 0746 hours, showed Patient 5 was called to triage and was LWBS due to long wait time. However, there was no documentation to show the ED staff called Patient 5 three times within four hours.

On 7/26/23 at 0824 hours, an interview and concurrent review of Patient 5's medical record was conducted with Nurse Manager 1. When asked, Nurse Manager 1 stated it seemed Patient 5 relayed the information of leaving the ED to the nurse by reviewing the medical record. When asked, Nurse Manager 1 stated the AMA process should have been initiated if Patient 5 verbalized to leave the ED.


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c. Patient 20 's medical record was reviewed on 7/26/23. Patient 20's medical record showed Patient 20 arrived at the ED on 4/3/23 at 1134 hours.

Review of the Patient Summary Record dated 4/3/23, showed Patient 20 was triaged at 1134 hours with an acuity of 4, which showed Patient 20 was stable and able to wait.

Review of the orders showed a Medical Screening Exam (MSE) was ordered on 4/3/23 at 1134 hours.

Review of the Emergency Documentation showed Patient 20 was called twice for MSE on 4/3/23 at 1315 and 1800 hours and documented twice as "no answer".

Further review of Patient 20's medical record showed Patient 20's preferred language was Language 1 and needed an interpreter.

On 7/26/23 at 1400 hours, an interview and concurrent review of Patient 20's medical record review was conducted with Nurse Manager 1. Nurse Manager 1 stated based on the hospital's P&P, the expectation was for the ED staff to call a patient three times within four hours if no response from the patient and document 'no answer' in the medical record each time. Nurse Manager 1 reviewed Patient 20's medical record and could show no documentation Patient 20 had been paged in her preferred language. Nurse Manager 1 verified Patient 20 was called only twice instead of three times and not within four hours. Nurse Manager 1 stated the expectation was for Patient 20 to have been called by the ED staff a total of three documented 'no answer' times, not two as documented and within four hours.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for four of 21 sampled patients (Patients 1, 6, 10, and 16).

1. The ED staff did not ensure the pain management for Patients 1, 6, 10, and 16 as per the hospital's P&P.

2. The ED staff did not conduct reassessment including the vital signs every four hours to Patients 1 and 16 as per the hospital's P&P.

3. The ED staff did not ensure Patient 16 was provided with the risk and benefit discussion by a provider prior to leaving the ED as per the hospital's P&P.

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 Pain Management dated April 2022 showed Numerical Rating Scale (NRS) is one of the pain scales approved for use in the hospital. NRS is a numeric pain assessment tool in which patients are asked to verbally rate their current pain intensity on a scale of zero to 10 with zero being in no pain and 10 being the worst possible pain. Patients will be screened for the presence or absence of pain upon admission or initial contact in the ambulatory care setting utilizing one of the above-mentioned pain scales. If pain is present, it will be assessed and treated per the pain clinical standard.

a. Review of the Nursing Clinical Standard titled Pain Management dated May 2023 showed to assess for oversedation, hypotension, and respiratory depression (for opioids) and for effectiveness for all prn pain medications: within 15-30 minutes of intravenous administration; and within 30 to 60 minutes of oral, intramuscular, subcutaneous, and rectal administration.

Patient 1's medical record was reviewed on 7/24/23. Patient 1's medical record showed Patient 1 arrived at the ED on 6/23/23 at 1325 hours.

Review of the ED Triage to Room dated 6/23/23 at 1357 hours, showed Patient 1 had pain to the finger with the pain level of seven out of 10.

Review of the Orders-Medications showed on 6/23/23 at 1958 hours, acetaminophen 650 mg and ibuprofen 400 mg were ordered to be administered orally to Patient 1.

Review of the Medication Administration Report showed on 6/23/23 at 2000 hours, Patient 1 received the above pain medications.

Review of the ED Notes dated 6/23/23 at 2001 hours, showed the Assessment MSE section showing Patient 1 was stable to wait.

However, there was no documented evidence showing the ED staff had reassessed pain for Patient 1 after administering the pain medications to the patient on 6/23/23 at 2000 hours.

On 7/25/23 at 1410 hours, an interview and concurrent review of Patient 1's medical record was conducted with Nurse Manager 1. When asked, Nurse Manager 1 stated to reassess pain level within one hour after oral pain medication administration. Nurse Manager 1 verified the above findings.

b. Patient 6's medical record was reviewed on 7/25/23. Patient 6's medical record showed Patient 6 arrived at the ED on 6/3/23 at 0312 hours.

Review of the ED Note-Provider dated 6/3/23 at 0554 hours, showed the physician performed the examination for Patient 6.

Review of the Pain dated 6/3/23 at 0936 hours, showed Patient 6 had pain with the pain level of eight out of 10.

Review of the Medication Administration Record showed on 6/3/23 at 0944 hours, Patient 6 received Toradol (a pain medication) via IV.

Review of the Pain dated 6/3/23 at 1214 hours (or two hours and 30 minutes later), showed Patient 6 reported pain level of seven out of 10.

Further medical record review failed to show the pain intervention when Patient 6 reported pain on 6/3/23 at 1214 hours.

Further review of Patient 6's medical record showed Patient 6 was discharged on 6/3/23 at 1548 hours. However, there was no pain assessment upon Patient 6's discharge.

On 7/25/23 at 1410 hours, an interview and concurrent review of Patient 6's medical record was conducted with Nurse Manager 1. When asked, Nurse Manager 1 stated the ED staff should reassess the pain level within 30 minutes after IV pain medication administration.

On 7/26/23 at 0824 hours, Nurse Manager 1 verified the above findings.


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c. Patient 10's medical record was reviewed on 7/26/23. Patient 10's medical record showed Patient 10 arrived at the ED on 5/7/23 at 1314 hours.

Review of Patient 10's pain assessment dated 5/7/23 at 1322 hours, showed Patient 10 had abdominal pain with the pain level of six out of 10.

Review of the Medication Administration Report dated 5/7/23 at 1335 hours, showed Patient 10 was given 4 mg of morphine (an opioid or pain medication) via IV push.

Review of Patient 10's pain assessment dated 5/7/23, showed no pain reassessment was documented as completed within 15-30 minutes of the administration of the IV morphine.

Review of Patient 10's pain assessment dated 5/7/23 at 1503 hours, showed Patient 10 reported the pain level of seven out of 10 to his flank.

Review of the Medication Administration Report dated 5/7/23 at 1503 hours, showed Patient 10 was given 4 mg of morphine via IV push.

Review of Patient 10's pain assessment dated 5/7/23, showed no pain reassessment was documented as completed within 15-30 minutes of the second administration of the IV morphine.

On 7/26/23 at 1300 hours, an interview and concurrent review of Patient 10's medical record review was conducted with Nurse Managers 1 and 2. Nurse Manager 1 stated the expectation was for the nursing staff to assess pain, provide treatment (medication) as ordered, and reassess a patient's pain again based on the type of treatment or medication provided. Nurse Manager 1 stated the expectation for a patient who was receiving an IV medication like morphine was to be reassessed for pain in 15 to 30 minutes of the IV medication administration. Nurse Manager 1 stated the rationale for the reassessment was to ensure the patient was not oversedated, had hypotension or respiratory depression from an opioid medication; the reassessment was also done to see how well the medication treated the patient's pain. Nurse Manager 1 reviewed Patient 10's pain assessment and MAR dated 5/7/23. Nurse Manager 1 verified Patient 10 was assessed for pain, and provided the IV opioid medication twice; but Patient 10 did not receive a pain reassessment within 15-30 minutes as per the hospital's P&P.

d. Review of the Nursing Clinical Standard titled Pain Management dated June 2020 showed to assess for effectiveness for all pain medications within 30 to 60 minutes of oral, intramuscular, subcutaneous, and rectal administration.

Patient 16's medical record was reviewed on 7/26/23. Patient 16's medical record showed Patient 16 arrived at the ED on 2/9/23 at 1136 hours.

Review of Patient 16's initial first assessment dated 2/9/23 at 1152 hours, showed Patient 16 reported the patient's pain level was 10 out of 10 to the abdomen.

Review of the Medication Orders dated 2/9/23, showed 650 mg of oral acetaminophen was ordered at 1217 hours.

Review of the Medication Administration Record dated 2/9/23, showed Patient 16 was given oral acetaminophen 650 mg at 1309 hours.

Review of the Patient Summary Report dated 2/9/23, showed an order for a medication administration follow-up at 1339 hours.

Review of the pain assessment showed no pain reassessment was completed for Patient 16 within 30 to 60 minutes of the oral administration of the pain medication.

Review of the Patient 16's second assessment dated 2/9/23 at 2133 hours, showed a reassessment with the pain level of seven out of 10 to the abdomen.

Review of the Medication Orders dated 2/9/23, showed 650 mg of oral acetaminophen and 400 mg of oral Ibuprofen was ordered at 2145 hours.

Review of the Medication Administration Record dated 2/9/23, showed Patient 16 was given oral acetaminophen 650 mg and 400 mg of oral ibuprofen at 2215 hours.

Review of the Patient Summary Report dated 2/9/23, showed an order for a medication administration follow-up at 2245 hours.

Review of the pain assessment showed no pain reassessment was completed Patient 16 within 30 to 60 minutes of the oral administration of the pain medication as per the hospital's P&P.

On 7/26/23 at 1328 hours, an interview and concurrent review of Patient 16's medical record was conducted with Nurse Managers 1 and 2. Nurse Manager 1 stated the expectation was for the nursing staff to assess pain, provide treatment (medication) as ordered, and reassess a patient's pain again based on the type of treatment or medication provided. Nurse Manager 1 stated the expectation for a patient who was receiving an oral medication was to be reassessed for pain in within 30 to 60 minutes of administration. Nurse Manager 1 reviewed Patient 16's pain assessment and MAR dated 2/9/23 and verified Patient 16 was assessed for pain, and given oral pain medications twice, but Patient 16 did not receive a pain reassessment within 30- 60 minutes as per the hospital's P&P.

2. Review of the hospital's P&P titled Triage- Nursing Role Responsibilities dated September 2021 showed the patients categorized as acuity 3 will be reassessed, including vital signs a minimum of every four hours.

a. Patient 1's medical record was reviewed on 7/24/23. Patient 1's medical record showed Patient 1 arrived at the ED on 6/23/23 at 1325 hours.

Review of the ED Triage to Room dated 6/23/23 at 1357 hours, showed Patient 1 was triaged as acuity 3.

Review of the ED Notes dated 6/23/23 at 2001 hours, showed the Assessment MSE section showing Patient 1 was stable to wait.

On 7/25/23 at 1410 hours, an interview and concurrent review of Patient 1's medical record was conducted with Nurse Manager 1. When asked, Nurse Manager 1 stated patients whose acuity was categorized as 3 should be assessed every four hours including the vital signs.

However, there was no documentation of encounter for Patient 1 until 6/24/23 at 0203 hours (or approximately six hours later).

Nurse Manager 1 verified the above findings.

b. Patient 16's medical record was reviewed on 7/26/23. Patient 16's medical record showed Patient 16 arrived at the ED on 2/9/23 at 1136 hours.

Review of the ED Triage dated 2/9/23 at 1138 hours, showed Patient 16 was triaged as acuity 3.

Review of Patient 16's initial first assessment with vital signs and pain dated 2/9/23 at 1152 hours, showed Patient 16 reported the patient's pain level was 10 out of 10 to the abdomen.

Review of the Patient 16's second assessment dated 2/9/23 at 2133 hours (which occurred over nine hours later and not four hours as per the hospital's P&P), showed Patient 16 was reassessed for vital signs and pain with the pain level of seven out of 10 to his abdomen.

On 7/26/23 at 1328 hours, an interview and concurrent review of Patient 16's medical record was conducted with Nurse Managers 1 and 2. Nurse Managers 1 and 2 reviewed the Triage policy and verified a patient assessed at acuity 3 needed to be reassessed, including vital signs a minimum of every four hours. Nurse Manager 1 verified Patient 16 was assessed at 1152 hours and then again at 2133 hours, which was over nine hours apart. Nurse Manager 1 stated the expectation was for the ED nursing staff to follow the hospital's P&P and assess Patient 16 every four hours, which included both vital signs and pain level. Nurse Manager 1 verified no documentation to show Patient 16 had been reassessed for vital signs or pain every four hours during his stay prior to leaving the ED, without completing his treatment.

3. Review of the hospital's P&P titled EMTALA Compliance dated 9/22/22, showed an individual retains the right to refuse necessary stabilizing treatment and further medical examination, as well as a transfer to another facility. If an individual leaves the hospital before receiving a medical screening examination, either with or without notice to staff of his/her departure, staff should document the circumstances and reasons (if known) for the individual's departure and the time of departure. If an individual who has received a medical screening examination refuses to consent to further examination or stabilizing treatment, the medical center must offer the examination and treatment to the individual, inform the individual the risks and benefits of the examination and treatment, and request that the individual sign a form that he/she refused further examination and treatment.

Review of the hospital's P&P titled Discharge/Transfers- Discharge Guidelines dated September 2021 showed patients who leave the department either prior to or after being medically screened will be handled in the following way:

* Healthcare worker or provider calling the patient who does not respond will document in the medical record that the patient is a "no answer."

* Each patient will be called in the waiting room a total of three times over a 4-hour period.

* If after four hours and three pages the patient does not respond, the patient status will be changed to left without being seen (LWBS) or left before treatment complete (LBTC).

Review of the hospital's P&P titled Leaving Against Medical Advice dated 5/26/22, showed for the patient (or surrogate for a minor) to make an informed decision about whether to leave the hospital, the physician must attempt to explain to the patient the reasons for recommending continued hospitalization and treatment; the risks and consequences of leaving; the benefits of continuing hospitalization; and any alternatives, such as transfer to another facility or outpatient treatment, if appropriate in the specific situation. If the patient still insists on leaving the hospital, the staff must attempt to have the patient sign and AMA form. The provider should carefully document the above risks and benefits discussion held with the patient. If the patient refuses to sign the AMA form, a notation should be made on the form that the patient refused to sign, and the circumstances around the patient's departure should be documented in the medical record.

Patient 16's medical record was reviewed on 7/26/23. Patient 16's medical record showed Patient 16 arrived at the ED on 2/9/23 at 1136 hours.

Review of the ED Triage dated 2/9/23 at 1138 hours, showed Patient 16 was triaged as acuity 3.

Review of Patient 16's Patient Summary Form dated 2/9/23 showed Patient 16 was at the ED from 2/9/23 at 1136 hours to 2/10/23 at 0425 hours.

Review of the nursing note dated 2/9/23 at 2358 hours, showed Patient 16 had informed the nurse that Patient 16 no longer wanted to be seen. Patient 16 stated he was going to a different hospital.

Review of Patient Summary Form showed a no answer on 2/9/23 2359 hours (one minute after the nurse documented Patient 16 stated the patient wanted to leave to go to a different hospital) and 2/10/23 at 0145 and 0301 hours.

Review of the Patient 16's medical record showed no documented AMA form.

Review of Patient 16's medical record showed no documented evidence the ED nursing staff notified the provider of Patient 16's wish to leave and go to another hospital.

Review of Patient 16's medical record showed no documented evidence of Patient 16's provider was attempting to discuss the risks and benefit for leaving against medical advice with the patient.

On 7/26/23 at 1328 hours, an interview and concurrent review of Patient 16's medical record was conducted with Nurse Managers 1 and 2. Nurse Manager 1 verified the facility followed their house "left without being seen" policy and their house "AMA policy" in the ED. Nurse Manager 1 stated there was difference between the two policies. For the left without being seen (LWBS) or left before treatment complete (LBTC) policy, the ED staff was unaware the patient had left and must attempt to call them three times. With the AMA policy, the ED staff was aware the patient wanted to leave and must notify the provider and the provider must attempt to have a risk/benefits discussion with the patient. The ED staff also needed to make an attempt to complete an AMA form with the patient. Nurse Manager 1 reviewed the nursing note in Patient 16's medical record and verified the ED staff were aware of Patient 16's desire to leave. Nurse Manager 1 verified no documentation to show Patient 16's provider was notified by the ED nursing staff of the patient's desire to leave the ED and go to a different hospital. Nurse Manager 1 verified no documentation to show Patient 16 was provided with the risks and benefits discussion of leaving the ED to seek treatment at a different hospital. Nurse Manager 1 verified there was no completed AMA form in Patient 16's medical record.

Nurse Manager 1 stated the ED staff should have followed the AMA process as Patient 16 had informed them the patient wanted to leave.