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Based on record review and interview, the hospital failed to provide a medical screening that included assigning an Emergency Severity Index, the use of VS, lab work, and diagnostic testing (per their policy) on 01/17/25 for one (Patient #8) of 20 patients. This failed practice had the likelihood for an emergency medical condition to go unrecognized, cause a delay in treatment and a risk to patient safety and possible adverse health outcomes. (see 2406)

Based on record review and interview, the hospital failed to provide a medical screening that included assigning an Emergency Severity Index, the use of VS, lab work, and diagnostic testing (per their policy) on 01/17/25 for one (Patient #8) of 20 patients. This failed practice had the likelihood for an emergency medical condition to go unrecognized, cause a delay in treatment and a risk to patient safety and possible adverse health outcomes.

Findings:

Review of policy titled "Triage" number: NSG.6230.828 with a review date of 06/30/23 read in part:
1. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories;
2. Resuscitative (level 1) - immediate care, life-threatening conditions;
3. Emergency (level 2) - major injury or illness but stable; treatment and reassessment should occur within five to 15 minutes;
4. Urgent (level 3) - treatment and reassessment should occur in 15-45 minutes;
5. Semi-Urgent (Level 4) - treatment and reassessment should occur in one to two hours."

Review of policy titled "Assessment and Reassessment Emergency Department" with a review date of 06/30/24 read in part, "The Emergency Department nurses shall initiate accurate and ongoing assessment of physical and psychosocial needs of patients within the emergency department...All patients admitted to the Emergency Department will have the following documentation:... Initial vital signs, Additional vital signs shall be obtrained depending on the patient's condition. Critical patients every five to fifteen minutes, as needed. Intermediate every one hour. All other partients every two hours or prior to discharge."

Patient #8
A review of the medical record showed:
1) A form titled, "The History of Present Illness" documented prior to emergency medical personnel transporting the patient to the hospital the patient's primary physician prescribed Hydrocodone 10-325 mg 1 tablet by mouth every 6 hours as needed for pain and Fentanyl 12 mcg patch for pain (first patch placed transdermally 1/16/25 on day prior to arrival);
2) A Darrouzett EMS Short Form documented the patient vomited and complained of pain while enroute to the hospital 01/17/25:
a) An IV was placed 01/17/25 at 12:26 am;
b) Morphine 2 mg IV 01/17/25 was administered at 12:18 am;
c) Zofran 4 mg IV 01/17/25;
d) Morphine 2 mg IV 01/17/25 at 12:28 am;
e) Morphine 2 mg IV 01/17/25 at 12:28 am;
f) Morphine 2 mg IV 01/17/25 at 12:30 am;
g) Morphine 2 mg IV 01/17/25 at 12:30 am was administered for a total of Morphine 10 mg IV;
3) 01/17/25 at 1:04 am patient arrived at the Emergency Department via EMS, complaining of back pain and pain in both legs (the patient had a reported history of suspected metastatic cancer with a pathological lumbar spine fracture);
4) Admission vital signs (VS):
a) blood pressure of 130/114, pulse 60, temperature 98.0, and oxygen saturation 95% on oxygen (no date and time documented).
b)No VS located in the medical record (provided to the surveyor) and no re-check documented;
5) No lab work was ordered to determine current physiological status (hydration, malnutrition, etc..);
6) No diagnostic testing was completed to rule out illnesses, other fractures, spinal cord injury, or bowel impaction/obstruction. (an MRI dated 01/10/25 showed ".... appearance is concerning for a metastatic process affecting L1, L4 and L5 and this appears to have led to a pathologic compression fracture to L4 vertebrae);"
7) ED documentation dated 01/17/25 showed no Emergency Severity Index assigned in triage;
8) ED documentation dated 01/17/25 showed no nursing assessment completed.
9) Patient left the emergency department via EMS 01/17/25 at 4:14 am enroute to home. The discharge diagnoses were:
a) bilateral sciatica;
b) chronic low back pain with bilateral sciatic, unspecified back pain laterally;
c) chronic prescripation opiate use.

The HPI shows the patient's primary physician had been evaluating patient for malignancy. The patient's primary physician started the patient on narcotics for pain management and the patient was to be set up for an appointment with an oncologist for a PET scan. Pain symptoms increased and the paient received a prescription for fentanyl patches.

On 03/13/24 at 3:30 pm, Staff A stated,
1. The triage level was not assigned to Patient #8;
2. There was nothing documenting the BP was re-checked;
3. The nursing assessment was not completed.

On 03/20/25 at 11:59 am, Staff J stated "I didn't feel it was necessary to order testing with the presenting symptoms and the history I had read."

Based on record review and interview, the hospital failed to ensure notice of patient rights for five (Patients # 8, 11, 17, and 19) of 5 patients who requested a printed copy of patient rights.

Findings:

A Review of a facility document titled, "Partient Bill of Rights Handout" showed an address for the SSA that was vacated in November 2020.

On 03/14/25 at 10:20 am Staff A was shown the correct address and phone number for the SSA.

On 03/14/25 at 10:20 am Staff A stated the contact information for the Oklahoma State Department of Health provided by the facility was not correct.