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Based on review of medical records, policies and procedures, hospital ' s web site, and patient and staff interviews the hospital failed to ensure that when an individual " comes to the emergency department " an appropriate medical screening examination must be provided that is within the capability of the hospital ' s emergency department, including ancillary services routinely available to the emergency department (ED) to determine whether or not an emergency medical condition exists for 1 (Patient #1) of 22 sampled patients. The patient left the ED without receiving a medical screening examination by a qualified medical person.
Refer to findings in tag A-2406.
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Based on observations, review of policies and procedures, emergency department logs, patient and staff interviews the hospital failed to maintain a central log for each individual who comes to the emergency department (ED) seeking assistance and whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (Patient #1) of 22 sampled patients who presented to the ED with complaints of chest pain.

The findings included:

On 4/26/16 at 10:45 a.m., during a tour of the ED waiting room and intake area, the following observations were made: The ED waiting room had sliding glass doors to the outside. When a patient walked in, they faced ½ glass windows where the Patient Access Clerks sat. On the left side of the glass windows was a wooden door; next and to the left was the Triage Office with a glass door that allowed observation. Behind the wooden door was a small hallway which led to an open door and small office where the PBX Operator sat. This office allowed observation of the 2 areas where the Patient Access Clerks sat. At the end of the small hallway was a wooden door with access to the ED.
** Photo on file **

The hospital's policy ORG-E.009 titled EMTALA: Medical Screening, Treatment & Patient Tfr (transfer) was reviewed. The policy specified in part, in Section 6, "Emergency Room Log. Lehigh Regional Medical Center maintains a central log on each individual who comes to the emergency department seeking assistance and whether the individual refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged."

In an interview on 4/22/16 at 4:05 p.m., Patient #1 reported he went to the hospital's emergency room (ER) on 4/10/16 at approximately 12:05 a.m. He stated, "I had severe chest, back and left arm pain and the hospital was only 2 minutes from my house. I parked in the ER parking lot and walked into the ER. When you walk in, the triage room is on the left and there are 2 glass windows where the intake people sit and there was no one there... woman in her thirties came out from an office and asked me, 'Are you going to the back or do you need intake?' and I told her I needed to go in the back and I was having chest pain. She was wearing street clothes and went down a hallway, I could see her about forty feet away and she went into her office and started typing on a computer. She never came close to me as she was always twenty feet away. I only saw her, and I stayed 20 minutes and did not observe any other staff there. Review of the hospital's Emergency Room Central Log failed to find Patient #1 listed on or about 4/10/16.

In an interview on 4/26/16 at 11:20 a.m., the Patient Access Manager (Staff B) reported from 11:00 p.m. to 7:00 a.m., there should be 1 Patient Access Clerk sitting at the glass window.

In an interview on 4/26/16 at 12:55 p.m., regarding the events of 4/10/16, Staff C (Patient Access Clerk) said, "I told [PBX Operator Staff D] before I left that if anyone came in to tell them to have a seat and I would register them when I came back. I returned 5 minutes later and one of the patients in the ER waiting room told me a patient had come in. [Staff D] told me someone had come in and left. She told me she had told this person to have a seat until I came back. When I returned to the ER intake area, the patient was gone. "

In a second interview on 4/26/16 at 1:08 p.m., the Patient Access Manager said on 4/10/16 Staff C " was assigned the Patient Access Desk from 11:00 p.m. to 7:00 a.m. He usually does not work the night shift. I do not know how long he was in the bathroom. He is not used to working the night shift as he was trying it out to see if he liked it, as I had a position open on that shift. "


She said when she spoke to PBX Operator Staff D on the night of 4/10/16, Staff D reported the patient did not tell her what was wrong with him. She told the Patient Access Manager she had looked out to the waiting room from her desk and had seen the patient standing at the intake glass window. The Patient Access Manager said, "She is new here, I usually cross train the PBX Operator to ask all patients what is wrong with them, I did not train [Staff D] yet. I don't have evidence that she was trained in helping out with registering the patients. My plan now is to cross train all PBX Operators especially [Staff D], since she has been here less than 1 year. "

The facility failed to ensure that their Emergency Room Log policy and procedure was followed as evidenced by failing to maintain a central log, and failed to register or triage patient #1 on 4/10/2016 when he presented to the hospital's ED waiting area complaining of chest pains.

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Based on review of medical records, policies and procedures, hospital ' s web site, and patient and staff interviews the hospital failed to ensure that when an individual " comes to the emergency department " an appropriate medical screening examination must be provided that is within the capability of the hospital ' s emergency department (ED), including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 (Patient#1) of 22 sampled patients. The patient left the ED without receiving a medical screening examination by a qualified medical person.

The findings include:


Hospital policy ORG-E.009 titled EMTALA: Medical Screening, Treatment & Patient Tfr (transfer) included section I.A.1. Medical Screening. "When an individual comes to the emergency department of the hospital, or to any location on hospital property, and a request is made on the individual's behalf for a medical examination or treatment of a medical condition an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists, ..."

Hospital policy ER-1 titled Standards of Care included section N. Additional Standards which directs, "1. Patients will be triaged/seen by a registered nurse as soon as possible after their arrival to the Emergency Department."

According to the Agency's public website (FloridaHealthFinder.gov), the hospital has an Emergency Department and Emergency Services including Cardiology and Emergency Medicine.

In an interview on 4/22/16 at 4:05 p.m., Patient #1 reported that he went to the hospital's emergency room (ER) on 4/10/16 at approximately 12:05 a.m. He stated, "I had severe chest, back, and left arm pain and the hospital was only 2 minutes from my house. I parked in the ER parking lot and walked into the ER. When you walk in, the triage room is on the left and there are 2 glass windows where the intake people sit and there was no one there... woman in her thirties came out from an office and asked me are you going to the back or do you need intake and I told her I needed to go in the back and I was having chest pain. She was wearing street clothes and went down a hallway, I could see her about forty feet away and she went into her office and started typing on a computer. She never came close to me as she was always twenty feet away. I only saw her and I stayed 20 minutes and did not observe any other staff there... I went home and took 4 aspirins. I did not take nitro [nitroglycerine, a medication for chest pain] as my prescription had expired. The aspirin did help my chest pain, but it did not go away. On Monday morning I called my doctor and he sent me to another hospital's ER. I was seen there and transported by ambulance to a hospital that specializes in cardiac care for a stress test which I failed, and had to receive IV [intravenous] nitro. I then had 5 stents placed. " (A stent is a medical device to keep the coronary artery open.)

In an interview on 4/26/16 at 12:55 p.m., regarding the events of 4/10/16, Staff C said, "I told [PBX Operator Staff D] before I left that if anyone came in, to tell them to have a seat and I would register them when I came back. I returned 5 minutes later and 1 of the patients in the ER waiting room told me a patient had come in. Staff D told me someone had come in and left. She told me she had told this person to have a seat until I came back. When I returned to the ER intake area, the patient was gone. If someone came to my intake window complaining of chest pain, I would call the ER and tell the nurse to come out. I would take the patient's name and finish registering the patient in the ER area. On this night the ER was not that busy."

In an interview on 4/26/16 at 5:40 p.m., regarding the events of 4/10/16, Staff D said, Staff C " told me he was going to the bathroom in the ER. He told me to keep an eye on the intake area if anyone came in. I saw someone on my camera come in and I came out of my office. I did not ask him why he wanted to be seen in the ER. I was not cross-trained on how to register a patient. I know to call the ER if someone was having chest pain or having a baby. If this person had told me he was having chest pain, I would have called the ER. I am not allowed to leave my office, unless someone replaces me. On that night, the ER was not busy and there were a few patients in the waiting room. "

In a second interview on 4/26/16 at 1:08 p.m., the Patient Access Manager said on 4/10/16 Staff C " was assigned the Patient Access Desk from 11:00 p.m. to 7:00 a.m. He usually does not work the night shift. I do not know how long he was in the bathroom. He is not used to working the night shift as he was trying it out to see if he liked it, as I had a position open on that shift. " She said when she spoke to the PBX Operator Staff D on the night of 4/10/16, Staff D reported the patient did not tell her what was wrong with him. She told the Manager she had looked out to the waiting room from her desk and had seen the patient standing at the intake glass window. The Manager said, "She is new here, I usually cross-train the PBX Operator to ask all patients what is wrong with them, I did not train [Staff D] yet. I don't have evidence that she was trained in helping out with registering the patients. My plan now is to cross-train all PBX Operators, especially [Staff D] since she has been here less than 1 year.

In an interview on 4/26/16 at 1:58 p.m., the ER Director said, "My expectation of my staff is that the triage area is staffed 24 hours a day. On Saturday night [4/9/16 through 4/10/16], the ER was not busy according to the ER census that I printed for you. I am not surprised that we did not have triage covered that night. For staffing, we had one ER tech 7:00 p.m. to 7:00 a.m. and one ER tech 3:00 p.m. to 3:00 a.m. We should have had three ER techs, but we had enough nurses on the schedule to cover triage.

In an interview on 4/27/16 at 10:45 a.m., the PBX Operator Staff F explained that at night the operator is the back-up for registration/triage if that person takes a break. She said, "At night, if I see someone come in, I greet them, ask if they've been here before, and I contact registration." She was unsure if triage was staffed all night.

Review of Patient #1's medical records from the second hospital revealed emergency service note of 4/13/16 "Patient presents with chest pain." A consult of 4/14/16 noted: "Patient has history of Coronary Artery Disease and Coronary Artery Bypass Grafting surgery in 2007 while in NY. He has been having intermittent chest pain which began 5 days ago... Patient symptoms were felt to be consistent with Acute Coronary Syndrome..." Hospital course note of 4/16/16 included: "Status Post Catheterization with 5 bare-metal stents placed... Condition at discharge: Stable. Discharged to home."

The facility failed to ensure that on 4/10/16 Patient #1 who came to the hospital ' s emergency department complaining of chest pain was provided an appropriate medical screening examination. Patient #1 presented to the hospital ' s emergency room and was not triaged or registered. After about 20 minutes, Patient #1 left without receiving a medical screening examination by a qualified medical person. Lehigh Regional Medical Center had the capability and capacity to provide the medical screening examination for Patient #1 on 4/10/16.