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The hospital failed to comply with the provisions of 42 CFR 489.24 when it failed to provide:

1. Timely MSEs, including ancillary services routinely available to the ED to determine whether or not an EMC existed for three of 33 sampled patients (Patients 1, 12, and 17). Cross reference to A2406.

2. Stabilizing treatment by the ED nursing staff for an EMC within the capabilities of the hospital for one of 33 sampled patients (Patient 3) presenting to the hospital's ED. Cross reference to A2407.

Based on interview and record review, the hospital failed to ensure a complete on-call log of physicians was maintained to provide further evaluation and/treatment if needed after the initial examination of a patient when the name and contact information for the on-call anesthesiologist was omitted from the call roster, creating the increased risk of substandard patient care.

Findings:

In an interview with EMT 1 on 10/28/15 at 0745 hours, the EMT provided the on call list for 10/28/15. The EMT stated the ED received a list of on-call physicians daily.

Review of the on-call list of physicians showed the names of physicians in each speciality. However, there was no physician's name filled in next to the "anesthesiologist."

In a follow-up interview, EMT 1 stated the anesthesiologist's name was not provided; staff must call the House Supervisor to get the name of the on-call anesthesiologist.

On 10/28/15, review of the binder containing the daily on call rosters showed the rosters did not contain the name of the on-call anesthesiologist.

Based on interview and record review, the hospital failed to ensure a complete ED log was maintained and available for review when the log omitted data for some ED patients, creating the risk of substandard ED care.

Findings:

The ED logs for past six months were requested on 10/28/15. Review of the logs showed a header indicating it was printed by the CNO on 10/28/15 at 1125 hours. The log showed the disposition data for some patients was incomplete. For example, the log dated 9/1 through 9/4/15, showed blank spots for 14 patients under the column for "ED Disposition." In addition, the ED disposition for five patients was recorded as "observation." Further inquiry showed the five patients were observed in the ED; however, whether those patients were subsequently discharged, admitted, or transferred could not be determined from the log.

In an interview with the ED Medical Director on 10/29/15 at 1300 hours, the Director stated the hospital's new electronic health record system was requiring additional effort to use; there might be some incomplete entries.

In an interview with RN 1 on 11/3/15 at 1045 hours, the ED log was reviewed. The RN concurred some log entries were incomplete and did not contain discharge data.

Based on interview and medical record review, the hospital failed to ensure an MSE was provided in a timely manner, including ancillary services routinely available to the ED to determine whether or not an EMC existed for three of 33 sampled patients (Patients 1, 12, and 17) as evidenced by:

1. For Patient 17, the patient was not evaluated by a triage nurse on arrival to the ED by ambulance as directed to the hospital's triage policy to determine the urgency of Patient 17's condition but was placed to wait in the hallway on a gurney with an EMT. Thirty four minutes after arriving at the hospital, a passing RN noted the patient was unresponsive and pulseless.

2. For Patient 1, there was no documented evidence to show the physician conducted a MSE for Patient 1 to determine whether an EMC for complaints of chest pain and shortness of breath existed prior to the patient leaving the hospital without being seen by the physician eight hours after arrival to the ED.

3. For Patient 12, there was no documented evidence to show the nursing staff communicated with the physician or provided the interventions for the patient regarding complaints of pain at a level of seven out of 10 at the time of triage. There was no documented evidence to show the nursing staff reassessed the patient's vital signs or pain levels for four hours in the waiting room. There was no documented evidence to show the physician examined the patient to determine whether an EMC existed prior to the patient leaving the hospital. Failure to provide an appropriate MSE could potentially result in patients with an unidentified EMC not receiving appropriate and timely care.

Findings:

Review of the hospital's P&P titled Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance and Transfer revised 11/13 showed a MSE must be offered to any individual presenting for examination or treatment of a medical condition. The examination must be provided within the capacities of the hospital. The examination must be the same appropriate screening examination that the hospital would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care. A MSE is the process required to reach the point at which it can be determined whether an EMC does or does not exist. The triage is not equivalent to a MSE; the triage merely determines the "order" in which patients will be seen, not the presence or absence of an EMC.

Review of the hospital's P&P titled Triage and Treatment of Patients in the ED revised 8/15 showed the hospital shall provide triage treatment to all patients who present to the ED. Triage is a process by which a patient is assessed by the RN to determine the urgency of the problem and appropriate health care resource(s) needed to care for the identified problem.

All ED patients are classified by the triage nurse according to the extent of illness or injury using the Emergency Severity Index (ESI) triage system. The triage nurse has the primary responsibility for assessing and prioritizing patient needs and expediting patient care. The triage nurse shall evaluate each patient upon notification of their arrival. The evaluation includes documentation of: chief complaint, medical information, medications currently being taken, immunization status, allergies, vital signs, physical assessment, and screening for signs of abuse.

Each patient is classified by the triage nurse into one of the following classifications using the ESI:

ESI 1: requires immediate life-saving intervention.
ESI 2: High risk situation or confused/lethargic/disoriented or severe pain/distress.
ESI 3: Vital signs within normal limits. Requires many resources (i.e. labs, electrocardiogram
(EKG), x-ray, IV therapy or intramuscular medications, urinary catheter, laceration repair).
ESI 4: Requires one resource.
ESI 5: Requires no resources (i.e. medication refill, simple wound care, rechecks, splints, oral medication).

The triage nurse shall use professional judgment in the application of the triage guidelines, adhere to the assessment standards established by the ED, and refer patients in immediate danger or in whom there is question as to urgency of their problem to the provider immediately.

For all patients triaged as ESI Levels 1 and 2, the nurse should notify the charge nurse to obtain a bed for immediate treatment and notify the registration personnel.

For all patients triaged as ESI level 3, the nurse should send the patient to the waiting area and instruct them to be seated until their name is called in the event a bed is not immediately available, update the vital signs and assessment on these patients every two hours or more frequently if necessary, and inform the patient to notify staff if they have a change in condition.

Review of the ESI Triage Algorithm of the Triage and Treatment of Patients in the ED showed danger zone vital signs are defined as a HR more than 100 bpm (normal HR is from 60 to 100 bpm), respiratory rate more than 20 breathes per minute, and/or an oxygen saturation (measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) less than 92%; consider the patient assigned with ESI Level 2 if any vital sign criterion is exceeded.

Review of the hospital's P&P titled Protocol: Emergency Department Treatment and Diagnostic revised 10/13 showed a qualified RN in the ED may initiate the emergency treatment standardized procedures for specific conditions. The RN applies the nursing process to the above factors to determine which, if any, tests should be ordered by the nurse. The RN should assess the patient for pain and notify the ED physician for pain medications as needed prior to diagnostic study as appropriate and initiate order sets at triage in collaboration with the ED physician.

For lower abdominal pain, the protocol showed a order set for CBC (complete blood count is a blood test to measure several components and features in the blood), BMP (basic metabolic Panel is blood test to provide key information regarding fluid and electrolyte status), kidney function, blood sugar levels, UA (urine analysis), and UCG (pregnancy test for females who can menstruate).

Review of the hospital's P&P titled Pain Management revised 9/13 showed the pain intensity will be assessed by using a pain scale consistently according to age and developmental level as appropriate. A pain level between 4 and 6 indicates the patient has moderate pain. A pain level between 7 to 10 indicates the patient has severe pain. Pain management including medications will be provided to the patient by a physician order; when pain is constant, administer the pain medications around the clock as ordered. The goal is to maintain a pain rating of the patient's own comfort level goal. This may be documented with the pain intensity score by indicating the intervention is effective, or by the patient's statement that they do not need treatment for pain.

1. Medical record review for Patient 17 was initiated on 10/29/15. The patient was brought into the ED by a basic life support (BLS) ambulance from a skilled nursing facility (SNF) on 10/9/15, due to fever. The time of arrival was documented in the medical record as 1608 hours.

Review of documentation showed soon after arrival into the ED, before the patient was placed in a bed, Patient 17 was noted as pulseless and was not breathing. A Code Blue was called and CPR (cardiopulmonaryresuscitation, a lifesaving technique by forcing air into lungs with chest compression to stimulate breathing and circulation) was immediately started.

Documentation showed Patient 17 was placed in a treatment room at 1608 hours, a breathing tube was inserted into the patient's windpipe and was connected to a mechanical ventilator to help the patient breathe.

Review of the nursing documentation by RN 4 showed the patient was unresponsive upon arrival, pulseless, with no chest rise, and pale. The ED physician was notified and a Code Blue was initiated. However, RN 4's notes were documented at 1552 hours (16 minutes before the arrival time and the time the patient was found unresponsive).

Review of the ambulance run sheet dated 10/9/15, showed the BLS ambulance arrived at the hospital's ED at 1534 hours, not at 1608 hours, and not at 1552 hours, as documented in Patient 17's medical record (34 minutes before the patient was noted as unresponsive).

Documentation by the BLS EMT showed the patient's vital signs were unchanged during the trip to the hospital, at 1515 hours and at 1525 hours. The patient's wheezing and decreased mental status was documented by the BLS EMT as the patient's "norm" per the sending LVN at the SNF. The ambulance run sheet showed the EMT documented "Incident: patient became apneic (not breathing) and pulseless at hospital ER." The documentation showed chest compressions were initiated by the EMT before Patient 17 was placed in an ED bed where ED staff took over the resuscitation.

On 10/29/15 at 1100 hours, in an interview with RN 11 who was present during Patient 17's resuscitation, the RN stated when Patient 17 arrived in the ED, the Charge Nurse (RN 3) did not have time to perform routine responsibilities such as to receive report from the ambulance EMT and assess the patient. RN 4 instructed the EMT to "Hold the wall," without assessing whether the EMT could appropriately monitor Patient 17's condition. RN 11 explained to "hold the wall" was for the EMT to stay and monitor the patient in the hallway of the ambulance entrance until the ED was ready to room the patient. RN 11 further stated the EMT was standing in the hallway beside Patient 17's gurney when one of the ED nurses was passing by and telling the EMT, "Your patient does not look good." Only then the EMT noticed that Patient 17 was pulseless and not breathing. The EMT started the chest compressions and the patient was placed in a treatment room. Resuscitation ensued after.

On 10/29/15 at 1300 hours, the ED patient census and staffing for 10/9/15, was reviewed with RN 11. Documentation showed the ED was saturated with patients at the time of Patient 17's arrival. Five other ambulance patients were waiting for beds in the hallway and 11 patients were registered and waiting to be seen in the lobby. RN 11 stated the ambulance EMTs monitored the ambulance patients in the hallway as there were no additional nurses available in the ED to help out and ease the load.

RN 11 further stated the House RN Supervisor was aware of the situation and instructed the ED staff to prioritize ambulance patients above the patients in the lobby, who were mostly clinic and urgent care type patients only.

RN 11 was asked how the ambulance patients were triaged upon arrival in the ED. RN 11 stated the current practice was for the front lobby triage nurse to focus on the walk-in patients and the Charge Nurse and/or the primary nurse who was assigned to the patient's room would assess ambulance patients.

Review of the ED records showed the first ambulance patient to arrive in the ED on 10/9/15, prior to Patient 17 was classified as an ESI Level 3 and had been in the ED hallway for 48 minutes. The second patient was classified as ESI Level 4 and had been in the ED hallway for an hour and 55 minutes. The third patient was classified as ESI Level 4 and had been in the ED hallway for 53 minutes. The fourth and fifth patients were classified as psychiatric patients but were not yet triaged as there was no ESI level documented for the patients after being in the ED hallway for 20-28 minutes.

On 10/29/15 at 1300 hours, during an interview with the ED Medical Director, he acknowledged the ambulance patients were the hospital's responsibility once the patients entered the hospital ground. The Director also acknowledged a policy was needed to provide direction for triage of ambulance patients.




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3. Review of Patient 1's medical record was initiated on 10/28/15. The patient arrived at the ED on 7/1/15 at 1605 hours, with a chief complaint of chest pain, shortness of breath, and alcohol withdrawal. The patient had a history of hypertension (high BP). The patient left the ED without being seen by a physician on 7/2/15 at 0005 hours, eight hours after arrival to the ED.

a. Review the Patient Care Timeline dated 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1605 hours, Patient 1 arrived at the hospital. At 1608 hours, the patient was assigned an ESI Level 2. The patient's HR was 106 bpm. The patient's BP was 132/62 mmHg. The patient complained of chest pain at a pain level of 5/10.

At 1609 hours, Patient 1 was triaged and an EKG (electrocardiogram, a test that checks for problems rate and rhythm of the heart) was done at 1611 hours.

Review of the EKG report showed the patient's HR was 105 bpm. The EKG was signed as reviewed by the physician; however, there was no date and time documented to show when the physician had reviewed and signed this EKG.

Review of the hospital's P&P showed a patient who was assigned an ESI Level 2 was classified as a high risk situation or a patient who was confused/lethargic/disoriented or in severe pain/distress. For patients triaged as ESI Levels 1 and 2, the nurse should notify the charge nurse to obtain a bed for immediate treatment.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1404 hours, the Director confirmed there was no date and time documented to indicate when the physician had reviewed Patient 1's EKG.

b. Review the Patient Care Timeline dated from 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1643 hours, Patient 1's airway, breathing and circulation were within defined limits. At 1654 hours, the patient was reclassified with an ESI Level 3. However, there was no documented evidence to show the nursing staff reassessed Patient 1's vital signs or pain levels prior to reassigning the patient with an ESI Level 3 on 7/1/15 at 1654 hours.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1404 hours, the Director confirmed the nursing staff had assessed Patient 1's vital signs only twice during the ED stay (on 7/1/15 at 1608 and at 1847 hours).

During an interview with RN 14 on 10/29/15 at 0950 hours, the RN stated an ESI Level 2 would be assigned to a patient who had tachycardia (high HR) and complained of chest pain.

During an interview and concurrent medical record review with RN 1 on 10/29/15 at 1545 hours, RN 1 confirmed Patient 1 was reassigned as an ESI Level 3 on 7/1/15 at 1654 hours. The RN stated the patient's ESI should have been an ESI Level 2, not ESI Level 3 on 7/1/15 at 1654 hours.

c. Review the Patient Care Timeline dated from 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1847 hours, Patient 1's HR remained tachycardic at 110 bpm. The patient's BP was 143/84 mmHg. The patient complained of pain at a level of 5/10. At 2003 hours, the registration of the patient was completed. On 7/2/15 at 0005 hours, the patient was no longer in the lobby and was dismissed.

There was no documented evidence to show Patient 1 was reassessed by nursing for five hours (from 7/1/15 at 1847 hours to 7/2/15 at 0005 hours) as per hospital's P&P.

There was no documented evidence to show the nursing staff communicated with the physician or provided any interventions when Patient 1 complained of chest pain on 7/1/15 at 1608 hours, and complained of pain on 7/1/15 at 1847 hours.

There was no documented evidence to show the physician conducted an MSE for Patient 1 to determine whether an EMC existed prior to the patient leaving the hospital without being seen by the physician on 7/2/15 at 0005 hours.

During an interview with RN 14 on 10/29/15 at 0950 hours, the RN stated a patient would be sent back to the waiting room if there was no open bed in the ED and instructed to inform the triage nurse if their condition worsened. The triage nurse would reassess the patient and if the patient had no further complaints, the triage nurse would reassess the patient every two hours.

During an interview and concurrent medical record review with RN 1 on 10/29/15 at 1545 hours, the RN stated Patient 1 was documented as having left the hospital without being seen by the physician on 7/2/15 at 0005 hours. The RN confirmed Patient 1 was not reassessed for five hours (from 7/1/15 at 1847 hours to 7/2/15 at 0005 hours).

4. Review of Patient 12's medical record was initiated on 10/28/15. The patient arrived to the ED on 5/18/15 at 2208 hours, with a chief complain of pain to the head. The patient had a history of CVA (cerebrovascular accident, or stroke)/TIA (transient ischemic attack or a mini - stroke), and took coumadin (a blood thinner). On 5/19/15 at 0202 hours, the patient left the hospital without being seen by the physician (four hours later).

Review of the Visit Summary Report dated 5/18/15, showed the following:

* At 2208 hours, Patient 12 arrived to the ED.

* At 2214 hours, the patient was triaged. The patient complained of headache at a pain level of 7/10. The patient reported she had hit her head on a hook over the stove at 2000 hours and had a hematoma (bruise).

* At 2220 hours, the patient was sent to the waiting room due to the ED saturation (no open beds).

* At 2232 hours, a CT scan of the head was performed for the patient.

* Four hours later on 5/19/15 at 0202 hours, the patient did not answer when called in lobby.

There was no documented evidence to show the nursing staff communicated with the physician, or provided any interventions when Patient 12 complained of pain at a level of 7/10.

There was no documented evidence to show the nursing staff reassessed the patient's vital signs or pain levels for four hours in the waiting room (from 5/18/15 at 2214 hours to 5/19/15 at 0202 hours).

There was no documented evidence to show the physician examined the patient to determine whether an EMC existed prior to the patient leaving the hospital.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1055 hours, the Director confirmed the above findings.

Based on interview and medical record review, the hospital failed to ensure one of 33 sampled patients (Patient 3) was provided stabilizing treatment by the ED nursing staff for an EMC within the capabilities of the hospital when there was no documentation to show the physician ordered the potent sedation medication administered to the patient who was documented as unresponsive. In addition, there was no documentation to show the patient's vital signs were monitored for 44 minutes immediately following an episode of very low blood pressure. These failures could lead to a delay in treatment or not providing appropriate treatment to the patients.

Findings:

Patient 3's medical record was reviewed on 10/29/15. Documentation showed Patient 3 drove himself to the hospital's ED parking lot on 7/6/15 at 1240 hours. While waiting to be triaged, the patient was found by the triage nurse at 1300 hours, sitting in the wheelchair with head tilted back, being unresponsive, and not breathing. Patient 3 was rushed to a treatment room where resuscitation was begun.

a. Patient 3 was immediately intubated (a breathing tube was inserted to patient's windpipe) and connected to a mechanical ventilator (a machine designed to mechanically move breathable air into and out of the lungs to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently).

Documentation showed at 1305 hours, an IV access needle was inserted and Versed (a potent IV sedation medication) 2 mg was given by RN 5, although Patient 3 remained unresponsive. Further review of the medical record failed to show a documented physician's order to administer Versed.

On 10/29/15 at 1000 hours, RN 11 reviewed Patient 3's medical record and acknowledged there was no written physician's order for Patient 3 to receive Versed.

b. Review of Patient 3's resuscitation's narrative account showed the Code Blue resuscitation was ended at 1313 hours as Patient 3 had an acceptable HR at 111 bpm (normal HR is from 60 to 100 bpm) and BP of 91/59 mmHg (normal is 90/60 to 120/80 mmHg). However, documentation showed Patient 3's BP was very low, 53/38 mmHg at 1352 hours and 52/44 mmHg at 1353 hours.

Despite the patient's very low BP, there was no documentation to show Patient 3's HR and BP were monitored from 1356 to 1440 hours (a total of 44 minutes). Documentation showed during that time, the x-rays of patient's chest and bilateral hip were done followed by an ultrasound of the bilateral legs and a 12 lead electrocardiogram.

Documentation also showed the patient's HR began to decline at 1440 hours. A Dopamine drip (medication to increase HR and BP) was infused intravenously. A Code Blue was called again at 1450 hours. However, at 1528 hours, the Code Blue was terminated and Patient 3 expired.

On 10/29/15 at 1000 hours, RN 11 stated she missed validating the monitored vital signs so the computer did not record the patient's BP and HR in the record.