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Based on observations and interviews it was determined the facility failed to post signage in the ambulance bay entrance of the facility. Interview with the Chief Nursing Officer on 02/05/15 at 1:45 PM revealed patients could access the Emergency Department through the ambulance entrance. She stated on average approximately ten patients presented to the ambulance entrance with family members requesting treatment in the Emergency Department. Continued interview revealed signage was posted in the lobby of the Emergency Department only (refer to A2402).

Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department central logbook. The facility failed to have a system in place to ensure that the names of all patients who presented to the Emergency Department (ED) but left without receiving a medical screening were logged into the registration logbook (refer to A2405).

Based on interview and a review of the facility's Emergency Department registration logbook, the facility's investigation, and the facility's policies, it was determined the facility failed to ensure a medical screening was provided for two (2) of twenty-one (21) patients (Patient #1 and Patient #21) that presented to the facility's Emergency Department (ED) for treatment. Interview revealed Patient #1 (a 12-month-old) presented to the facility on 12/20/14 with difficulty breathing and fever.

Patient #1's guardian attempted to have staff screen/assess the patient. Even though no one had screened/assessed Patient #1, staff told the guardian they were busy and it would be two (2) hours before Patient #1 could be seen. Patient #1's guardian left the facility with Patient #1 and went to an outpatient clinic (Facility #2) where Patient #1 was diagnosed with Croup and was transferred back to the facility for admission (Croup is a condition that causes an inflammation of the upper airways - the voice box (larynx) and windpipe (trachea). As the upper airway continues to swell, it becomes even more difficult for a child to breathe, and you may hear a high-pitched or squeaking noise during inhalation (stridor). A child also might breathe very fast or have retractions (when the skin between the ribs pulls in during breathing). In the most serious cases, a child may appear pale or have a bluish color around the mouth due to a lack of oxygen.)

Interview also revealed Patient #21 (a nine-year-old) presented to the facility on 09/27/14 with difficulty breathing. Patient #21's guardian attempted to have staff screen/assess the patient; however, staff told the guardian that they were busy and Patient #21 was fine and would need to wait, even though no one had screened/assessed Patient #21 to determine if he/she was medically stable. Patient #21's guardian left the facility with Patient #21 and went to an outpatient clinic (Facility #3) where Patient #21 was diagnosed with Asthma and Acute Respiratory Failure (Asthma is a common chronic inflammatory disease of the airways. Common symptoms include wheezing, coughing, chest tightness, and shortness of breath.), and was transferred back to the facility for direct admission to the Intensive Care Unit (refer to A2406).

Based on observations and interviews it was determined the facility failed to post signage in the ambulance bay entrance of the facility.

The findings include:

The facility's EMTALA policy did not address signage in the Emergency Department.

A tour of the facility Emergency Department on 02/05/15 at 1:30 PM revealed the ambulance bay entrance did not have signage posted.

An interview with the Chief Nursing Officer on 02/05/15 at 1:45 PM revealed patients could access the Emergency Department through the ambulance entrance. She stated on average approximately ten patients presented to the ambulance entrance with family members requesting treatment in the Emergency Department. Continued interview revealed signage was posted in the lobby of the Emergency Department only.

Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department central logbook. The facility failed to have a system in place to ensure that the names of all patients who presented to the Emergency Department (ED), but left without receiving a medical screening, were logged into the registration logbook.

The findings include:

The facility did not have a policy related to the keeping of the Emergency Department logbook.

Interview with Patient #1's guardian on 02/04/15 at 2:30 PM revealed Patient #1 presented to the ED on 12/20/14 at approximately 1:00 PM. Patient #1's guardian spoke with Patient Registration Clerk #1; however, Patient #1's guardian left with the patient at approximately 1:30 PM without being medically screened by facility staff.

A review of the facility's ED logbook revealed there was no record of the patient's visit on 12/20/14 in the ED logbook.

An interview with Patient Registration Clerk #1 on 02/05/15 at 1:50 PM revealed the facility's protocol for maintaining the ED logbook was the following: the triage nurse triaged the patient and wrote the patient's name, date of birth, and complaint on a piece of paper. The triage nurse then gave the scrap paper to the registration clerk. After the triage assessment and registration, staff placed the patient in a room in the ED if a room was available, or placed the patient in the lobby. After registration, staff placed the patient's name and information in the ED logbook and on the tracking board in the ED.

Interview with Triage Nurse #1 on 02/05/15 at 11:50 AM confirmed staff did not document a patient's name and information in the ED logbook until after the patient was triaged and registered at the ED. Triage Nurse #1 stated Patient #1's name was not entered into the ED logbook because the patient never received a triage assessment.

Interview with the ED Manager on 02/04/15 at 12:30 PM revealed a patient's name was not written on the ED logbook unless the patient received a triage assessment and was registered in the ED. The ED Manager stated Patient #1's name was not entered into the ED logbook because the patient never received a triage assessment.

Based on interview and a review of the facility's Emergency Department registration logbook, the facility's investigation, and the facility's policies, it was determined the facility failed to ensure a medical screening was provided for two (2) of twenty-one (21) patients (Patient #1 and Patient #21) that presented to the facility's Emergency Department (ED) for treatment. Interview revealed Patient #1 (a 12-month-old) presented to the facility on 12/20/14 with difficulty breathing and fever. Patient #1's guardian attempted to have staff screen/assess the patient. Even though no one had screened/assessed Patient #1, staff told the guardian they were busy and it would be two (2) hours before Patient #1 could be seen. Patient #1's guardian left the facility with Patient #1 and went to an outpatient clinic (Facility #2) where Patient #1 was diagnosed with Croup and was transferred back to the facility for admission (Croup is a condition that causes an inflammation of the upper airways - the voice box (larynx) and windpipe (trachea). As the upper airway continues to swell, it becomes even more difficult for a child to breathe, and you may hear a high-pitched or squeaking noise during inhalation (stridor). A child also might breathe very fast or have retractions (when the skin between the ribs pulls in during breathing). In the most serious cases, a child may appear pale or have a bluish color around the mouth due to a lack of oxygen.)

Interview also revealed Patient #21 (a nine-year-old) presented to the facility on 09/27/14 with difficulty breathing. Staff triaged the patient; however, after waiting in the waiting room for approximately 40 minutes, the patient worsened; staff told the guardian they would need to wait, even though no one had screened/assessed Patient #21 to determine if he/she was medically stable. Patient #21's guardian left the facility with Patient #21 and went to an outpatient clinic (Facility #3) where Patient #21 was diagnosed with Asthma and Acute Respiratory Failure (Asthma is a common chronic inflammatory disease of the airways. Common symptoms include wheezing, coughing, chest tightness, and shortness of breath.), and was transferred back to the facility for direct admission to the Intensive Care Unit.

The findings include:

A review of the facility's policy titled "Admission to the Emergency Department-Registration and Examination," undated, revealed any person who presented to the Emergency Department would be examined by the physician in the Emergency Department. Any patient, regardless of race, color, creed, or financial status, who considered himself acutely ill or injured would be admitted to the Emergency Department and would be seen by the ED physician. The policy stated the physician would evaluate, treat, and/or give disposition of the case based on the triage category determined by the RN in the Triage Area. The policy further stated all patients would be triaged within five (5) minutes of their arrival.

Review of the facility's Rules and Regulations revealed the facility had established that a physician or a Qualified Medical Person would perform the medical screening in order to determine if an emergency medical condition existed.

1. Interview with Patient #1's guardian, who is a paramedic, on 02/04/15 at 2:30 PM, revealed he took Patient #1 to the facility's ED on 12/20/14 for treatment for difficulty breathing. He stated that he spoke with Registration Clerk #1, who told him the ED was "busy" and it would be "two hours" before Patient #1 could be seen. The guardian also stated that Registration Clerk #1 told him the outpatient clinic, located in a different community, was open and seeing patients. He stated RN #1 walked into the triage area and said "hello" to him, but never asked what he was doing in the ED or if Patient #1 had been triaged, even though Patient #1 was wheezing and having difficulty breathing. The guardian stated he left the facility with Patient #1 and drove 45 minutes to the outpatient clinic (Facility #2). Patient #1 was evaluated and treated by Physician #1, then transferred back to the facility and admitted on 12/20/14, with a diagnosis of Croup.

Interview with Registration Clerk #1 on 02/05/15 at 1:50 PM revealed she was working in the ED on 12/20/14. She stated that Patient #1's guardian brought the patient to the ED. She stated the guardian asked if the ED was busy and she stated "yes." Registration Clerk #1 stated she informed Patient #1's guardian that the ED was full, people were waiting in the lobby, and it would be around two (2) hours before Patient #1 would be seen. Continued interview revealed Registration Clerk #1 informed the guardian that the outpatient clinic (Facility #2) in a nearby community was open and seeing patients.

Interview with Registered Nurse (RN) #1 on 02/05/15 at 11:50 AM revealed she was working as the triage nurse in the ED on 12/20/14. She stated she was assisting a patient in the ambulance bay and walked into the triage area and spoke to Guardian #1, but did not triage Patient #1 because the guardian was walking away from the desk.

Interview with Physician #1 on 02/05/15 at 12:00 PM revealed he received a text message from Patient #1's guardian on 12/20/14 asking the physician if he would see Patient #1 at the outpatient clinic (Facility #2). He stated he told Patient #1's guardian to bring the patient to the clinic. Continued interview revealed that when Patient #1 presented to the clinic, the physician was with a patient in another room, but could "hear [Patient #1] breathing from the lobby" and that anyone who came in contact with Patient #1 could have heard that the patient was having difficulty breathing. The physician stated Patient #1 required treatment for approximately one hour before Patient #1 was "somewhat" stabilized. Physician #1 stated he contacted ambulance services to transport Patient #1 back to the facility for admission and treatment; however, an ambulance was not readily available. Due to the patient's condition, the physician provided a portable oxygen tank for the patient to utilize while the guardians drove the patient back to the hospital. Physician #1 stated he contacted Physician #2, a Pediatrician, who agreed to meet the patient at the facility.

Interview with Physician #2 on 02/05/15 at 1:10 PM stated she met Patient #1 at the facility on 12/20/14. She stated Patient #1 had audible "stridor" (Stridor is a high-pitched breath sound, which is caused by a narrowed or obstructed airway. Inspiratory stridor often occurs in children with croup). She stated she was aware that Patient #1's guardian was upset because Patient #1 had not been seen in the ED and had to be taken 45 minutes away to be treated in an outpatient clinic. She stated she also complained to the administrator of the facility because Patient #1's guardian requested her phone number, but the facility failed to contact her or give the guardian information on how to contact the pediatrician. Physician #2 also stated the ED physician could have contacted her and she would have admitted the patient.

An attempt to obtain Patient #1's ED medical record from the facility for the visit on 12/20/14 was made; however, the facility did not have a record of Patient #1 being in the ED. Interview with RN #1 on 02/05/15 at 11:50 AM and with Registration Clerk #1 on 02/05/15 at 1:50 PM revealed Patient #1 did not have a medical record for the ED visit because the facility did not assess the patient.

Review of Patient #1's medical record from the outpatient clinic (Facility #2) revealed when the patient presented to the clinic on 12/20/14, Patient #1's oxygen saturation was 84% (normal is 95-100%) and his/her respiratory rate was 40 (normal for a 12-month-old is 18-30). The medical record further revealed that the patient did not have a fever, but was retracting (the skin between the ribs pulls in during breathing), had stridor respirations, and "you could hear [the patient] breathing in the lobby." The physician at the outpatient clinic diagnosed Patient #1 with Croup and admitted Patient #1 directly into the hospital.

Review of Patient #1's medical record from the facility revealed Patient #1 was admitted on 12/20/14 with diagnoses of Croup and Respiratory Distress. Upon admission, the patient's temperature was 99.6, the patient was in mild respiratory distress, and was "ill in appearance."

2. A review of Patient #21's ED medical record revealed ED staff triaged the patient on 09/27/14 at 2:49 PM for cough, wheezing, smothering, and shortness of breath. Patient #21's vital signs during triage were as follows: temperature - 97.2; pulse - 98; respirations - 20; blood pressure - 116/57, and oxygen saturation - 97% (all normal vital sign measurements). Continued review of the record revealed Patient #21 left the ED at 3:29 PM without receiving a medical screening.

Interview with Patient #21's guardian on 02/06/15 at 9:30 AM revealed she took Patient #21 to the facility's ED on 09/27/14 for treatment for difficulty breathing. She stated that she spoke with RN #3 and told the RN that Patient #21 was having difficulty breathing and she had given the patient a breathing treatment at home. She stated RN #3 triaged Patient #21, but would not listen when she told her that Patient #21 was having difficulty breathing. She stated while waiting in the lobby, Patient #21's breathing got worse and his/her wheezing got more pronounced. She stated she told RN #3 that Patient #21 was having difficulty breathing and RN #3 stated that Patient #21's oxygen level was stable when the patient was triaged and the patient would have to wait for a medical screening. She stated another staff member walked by and told her that Physician #1 was working in the outpatient clinic (Facility #3) and she could go there for treatment. She stated she took Patient #21 to Facility #3 and the patient was treated for Asthma and Acute Respiratory Failure and then directly admitted to the facility.

Interview with Physician #1 on 02/05/15 at 12:00 PM revealed he treated Patient #21 in an outpatient clinic on 09/27/14 for asthma and acute respiratory failure. He stated Patient #21's guardian brought the patient to the clinic after not being treated in the ED. Physician #1 stated Patient #21 was in respiratory failure and that the patient's guardian was a medical professional who understood the signs and symptoms of her child's illness and the ED staff should have listened to the guardian and treated the patient.

Review of Patient's #21's medical record from the outpatient clinic (Facility #3) revealed on 09/24/14 when the patient arrived at the clinic his/her oxygen saturation was 78% (normal is 90-100%). Patient #21 was evaluated and treated on 09/27/14, diagnosed with Asthma, and transferred back to the facility for hospitalization.

Review of Patient #21's medical record from the facility revealed Patient #21 was admitted to the Intensive Care Unit on 09/27/14 and treated for Acute Respiratory Failure. Patient #21 was discharged home on 10/01/14.