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Based on observation, interview, record review, and review of the facility's policies, it was determined Patient #1 presented to the facility with symptoms to include upset stomach, nausea, vomiting, and pale color, as a potential result of Albuterol poisoning. Patient #1 remained in the facility for fifty (50) minutes, during which time patient was not triaged nor provided a medical screening exam (MSE). Patient #1 left the facility and traveled to second facility, where the patient was immediately triaged and provided treatment.

Refer to findings in Tag A-2406

Based on review of the facility's policies, record review, review of video footage and interviews, it was determined the facility failed to perform an appropriate medical screening examination (MSE) for one (1) of twenty-five (25) sampled patients, Patient #1, on 11/08/2022.

Patient #1, a minor, was brought to the facility by family and presented with an upset stomach, nausea, vomiting, and pale color, due to possible Albuterol poisoning as patient had self-administered an unknown quantity of Albuterol which the patient had been prescribed for a respiratory infection. Upon arrival to the Emergency Department (ED), information was shared by the parent with the front desk staff. Patient #1's family went to the front desk three (3) times in fifty (50) minutes asking how long it would be before Patient #1 could be seen, before finally stating they asked directions to facility #2, a twenty (20) to thirty (30) minute drive, where patient received care.

The findings include:

Review of the facility's policy Medical Screening Examination, Stabilization & Transfer of Patients, effective date 04/26/2021, revealed the facility will provide an appropriate medical screening examination within the capabilities of the facility's emergency department to individuals coming to the facility's emergency department to determine whether an emergency medical condition exists. Continued review revealed if a patient with an emergency medical condition that has not been stabilized is transferred based on patient request, staff were to obtain the signature of the patient or authorized person and the reason for the request or transfer after explaining the facility's obligation to provide stabilizing treatment and explaining the risks of the transfer.

Review of facility policy Emergency Nursing Practice Guidelines, effective date 01/13/2021, revealed the emergency nurse triages each patient to prioritize and optimize patient flow, expediting those patients who require immediate care. The policy goes on to note the emergency nurse analyzes assessment with priorities always being airway, breathing, and circulation.

Review of facility policy Triage, effective date 02/05/2021, revealed triage screening will occur on all patients presenting to the ED to determine level of care and placement within the ED for treatment. The triage nurse obtains a history or brief assessment of the presenting complaint(s) to determine acuity and placement and observes patients in the lobby and updates the charge nurse with any changes when necessary. The policy goes on to reveal patients are assigned an acuity level one (1) to five (5) using the Emergency Services Index (ESI), with the appropriate acuity level documented in the medical record. The policy goes on to state that if a bed is available, the triage nurse and charge nurse will work together to assign patients to treatment rooms, with acuity level 1 and acuity level 2 patients to be in a treatment area and have the complete primary nursing assessment completed as soon as possible.

Review of Power Point presentation titled Triage and the E.R., not dated, revealed level 1 acuity is for patients requiring immediate life saving intervention. Acuity level 2 is identified as high risk based on interview, observation, and "sixth sense." Level 2 consists of conditions that could easily deteriorate and could be time sensitive. Levels 3 through 5 are based on the number of resources a patient is expected to need, with level 3 being 2 or more resources, level 4 being 1 resource, and level 5 requiring no resources. The presentation included six scenarios to discuss and assign acuity.

Review of Patient #1's medical record revealed Patient #1 was logged in to the ED on 11/08/2022 at 5:59 PM with his/her father and a chief complaint of drug overdose. Further review of a statement obtained by the receptionist (RN #1) revealed Patient #1 had gotten hold of his/her Albuterol inhaler and had ingested an unknown amount. Continued review of the record revealed Patient #1 was assigned an acuity level 2 (Emergent) and had a pending room assignment at 8:59 PM. Patient #1 was documented as left without being seen. There was no evidence in the medical record that the family of Patient #1 had been educated on the risks of transfer or the facility's obligation to provide stabilizing treatment, nor was there documentation signed by the family of Patient #1 stating Patient #1 was being transferred by family request or why.

Review of video footage (no audio) revealed on 11/08/2022 at 5:59 PM, there were twenty-five (25) people in the ED waiting area when Patient #1 arrived with a gentleman (later identified as Patient #1's father, after referred to as Father #1) and an older woman (identified as grandmother, after referred to as Grandmother #1), with Patient #1 in father's arms. Receptionist (RN #1) spoke with Grandmother #1 and provided her with an emesis bag for Patient #1. Patient #1 appeared to be nodding off on Father #1's shoulder at 6:03 PM. Father #1 with Patient #1, and Grandmother #1 moved away from receptionist desk at 6:03 PM. Father#1 was observed sitting down with Patient #1 directly across from receptionist desk. Grandmother #1 was observed standing nearby practicing social distancing (leaving a chair between them and another gentleman with a child). Observation of the video footage revealed that the camera was at an angle that prevented the camera from viewing Father #1 and Patient #1 for approximately 21 minutes. Grandmother #1 picked up Patient #1 from Father #1 at 6:24 PM as Father #1 goes out of view. Video footage revealed at 6:26 PM Father #1 returned into camera view, took Patient #1 where both Father #1 and Grandmother #1 were able to sit at this point. Video footage observation at 6:28 PM revealed the emesis bag was placed to the mouth of Patient #1. At 6:37 PM Grandmother #1 was observed walking to the receptionist desk to speak with RN #1 and returned within seconds. Father #1 was observed walking to the desk at 6:44 PM with Patient #1, who appeared awake and was observed looking around. Then, Father #1 and Patient #1 returned to their seat. Grandmother #1 exited the facility at 6:52 PM, had previously been on cell phone. Father #1 was observed exiting the facility with Patient #1 in his arms at 6:53 PM and Patient #1's head up. Video footage revealed a car pulls up at 6:54 PM in front of the ED. Father #1 was observed on the video footage placing Patient #1 in the back seat of the car, got into the passenger seat and the car drove away at 6:55 PM. Video footage revealed throughout time in ED waiting area, people were observed coming and going with several people having been in the ED prior to the arrival of Patient #1 and were still there when Patient #1 departed.

Review of Patient #1's medical record from facility #2 revealed Patient #1 arrived at 7:24 PM and was triaged at 7:37 PM.

Interview with the ED Manager on 12/06/2022 at 9:20 AM revealed things had been abnormally busy in the ED for the past couple of months. The ED Manager attributed this to a combination of the flu, RSV, Covid, and people just being sicker in general. The ED Manager stated he was not present when Patient #1 came through the ED on 11/08/2022, although he had received a voice mail message from Patient #1's mother (Mother #1) who had been very upset, stating Patient #1 had passed out several times in the waiting room, no one treated them, and as a result they took Patient #1 to Facility #2. The ED Manager stated he called Mother #1 back the following day and apologized that they had been busy. He stated that Mother #1 wasn't happy and stated Patient #1 should have been brought back right away. The ED Manager said he explained there was a critical patient in the back they were dealing with that had pulled their triage nurse away (RN #4). Interview with the ED Manager revealed when Mother #1 told him Patient #1 had passed out, he had asked if she said anything to anybody, at which point she began cussing him out and hung up on him. The ED Manager stated Mother #1 led him to believe she was present with Patient #1, but he had since found she was not. The ED Manager stated there was a critical patient in back that had pulled the triage nurse (RN #4) away. He stated all 32 rooms in the ED were full and described that as normal as there was usually an influx of patients between 5 PM and 7 PM. He stated the nurse receptionist (RN #1) does a visual assessment and collects information upon arrival, and assesses patients utilizing ESI, which is based on severity of condition and number of resources a patient will require. The ED Manager stated he spoke with RN #1, who stated Patient #1 looked good, didn't appear to have any ailments. The ED Manager concluded that by the time staff were available for Patient #1, the family had already left.

Interview with RN #1 on 12/06/2022 at 9:56 AM revealed she was working as the receptionist, or "Triage 1," on 11/08/2022 at the time Patient #1 came to the ED. She recalled Patient #1 had been brought in by his/her father and another woman as he/she had taken an unknown amount of Albuterol. She recalled that Patient #1 "looked alright," with good color and breathing, and she remembered telling the charge nurse (RN #3) Patient #1 had arrived. For Albuterol poisoning, RN #1 stated she would expect sweating and tachycardia; however, Patient #1 never "seemed lethargic or anything." She stated she tried to keep an eye on the patient, although the ED was busy, and she never saw anything to prompt her to intervene or get Patient #1 back to a room. She revealed she assigned Patient #1 an acuity level 2, emergent, in order to be seen more quickly. RN #1 stated she didn't remember any specific conversations with the family of Patient #1, although she did believe they asked how long the wait was, and came back to tell her they were leaving to go to another facility. She stated they never informed her Patient #1 had lost consciousness, and, if they had, she would have attempted to find a hallway bed to bring them back to immediately. She continued that they did not ask about other hospitals or transportation that she could remember.

Continued interview with RN #1 revealed her responsibility as receptionist is to triage whoever comes in, to determine who needs to be seen more quickly dependent on how emergent their complaint is. She stated she classifies acuity level 1 to 5 based on ESI, with 1 requiring immediate intervention, 2 emergent, try to see quickly, 3 urgent, 4 not as urgent, and 5 non-emergent. She stated clinical judgement plays a role in determining acuity, as does patient presentation, history, and vital signs. Further interview revealed that other than 1 requiring immediate intervention, there aren't time frames assigned to acuity, with staff trying to triage patients as quickly as possible, which is hard to do some days. She stated a second nurse ("Triage 2") usually gathers more data and takes vitals, although she couldn't remember whether a second nurse was working at the time Patient #1 presented. RN #1 shared she had EMTALA training every year, with EMTALA focused on not denying anyone the right to be seen, and stabilizing people if they must be sent elsewhere. In addition, she stated she has had training on Pediatric Life Support (PALS).

Interview with RN #2 on 12/06/2022 at 2:12 PM revealed she was working on 11/08/2022 from 7 AM until 7 PM, and recalled it was a very busy day. She stated for the past month or two, the ED had been very busy with very sick people. Although she didn't remember anything exceptional about 11/08/2022, she stated it was normal for them to have all ED beds full. She stated if there is an open room, someone is going back in it. She stated the nurse in the waiting room checks people in and assigns an acuity level using ESI from 1 to 5 based on the severity of the patient, which can change based on information obtained when vitals are taken by protocol nurse in triage room next to registration desk, or if there is an observed change in the patients' condition. She described a level 5 as not used often, usually only when someone needs a doctors note and doesn't require any assessment. She described 4 as things that don't require immediate medical attention. A level 3 was described as urgent, such as abdominal pain. A level 2 was described as significantly urgent, such as chest pain, shortness of breath, or other symptoms that are typically a 3 or 4 but with severe pain. RN#2 described a level 1 as very urgent, requiring immediate attention for stability. She stated she wasn't certain who was the protocol nurse that evening but did say the protocol nurse is the first pulled if something critical is going on. She stated she felt both acuity level 2 and 3 were emergent, with staff doing their best to get them back as quickly as possible. When the surveyor described Patient #1, based on presenting problem of Albuterol overdose and description provided by RN #1, RN #2 stated she would have probably assigned Patient #1 an acuity level of 3, although she acknowledged if uncertain, it was always better to err on the side of caution and give someone a more severe acuity score. RN #2 stated EMTALA is reviewed in orientation, and it is their duty to assess and treat anyone who walks through the door. She concluded by stating she felt doctors do a pretty good job of keeping an eye on what is up in the waiting room and will alert staff if they want someone triaged, although this doesn't always happen when doctors are busy.

Interview on 12/06/2022 at 2:54 PM with RN #3, the charge nurse on 11/08/22, revealed he was working until 7 PM on 11/08/2022. He stated these past few months, every single day had been busy, they all start to run together over time. He stated he did not have any dealings with Patient #1 or family, and nothing stood out about 11/08/2022. He stated they have been seeing a higher volume of patients since the pandemic but have enough staff to manage patient care. He stated a nurse checks everyone in to the ED and determines patient acuity at that time. From that point, the second protocol nurse (if available) will get vital signs on patients and may give patients a lower acuity score (indicating higher need) based on information obtained. He stated staff look at the ABCs, airway, breathing, and circulation, and assign patients an acuity score of 1 to 5. He explained 5 to be someone who needs a work note, 4 to be minor stuff, 3 is more urgent need but not critical, 2 is even more urgent, such as chest pains or shortness of breath, and 1 is emergent-needs right then and there. RN #3 revealed all thirty-six (36) beds were full, and further stated on normal days, there are also patients in beds in the hallway. He acknowledged there have been increased wait times, with many patients choosing not to wait and leaving without being seen. RN #3 stated staff have EMTALA training every year, which states they can't refuse care to patients.

Interview with the Educator Emergency Department (EED) on 12/06/2022 at 3:31 PM and again on 12/07/2022 at 1:33 PM revealed ESI stands for Emergency Services Index and is a triage scale which a nurse would use to assign to patients at initial triage. She went on to state ESI is based on how emergent a condition is, with 1 being if someone requires lifesaving care. Something time-sensitive would be a 2, as would other high-risk patients. She stated the patients of lower acuity would be higher priority than patients of higher acuity. She went on to describe ESI acuity as based on the number of resources a patient will need while in the ED. She stated the desk nurse assigns an acuity level upon presentation to ED based on information provided and observation of patient, with a second nurse collecting further information and obtaining vitals, which could potentially bump a patient up to a higher acuity level. She stated when she teaches ESI, if a patient is not a level 1 or 2, staff look at what kind of resources they are going to need. She stated a drug overdose that is alert could potentially be a 2 but went on to state acuity is not tied to any time frame unless the patient condition is life threatening or time sensitive. When discussing Patient #1 specifically, she stated she would toil between level 2 and level 3, depending on how Patient #1 was presenting, with 2 erring on the side of caution. She stated with an Albuterol inhaler overdose, there wouldn't be anything time sensitive or life threatening.

Regarding ESI, the EED shared there was no policy specific to ESI; however, she had created a power point which she presented to staff on hire which went over the algorithm as well as case scenarios. In addition, although not part of yearly training, she revealed staff are periodically provided refreshers on ESI.

Interview on 12/07/2022 at 11:13 AM with RN #4 revealed she was working as Protocol nurse completing the second part of triage ("Triage 2) at the time Patient #1 arrived on 11/08/22. She stated as Protocol nurse, her duties included gathering patient medical history, gathering blood work, completing EKGs, and getting patients back to rooms when rooms are available. She continued that they can put in protocol orders as well, and collaborate with physicians, providers, and the charge nurse in the back. She stated when patients first come in, she gets temperature, pulse oximetry, heart rate and weight, and if needed, she can continue to complete vital signs as necessary. Regarding Patient #1, she didn't know where she was on 11/08/2022 when Patient #1 came in. She stated she could have been rooming another patient (taking patient from ED waiting area to a room) or in back with an urgent patient, as she did not recall Patient #1. Regarding acuity, she shared they base acuity off of ESI, with patients being assigned a level of 1 to 5, with level 1 life threatening, level 2 high priority such as chest pain or overdoses if the patient is alert and oriented and could also include patients with altered mental status, level 3 urgent patients such as abdominal pain which could require more than two resources, level 4 would be minor, such as needing stitches or an x-ray, and level 5 would be non-urgent such as needing a refill or a work note. She stated acuity level is assigned at the front desk and depending on information she obtains, she could upgrade a patient to a higher acuity. She continued there is no actual time frame written down that she was aware of regarding timeliness of seeing patients based on acuity. She went on to reveal since the beginning of November, they have had increasing numbers of Covid and flu patients, as well as staff out sick. According to RN#4, when there weren't enough beds available upstairs, patients were being boarded in the back of the ED. She stated there is a window for the protocol nurse to look out on the waiting area from within the ED, and the registration nurse also monitors patients to make sure they are safe in the lobby. She continued it can take a long time to triage a patient, even if a patient is assigned a low acuity. She stated staff are diligent in ensuring patients are safe and getting them back as quickly as possible. She stated additional staff are called as needed.

Interview on 12/07/2022 at 12:57 PM with the Assistant Vice President (AVP) of Emergency Services (ES) revealed there is always a nurse at the front desk, a practice the facility adopted in 2015 to ensure clinical judgement in assigning acuity levels to patients, and to monitor patients for any changes in condition. She stated if the assigned nurse must step away for any reason, another nurse from the ED covers for them. The only time the ED nurse does not have eyes on patients and families in the ED waiting area were when he or she has their back to the lobby to speak with someone at the door to the ED about a patient, or when registering other patients coming in or answering patient questions. She stated there is no policy or job description that speaks to the duties of the registration desk nurse. She went on to reveal she had previously been an ED Manager, and one of the things she did was remove partitions from the lobby to ensure the nurse could see everyone in the lobby. She stated if the nurse sees a patient decompensating (which she defined as a negative change in condition), the nurse is to either contact the charge nurse by phone or shout out to someone back in the treatment area who would grab a stretcher or wheelchair or whatever was needed and bring them back to the treatment area. Regarding nurse coverage during high volume times, she stated the facility is actively hiring nurses, and when the patient census is high the facility sends out emails and text messages asking people to pick up shifts, which most will do to help co-workers, and families and friends that live in the community. She stated nurse managers are also out in the department working during high census times. She went on to reveal, when the ED is boarding patients who are waiting on beds upstairs, the logistics center assigns float pool nurses to the ED to care for patients being boarded so ED nurses are freed up to care for ED patients. AVP of ES shared there are great days when only 1 or 2 patients will be boarded in the ED, but more recently they've been boarding anywhere from 10 to 20 patients a day. She revealed on 11/08/2022, there were 10 or 11 patients boarding in the ED. She was able to describe ESI and discuss acuity levels and stated, even within acuity levels, there are differences. She provided an example of someone coming in with chest pain and not as asymptomatic compared with someone also having chest pains that might need to go to the catheter lab. When discussing Patient #1, she stated there were no policies specific to overdoses or poison ingestion, with determination of acuity based on the substance in question, the information provided, and presenting symptoms.

Interview on 12/07/2022 at 2:34 PM with RN #5, who had worked in the ED for fifteen (15) years, revealed as a registration nurse in the ED, she would be responsible for verifying patient identify, asking the chief complaint, while observing patient breathing and color to see if distressed, while also getting information on Covid exposure before assigning the patient an acuity level based on ESI. She stated the registration nurse could also check vital if a patient appeared distressed, but if they did not appear distressed, she would not. She stated as the registration nurse, she would only be away from her desk if she had a problem or had to get the charge nurse, or if she had to assist a patient from a car. She stated the registration nurse keeps an eye on everyone in the waiting room, watching for alertness, increasing shortness of breath, and kids that come in with head injuries, sleepy, or vomiting. She stated when assigned as protocol nurse, she would do the rest of triage in the electronic health record, as well as check vitals, review medical and surgical history, as well as alcohol and tobacco use, suicide and fall risk, immunization information, as well as pharmacy information. She stated if patients expressed something more concerning than shared at the front desk, she could bump up patient acuity level. RN #5 shared in addition to orientation, she had a class on ESI on either competency day or skills day, and there was an ESI chart at the front desk which presents what to look for regarding level 1 and 2, and how to evaluate for levels 3 and 4. She stated if a patient were to come in with a drug overdose or poisoning, she would look for alertness, especially with children. She emphasized with children, its about how they look, and discussed the pediatric triangle, and that she would not be as concerned with a child with good color and normal interactions, whereas she would be more concerned if the child was droopy looking or hyper, in which case she would attempt to get a heart rate, which she described as very hard to do with kids at the front desk. She stated if someone in the waiting room had low oxygen, or was droopy and not staying alert, she would ensure they went back right away. She concluded the interview by stating when there is a high volume of patients, the charge nurse will make phone calls or send messages to get additional staff.

Interview with RN #6 on 12/07/2022 at 3:07 PM revealed she had worked in the ED for over six years. She revealed, when assigned duties as registration nurse, she would log people in, and direct traffic as needed. She stated, in assigning patients acuity, she would take into consideration patient age, medical history, and how they present, as it all plays a role in the ESI number. She stated as registration nurse, her job would also be to keep an eye on patients in the lobby, and if there are a lot of people out there, she would tell them when they were at the desk if something changes to come to the desk so they can address things as appropriate. She stated they are taught ESI on orientation, and review ESI every year on skills day or competency day. When assigned as protocol nurse, she revealed she would pull patients into the protocol room next to the ED desk, take vitals, do EKGs if needed, review patient history and meds taken at home to get a better idea of what is going on with patients. She revealed when there are patients waiting, she would pull them into the protocol room based on their ESI number, with lower numbers having priority. She went on to reveal if patient vitals or EKG looked abnormal, she would talk to the charge nurse or maybe prioritize patients further. When asked about drug overdoses or poison, RN #6 stated there is no specific policy or protocol relating to it. She stated depending on the substance, providers would get in touch with the poison control center to get their recommendations. Regarding patient acuity, she stated it would depend on the item ingested or overdosed on, and how the patient presented, with patients being assigned a level 2 or level 3 acuity. When asked about 11/08/2022, as RN #6 worked that day, she stated nothing stood out to her regarding that date, as the hospital has had a high volume of patients for at least the last two to three months.

Review of the ED log for 11/08/2022 revealed twenty-two (22) patients were marked as acuity level 2, with wait times before MD assignment ranging from as short as one (1) minute to as long as three (3) hours and fifty-four (54) minutes, with an average wait time of forty-eight (48) minutes. Wait times were longer after 4 PM regardless of acuity level, with four (4) patients leaving without being seen after having to wait approximately three (3) hours.

Interview on 12/08/2022 at 9:18 AM with the Director of Patient Logistics and Resource Operations Center (DL) revealed she is responsible for bed placement for the system of hospitals which include the facility and monitors all admissions from any type of procedural area, to include the ED, and any direct admissions or transfers from within the facility as well as from outside organizations. She revealed she is responsible for assigning nurses to support patients who are boarding the ED. She stated ED boarding is evaluated around the clock, with the National Emergency Department Over Crowding Score (NEDOCS) and assign nursing staff to assist in caring for boarders so ED nurses can continue their jobs. She shared in addition to assigning nurses from float pools to assist with boarders (at the time of interview, three (3) were assigned to care for twenty-one (21) boarders in facility ED), the facility had opened an overflow admissions area and had moved six patients to that area. She shared that all facility affiliated hospitals in neighboring counties are boarding patients as well, with as few as one (1) to as many as thirty-three (33) patients boarded in sister facilities.

Review of documentation of patients being boarded in the ED during the month of November 2022 revealed on November 8 at 1:00 PM thirteen (13) patients were boarded in the ED, which went down to three (3) patients being boarded at 5:00 PM, then down to 1 at 10:00 PM.

In summary, Patient #1 was visually assessed in only a limited fashion by a nurse at the registration desk. Triage and MSE not done.