HospitalInspections.org

Based on review of the Hospital 's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, Medical Record reviews, Security Video Review, Policies and Procedures, Plan for the Provision of Patient Care related to Emergency Services (ES), Medical Staff Rules and Regulations and interviews, it was determined Medical West Hospital failed to:

1). Maintain the ED Log by failing to enter Patient Identifier (PI) # 1's arrival, visit and/or discharge to the ED via ambulance on 3/15/16.

2). Provide a Medical Screening Examination and stabilizing treatment to PI # 1, patient who presented by ambulance post syncopal episode and has a history of Narcolepsy.

Findings include:

Please refer to findings at A2405 - Maintain a Central Log and A2406 - Medical Screening Examination.

Based on a review of Hospital # 1's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, Security Video Review, Emergency Medical Treatment and Active Labor Act Policies and Procedures and interviews, the hospital failed to document PI # 1's arrival, visit and/or discharge to the ED via ambulance on 3/15/16. This affected one of 25 sampled patients, but has the potential to negatively affect all patients who present to the ED for an evaluation.


Findings include:

Hospital # 1's Communication Control Log EMS (Emergency Medical Services) dated 3/15/16:

A review of the log maintained by Hospital # 1 revealed a call was received from EMS on 3/15/16 at 17:58 regarding the impending arrival of PI (Patient Identifier) # 1 by a staff ED (Emergency Department) RN (Registered Nurse) at Hospital # 1. Patient Information/Assessment: This 54 year old male experienced a syncopal episode and has a history of Narcolepsy.
Oxygen Saturation: 98% on room air.
Blood pressure: 134/87, Pulse 94: Respirations: 18. Blood Sugar via dextrose stick: 138.
Hospital of Patient Choice: Hospital # 1.
Hospital Patient Transported to: Hospital # 1.
ETA (Estimated Time of Arrival): 3 - 4 minutes.


Review of EMS Report Dated 3/15/16: (Incident Number: 1603-0244) Includes:

Dispatched: 17:19
Enroute: 17:19
On Scene: 17:37
Complete: 17:51 ("at ED" documented on form)
Patient Name: PI # 1
Age: 45
Allergies: ASA (Aspirin)
Medical History: Narcolepsy, TIA (Transient Ischemic Attack)
17:43 - Blood Pressure: 134/87, Pulse: 92, Respirations: 138
Glucose: 138
Narrative: "45 year old male (PI # 1) chief complaint of syncopal episode. Pt. (Patient) states he feels like his narcolepsy has caused said incident. Patient is not compliant with medication. Vital signs and monitoring enroute. Refuses IV (intravenous) therapy. Patient transported to Hospital # 1 without incident. ** Prior to arrival report was called in. Nurse stated that the hospital (Hospital # 1) was on CC (Critical Care) divert. Upon arrival at ER, crew and patient had to wait in hallway of ER for over 1 hour. Pt. Patient (PI # 1) demanded to be taken off stretcher and left ER AMA (Against Medical Advice)...Charge Nurse signed receiving patient." Documented by EMT-P / EI # 2.


EMS Incident Report regarding PI # 1 dated 3/15/16:

Date of incident: 3/15/16
Description of incident: "At approx (approximately) 17:51 hours EMS arrived at Hospital # 1 with a patient (PI # 1) who had had a narcoleptic incident at work. (Name of) EMS crew and patient proceeded to stand in hallway until 19:08 hours at which time the patient demanded to be taken off of stretcher as he wanted to leave ER. ER staff told patient he needed to sign AMA (Against Medical Advice) documents but patient proceeded to leave...Charge Nurse signed for patient.
Signature of Person Reporting: EMT-P / EI # 2


Review of Hospital # 1's ED Log:

A review of Hospital # 1's Central ED Log revealed no documentation of PI # 1's presentation to the ED on 3/15/16.


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


PI # 1's ED Medical Record Review dated 3/16/16 includes:

Comments: Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor...


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


Hospital # 1's EMTALA ("Emergency Medical Treatment and Active Labor Act") Policies and Procedures Issued 10/1/12 Includes:


...5.5.2 The triage nurse shall perform an assessment to determine the individual's chief complaint, history, medications, allergies, a description of positive and negative findings and vital signs as necessary to inform the nurse of the nature and severity of the individual's condition.

5.5.3 The information obtained from the assessment shall be documented in the ED record and shall become part of the medical record...


5.6.8 Time of screening, category of priority, time of arrival, time of placing in a treatment room, time of MSE (Medical Screening Examination)...shall be noted in the record...



Interviews:

Interview on 4/19/16 at 09:04 with EI # 3 / Hospital # 1's Chief Quality Officer (CQO):

During the interview the CQO verified there was no medical record created for PI #1's ED visit on 3/15/16.


Interview on 4/19/16 at 13:05 with EMT-P (Advanced level Emergency Medical Technician- Paramedic) / Employee Identifier (EI) # 2:

During a telephone interview on 4/19/16 at 13:05, EI # 2 confirmed he transported Patient Identifier (PI #1) to the ED (Emergency Department) at Hospital # 1 via ambulance on 3/15/16. EI # 2 states he called report via radio to the ED regarding the impending arrival of PI # 1.


According to EI # 2 the, "Charge Nurse said what you got?" EI # 2 said he told the nurse, "This is the patient (PI # 1) with Narcolepsy. We called report."

Interview on 4/19/16 at 16:00 with ED RN / EI # 8:

The RN, responsible for the triage of PI # 1 when he returned to Hospital # 1's ED on 3/16/16 said she enters / types exactly what the patient reports as their chief complaint in the medial record. According to PI # 1's ED medical record dated 3/16/16 EI # 8 documented, "Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor... "


Interview on 4/20/16 at 11:00 with ED RN / EI # 9 (Charge Nurse 07:00 - 19:00 Shift ). Called in to work in ED on 3/15/16 from 0900 - 17:00 due to increased census and ICU (Intensive Care Unit) at full capacity):

EI # 9 stated he had no knowledge of PI # 1's presentation to Hospital # 1's ED on 3/15/16.


Interview on 4/20/16 at 15:25 with the CQO (Chief Quality Officer / EI # 3:

EI # 3 verified there is no documentation regarding PI # 1's presentation to the ED at Hospital # 1 on 3/15/16. There is no evidence to include an EMS Report, a medical record and/or a face sheet to confirm PI # presented to the ED via EMS on 3/15/16.


Interview on 4/22/16 at 13:05 with PI # 1:

During a telephone interview on 4/22/16 at 10:50 AM, PI # 1 confirmed he was transported via EMS (Emergency Medical Services) to the ED at Hospital # 1 on 3/15/16. According to PI # 1, he passed out at work and when he "came to" they (co-workers) wanted to take him to the ER (Emergency Room). "I sat on the gurney (stretcher) for almost two hours (after arriving at Hospital # 1's ED)."

PI # 1 stated, "I remember waking up in the middle of the ride (EMS/ambulance transport). I don't remember anybody (ED staff) coming to see me."

Interview on 4/19/16 at 15:35 with the Director Emergency Services /EI # 5:

The Director was asked to describe the triage process to include staff responsible for the screening/triage of patients who arrive via EMS to the ED. EI # 5 was asked to define the usual procedure initiated by staff when the activity and acuity is high in the ED. According to EI # 5, patients who arrive via EMS are greeted by the Charge Nurse and the ED Physicians. Staff assignments are per room. An EMS patient is assigned to the RN who is assigned to the room. Triage of an EMS patient can began in the hall if a room is not available.

The Charge Nurse "quarterbacks" patient flow and is responsible for all patients who present to the ED in collaboration with the ED physician. EI # 5 stated staffing was increased on 3/15/16 due to the large number of ICU patients and the increased inpatient census. The Director verified EI # 7 was the charge nurse on 3/15/16 on the 07:00 to 19:00 shift.


Telephone Interview on 4/20/16 at 14:00 with ED RN / EI # 4 (Charge Nurse 19:00 - 07:00 Shift) on 3/15/16:

EI # 4 was asked who is responsible for triaging patients who present to the ED via ambulance. She said, "One of the RN's (Registered Nurse)." Patient assignments are based on room numbers. If a room is available it is the responsibility of the RN who has the room assignment to accept the patient from EMS staff.


EI # 4 was asked about the timing of triage for patients who arrive via EMS. EI # 4 stated, "As they come in the ER. We talk to EMS (staff) and know their assessment; What they told us and put the patient in a room." We (ED RN's) look at the patient and note if the patient is alert and oriented. "Sometimes ask the patient. I tell the doctor. We start treatment in the hall (if room not available) and move patient" to a room as soon as possible.

EI # 4 was asked where patients who present to the ED via ambulance are placed in the ED at Hospital # 1. The RN responded the EMS staff with a patient on a stretcher park where they can be seen from the nurses' station. "We (ED RN's) recognize EMS when they come in." EI # 4 was also asked who is responsible for keeping up with the communication from EMS to the ED regarding incoming patients. EI # 4 stated, "Whoever is close by. An RN."

The Charge Nurse / EI # 4 was asked when a patient arriving via EMS is entered into the electronic medical record system. According to EI # 4 staff can create a medical record for a patient who is not in a room (patient on a stretcher in the hall), but we, "Prefer patient to be in a room." A patient may be entered into the system, "At any point."

EI # 4 was asked if she recalled providing triage services to PI # 1 on 3/15/16. EI # 4 said she, "Doesn't remember." The RN was advised the ED Director and the ED Manager think her signature is on the ambulance run report as the signature of the person receiving PI #1.

During a telephone call from EI # 4 on 4/22/16 at 09:00, the RN stated the signature on the EMS report regarding PI # 1 dated 3/15/16 is not her signature. According to EI # 4, she reviewed a copy of the EMS report and determined she did not sign the form.


Interview on 4/21/16 at 11:38 with ED RN / EI # 7 (Charge Nurse 07:00 - 19:00 Shift) on 3/15/16 (RN documented call from EMS re PI # 1's impending arrival to the ED in Hospital # 1's Communication Control Log EMS):

The Charge Nurse stated she remembered taking the call re PI # 1 from EMS staff because of the diagnosis of Narcolepsy. However, EI # 7 did not recall the arrival of the patient to the ED via EMS on 3/15/16.

According to EI # 7 it is, "Unusual for ambulance patients to leave." If there is a change in the condition of a patient who presents to the ED via EMS, EMS staff notifies us (ED staff). Patients wait if they are stable based on acuity. Staff, "Usually tells the paramedics we're really busy and they wait." The paramedics stay with the patient until they give report to ED staff.

Conclusion: PI # 1 presented to Hospital # 1's ED via EMS on 3/15/16. There is no documentation to support the patient's arrival, stay and/or discharge because staff failed to create a medical record for PI # 1's visit to the ED on 3/15/16.

Based on a review of Hospital # 1's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, PI (Patient Identifier) # 1's ED Medical Record, Security Video Review, Emergency Medical Treatment and Active Labor Act Policies and Procedures, Plan for the Provision of Patient Care related to Emergency Services (ES), Medical Staff Rules and Regulations and interviews, the hospital failed provide a Medical Screening Examination to Patient Identifier (PI) # 1 on 3/15/16 when he presented to the ED via ambulance after experiencing a syncopal episode. This affected one of 25 sampled patients and has the potential to affect all patients who present to the ED for evaluation.


Findings include:

Hospital # 1's Communication Control Log EMS (Emergency Medical Services) dated 3/15/16:

A review of the log maintained by Hospital # 1 revealed a call was received from EMS on 3/15/16 at 17:58 regarding the impending arrival of PI (Patient Identifier) # 1 by a staff ED (Emergency Department) RN (Registered Nurse) at Hospital # 1. Patient Information/Assessment: This 54 year old male experienced a syncopal episode and has a history of Narcolepsy.
Oxygen Saturation: 98% on room air.
Blood pressure: 134/87, Pulse 94: Respirations: 18. Blood Sugar via dextrose stick: 138.
Hospital of Patient Choice: Hospital # 1.
Hospital Patient Transported to: Hospital # 1.
ETA (Estimated Time of Arrival): 3 - 4 minutes.


Review of EMS Report Dated 3/15/16: (Incident Number: 1603-0244) Includes:

Dispatched: 17:19
Enroute: 17:19
On Scene: 17:37
Complete: 17:51 ("at ED" documented on form)
Patient Name: PI # 1
Age: 45
Allergies: ASA (Aspirin)
Medical History: Narcolepsy, TIA (Transient Ischemic Attack)
17:43 - Blood Pressure: 134/87, Pulse: 92, Respirations: 138
Glucose: 138
Narrative: "45 year old male (PI # 1) chief complaint of syncopal episode. Pt. (Patient) states he feels like his narcolepsy has caused said incident. Patient is not compliant with medication. Vital signs and monitoring enroute. Refuses IV (intravenous) therapy. Patient transported to Hospital # 1 without incident. Prior to arrival report was called in. Nurse stated that the hospital (Hospital # 1) was on CC (Critical Care) divert. Upon arrival at ER, crew and patient had to wait in hallway of ER for over 1 hour. Pt. Patient (PI # 1) demanded to be taken off stretcher and left ER AMA (Against Medical Advice)...Charge Nurse signed receiving patient." Documented by EMT-P / EI # 2.


EMS Incident Report regarding PI # 1 dated 3/15/16:

Date of incident: 3/15/16
Description of incident: "At approx (approximately) 17:51 hours EMS arrived at Hospital # 1 with a patient (PI # 1) who had had a narcoleptic incident at work. (Name of) EMS crew and patient proceeded to stand in hallway until 19:08 hours at which time the patient demanded to be taken off of stretcher as he wanted to leave ER. ER staff told patient he needed to sign AMA (Against Medical Advice) documents but patient proceeded to leave...Charge Nurse signed for patient.
Signature of Person Reporting: EMT-P / EI # 2


Review of Hospital # 1's ED Log:

A review of Hospital # 1's Central ED Log revealed no documentation of PI # 1's presentation to the ED on 3/15/16. However, PI # 1 returned to the ED on 3/16/16 as documented in the ED Log.


PI # 1's ED Medical Record Review dated 3/16/16 includes:

Triage:
Date: 3/16/16
Arrival Time: 16:40
Primary Triage: 16:51- Chief Complaint: Syncope
Blood Pressure: 133/73, Pulse: 92, Respirations: 18, Temperature: 98.6
Priority: Level 3 (a level in the five-level ED triage algorithm. Urgent, but stable. Multiple types of resources needed to treat patient such as lab, x-ray, etc., www.wikipedia.com)
Triage Time: 16:54
Chief Complaint: Syncope
Onset: Yesterday
Glasgow Coma Scale: 15 (A method for assessment of impairment of conscious level in response to defined stimuli, Glasgowcomascale.org).
Source of Information: Patient (PI # 1)
Arrival Mode: Walked
Comments: Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor...

Nursing Neurological Assessment 3/16/16 at 17:49:
Oriented x 4. Patient presents with complaint of multiple syncopal episodes over the last few weeks...States he can be sitting mid conversation and "pass out."


ED Physician Documentation:

Medical Screening Date: 3/16/16 Time: 17:45 (Documented by Employee Identifier (EI) # 1)
Emergent Condition: Yes. Immediate medical attention necessary and such treatment will occur immediately...
ED Provider: EI #1 / ER Physician
Time Seen: 17:46
Source of Information: Patient, Spouse
History of Present Illness:
Chief Complaint: Syncope
Stated Complaint: History of Narcolepsy
Witnessed by: Co-Workers
Onset: Yesterday
Position at time of Episode: Sitting
Character of Event: Collapsed, Became unresponsive
Duration of LOC (Loss of Consciousness): Brief
Location of Injury: None
Additional Details: Patient states continued generalized weakness as well as loss of memory to event. States prior history of Narcolepsy (Neurological disorder affects the control of sleep and wakefulness. May cause excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime, wwwwebmd.com) and TIA's (Transient Ischemic Attacks (caused by a clot; blockage is temporary, www.strokeassociation.org) in past. Does not take any medication currently for narcolepsy.

Review of Systems:
Neurological: Positive for syncope and weakness.

Past Medical History:
High Blood Pressure, TIA, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts, www.mayoclinic.org), Narcolepsy and Diabetes.

Home Medications:
Lantus Insulin 40 units BID (twice daily)
Metformin 50-500 milligrams (mg.) one tablet BID

Physical Examination:

General Appearance: Alert, no evidence of trauma.
Cardiovascular: Regular rate and rhythm; Heart sounds normal.
Respiratory: Breath sounds normal. Clear to auscultation bilaterally.
Neurologic: Oriented x 4 (person, place, time and event).

EKG (Electrocardiogram, a test that checks for problems with the electrical activity of the heart shown as line tracings on paper, www.webmd.com).

3/16/16 at 18:03: Normal sinus rhythm. Normal rate, axis, intervals, p-waves and QRS complex. Nonspecific T wave (Spikes and dips in the tracings are called waves (www.webmd.com) and represent repolarization of the ventricles, www.cardionetics.com).

Lab Results 3/16/16:

Creatinine Kinase: 796 H (High). Normal: 55-170 U/L (Units per Liter).

CK-MB (CK-2): 4.95 (H). Normal: 0.0 - 3.38 ng/mL (Nanogram per milliliter).

RBC (Red Blood Cells): 4.13 Low (L). Normal: 4.70 - 6.10 10^6/u/L (units per Liter).

Hemoglobin: 11.6 (L). Normal: 14.0 - 18.0 G/DL (grams per deciLiter).

Hematocrit: 36.0 (L). Normal: 42.0 - 52.0 %.

Chest X-ray:
3/16/16 at 18:18
Impression: Heart size and vasculature normal. No pleural collection or pneumothorax seen. Lungs are clear.

CT Scan (Computerized Tomography):
3/16/16 at 6:33 PM
Impression: Negative non - contrast cranial CT.

Primary Impression: Syncope.

Condition: Stable.

Work Release: Return to work on 3/21/16.

Additional Instructions: Keep appointment with your neurologist tomorrow.

ED Nursing Departure Note 3/16/16:

Disposition: Home at 20:15.


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


Hospital # 1's EMTALA ("Emergency Medical Treatment and Active Labor Act") Policies and Procedures Issued 10/1/12:

"1. Purpose: To establish guidelines for persons presenting to Hospital # 1 for unscheduled procedures or evaluation in accordance with the Emergency Medical Treatment and Active Labor Act.

3.1 Definitions:

...3.1.3. Medical Screening Examination (MSE) refers to the medical evaluation required to reach with reasonable confidence the point at which it can be determined whether an individual has an Emergency Medical Condition (EMC).

3.1.5. Stabilize means to provide such medical treatment of the Emergency Medical Condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility or that, in the case of a woman in labor, the woman has delivered the child and the placenta.

4. Standards:
4.1. It is the policy of this hospital that all persons presenting to the Hospital Campus for unscheduled procedures or evaluation shall receive a MSE by a Qualified Medical Professional to determine if an EMC exists or if the patient is in active labor...

5. Procedure:
5.1...All persons presenting to the Hospital Campus requesting treatment or examination shall be provided a Medical Screening Examination.

...5.4 Persons presenting by ambulance with an Emergency Medical Condition shall be taken directly to the Emergency Department...

5.5 Emergency Department Assessment / Triage

5.5.1 A designated triage nurse shall be stationed in the triage area of the ED on all shifts.

5.5.2 The triage nurse shall perform an assessment to determine the individual's chief complaint, history, medications, allergies, a description of positive and negative findings and vital signs as necessary to inform the nurse of the nature and severity of the individual's condition.

5.5.3 The information obtained from the assessment shall be documented in the ED record and shall become part of the medical record.

...5.5.5 The triage nurse shall assign a priority category to each individual utilizing the Emergency Severity Index (ESI) Algorithim.

5.6 Medical Screening Examination (MSE)

5.6.1 Medical Screening Examinations shall be performed as promptly as possible in accordance with the Emergency Service Index as assigned by the triage nurse.

5.6.1.1 Where individuals' priorities permit, in the judgement of the RN, or by the determination of a physician, ambulance patients shall be provided a MSE prior to others in order to make treatment facilities and capabilities available more rapidly to all individuals.

5.6.2 The purpose of the MSE shall be determine whether the individual has an Emergency Medical Condition (EMC).

5.6.2 The scope of further treatment shall be based on the Qualified Medical Professional's determination of whether the patient has an EMC...

5.6.8 Time of screening, category of priority, time of arrival, time of placing in a treatment room, time of MSE...shall be noted in the record.

5.7 Treatment and Stabilization

5.7.1 Necessary definitive care to stabilize the individual's condition shall be rendered in the hospital.

5.7.3 Individuals refusing examination, treatment, or transfer shall be documented with the appropriate portion of the Patient Transfer Policy..."

Plan for the Provision of Patient Care related to Emergency Services (ES) Includes:

Written: 2/10/03
Revised 2/6/14

Scope of Service: ES provides care to patients seeking treatment for unanticipated illness or injuries...

Goals of Service:
1. Patients presenting for emergency services for treatment of unanticipated illnesses / injuries shall be provided age-appropriate care...

2. All patients presenting for emergency services shall receive the highest quality emergency medical care in a timely and efficient manner...

Medical Staff Rules and Regulations (Revised and Approved 4/25/13:

...6. Medical Records...

7. Short-Stay Records

c. Such records must establish the diagnosis and show the results of physical examination of the vital organ system, in addition to any other examinations pertinent to the case.

d. Short-stay records must be signed, dated, timed by the responsible practitioner...

e. Short-stay record documentation may be made in the following manner:

1)...a comprehensive Emergency Department record...


Interviews:

Interview on 4/19/16 at 09:04 with EI # 3 / Hospital # 1's Chief Quality Officer (CQO):

During the interview the CQO verified there was no medical record created for PI #1's ED visit on 3/15/16.


Interview on 4/19/16 at 13:05 with EMT-P (Advanced level Emergency Medical Technician- Paramedic) / Employee Identifier (EI) # 2:

During a telephone interview on 4/19/16 at 13:05, EI # 2 confirmed he transported Patient Identifier (PI #1) to the ED (Emergency Department) at Hospital # 1 via ambulance on 3/15/16. EI # 2 states he called report via radio to the ED regarding the impending arrival of PI # 1. The EMT -P was notified Hospital # 1 was on Critical Care diversion, not ED diversion.

According to EI # 2 the, "Charge Nurse said what you got?" EI # 2 said he told the nurse, "This is the patient (PI # 1) with Narcolepsy. We called report." EI # 2 was unable to recall the nurse's name. The EMT- P said shift change occurred while they were waiting with the patient. EI # 2 said he and the EMS driver stood next to an empty room near the ambulance bay entrance and PI # 1 remained on the stretcher. PI # 1 was fully awake and remained on the stretcher until he (PI # 1) decided to leave.

According to the EMT-P, the wait in the ED was greater than one hour. EI # 2 said the patient's vital signs were not taken by ED staff. PI # 1 said, "I'm leaving...I want down. We (EI # 2 and EMS driver) let our stretcher down and the patient released the straps." He (PI # 1) said he was getting his wife and leaving. PI # 1's wife was in the waiting room. "I had to get a nurse." EI # 2 was asked if ED (Emergency Department) staff approached PI # 1. EI # 2 replied, "No one (ED staff) approached the patient." No vital signs were taken.

EI # 2 stated he notified the Chief at the EMS Station about the incident and the Chief notified the Medical Control Officer. According to EI # 2, he was advised the Medical Director said to make sure he (EI # 2) obtained signatures of the ED staff on the EMS report.

At 13:45 on 4/19/16, the EMT-P called and "corrected" the times that he previously documented on the EMS report dated 3/15/16. Arrival time was 18:01 and return to service time was 19:23.


Interview on 4/19/16 at 16:00 with ED RN / EI # 8:

The RN, responsible for the triage of PI # 1 when he returned to Hospital # 1's ED on 3/16/16 said she enters / types exactly what the patient reports as their chief complaint in the medial record. According to PI # 1's ED medical record dated 3/16/16 EI # 8 documented, "Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor... "


Interview on 4/20/16 at 09:50 with Director Emergency Services / EI # 5:

The Director was asked to describe patient tracking in the ED. According to EI # 5, the chart rack serves as a visual cue to let the physicians know the order in which patients are to be seen based on the triage assessment. There is also a system on the computer, "Physician Unassigned Tracker." Two large electronic display boards in the center of the ED display current patients who are in ED rooms and patients in waiting status. The ESI (Five-level ED triage algorithm, www.wikipedia.com) levels are also displayed on the board.

According to the Director, "It is not our (Hospital # 1's ED staff) practice to put a patient on the board until the patient is assessed by an RN and/or placed in a room" in the ED. The patient is triaged by the Charge Nurse and the physician. EMS patients are in the ED's "internal" waiting room as these patients are always in the visual line of staff.


Interview on 4/20/16 at 11:00 with ED RN / EI # 9 (Charge Nurse 07:00 - 19:00 Shift ). Called in to work in ED on 3/15/16 from 0900 - 17:00 due to increased census and ICU at full capacity):

EI # 9 stated he had no knowledge of PI # 1's presentation to Hospital # 1's ED on 3/15/16. The RN said everytime an EMS patient arrives he always gets report from the EMS crew. ED staff tries to clear EMS patients, but sometimes a noncritical patient who arrived via ambulance may have to wait to be seen by the staff/physician. Staff follows the triage process.


Interview on 4/20/16 at 11:35 with ED Manager / EI # 10:

EI # 10 was asked to identify staff responsible for a patient who arrives via EMS to the ED. The Manager said a charge nurse or a "floater" (RN not assigned to a room) can provide triage to a patient who arrives via ambulance to the ED. A floater worked on 3/15/16, but EI # 10 could not identify the floater based on the nursing schedule.

EI # 10 was asked to describe the triage process. He said triage involves talking to and visualizing the patient and getting report from the EMS crew. Patients triaged at a high acuity level are placed in a room. A patient with a lesser triage level may have to be moved out of a room and into the hall. The process fluctuates. Treatment may begin when the patient is on a stretcher in the hall if necessary. Nursing staff notifies the ED physician.

EI # 10 was asked to explain what would happen if a a patient arrives via EMS and is not "on the board" via the creation of an electronic medical record and no paper record is created, how is the ED physician notified about the patient. The ED Manager said staff would verbally notify the physician about the patient.


Interview on 4/20/16 at 15:25 with the CQO (Chief Quality Officer / EI # 3:

EI # 3 verified there is no documentation regarding PI # 1's presentation to the ED at Hospital # 1 on 3/15/16. There is no evidence to include an EMS Report, a medical record and/or a face sheet to confirm PI #1 presented to the ED via EMS on 3/15/16.


Interview on 4/22/16 at 13:05 with Patient Identifier (PI) # 1:

During a telephone interview on 4/22/16 at 10:50 AM, PI # 1 stated, "I suffer from Narcolepsy and I'm a diabetic." PI # 1 confirmed he was transported via EMS (Emergency Medical Services) to the ED at Hospital # 1 on 3/15/16. According to PI # 1, he passed out at work and when he "came to" they (co-workers) wanted to take him to the ER (Emergency Room). "I sat on the gurney (stretcher) for almost two hours (after arriving at Hospital # 1's ED)."

PI # 1 stated, "I remember waking up in the middle of the ride (EMS/ambulance transport). I don't remember anybody (ED staff) coming to see me."

PI # 1 said, "I checked myself out." PI # 1 was asked if he recalled ED staff asking him to sign any forms when he left the ED. He responded, "I don't." According to PI # 1, the ED (Hospital # 1) was crowded. He went to another ED, but did not present for treatment because the wait time was too long. PI # 1 stated he went home and slept. The patient stated he returned to the ED at Hospital # 1 on 3/16/16 in a private vehicle with his wife. PI # 1 suggested the state surveyor speak with his wife and he called his spouse to the telephone.

According to the PI # 1's wife, she followed the ambulance from PI # 1's work place and met him at Hospital # 1's ED. She stated the ED was "too crowded" and she noted the patient was on the stretcher when she arrived. PI # 1's wife said she went to the waiting room. "I had to ask the triage nurse to let the doctor know he (PI # 1) can't take aspirin." She also reported the patient PI # 1 has a history of stroke and TIA's. According to PI # 1's spouse, "When he (PI # 1) passes out and wakes up he is a little discombobulated and ready to go."

According to the patient's wife, PI # 1 was not seen in the ED by a physician at Hospital # 1 on 3/15/16. While in the waiting room, the patient's wife stated she asked a security guard to check to see if the PI # 1 was still in the hall (not in a room). PI # 1's wife said a security guard returned to the waiting rooms with "papers." The patient's wife was asked if she signed the forms. She said, "No. I was concerned no doctor talked to me." PI # 1 and his wife returned to the ED at Hospital # 1 on 3/16/16 and he was seen by a physician. PI # 1's wife voiced no concerns about PI # 1's visit on 3/16/16.


Interview on 4/18/16 at 14:00 with CQO (Chief Quality Officer / EI # 3):

According to the CQO / EI # 3, a total of fifteen patients arrived in the ED at Hospital # 1 between 17:00 and 18:00 (including patients presenting via ambulance) on 3/15/16 (PI # 1 arrived via ambulance on 3/15/16 at 16:40):

- Thirteen patients were assigned an ESI Level 3 (five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from least to most urgent based on patient acuity and resource needs. A Level 3 is a patient with a chief complaint that requires an in-depth evaluation, but felt to be stable in the short term, ahrq.gov).

- Two patients were determined to be ESI Level 4 (Likely to require one resource, ahrq.gov).

There were 18 patient arrivals to the ED between 18:00 and 19:00 on 3/15/16 to include:

- One emergent ESI Level 1 (Needs immediate treatment involving the airway, emergency medicines, or hemodynamic support, tomwademd.net).

- Seven ESI Level 3 patients; and

- Ten ESI Level 4 patients.

Hospital # 1's ED has 21 beds. Seven patients were in the process of
being admitted to the hospital. The ED went on diversion at 18:37 until 22:26 on 3/15/16 (same day PI # 1 arrived in the ED via EMS).


Interview on 4/19/16 at 15:35 with the Director Emergency Services /EI # 5:

EI # 5 was asked for a copy of the ED Nursing assignment sheet dated 3/15/16. The Director was also asked to describe the triage process to include staff responsible for the screening/triage of patients who arrive via EMS to the ED. EI # 5 was asked to define the usual procedure initiated by staff when the activity and acuity in the ED is high. According to EI # 5, patients who arrive via EMS are greeted by the Charge Nurse and the ED Physicians. Staff assignments are per room. An EMS patient is assigned to the RN who is assigned to the room. Triage of an EMS patient can began in the hall if a room is not available.

The Charge Nurse "quarterbacks" patient flow and is responsible for all patients who present to the ED in collaboration with the ED physician. EI # 5 stated staffing was increased on 3/15/16 due to the large number of ICU patients and the increased inpatient census. The Director verified EI # 7 was the charge nurse on 3/15/16 on the 07:00 to 19:00 shift.


Interview with ED Physician/EI # 1 on 4/19/16 at 16:25: (EI # 1 worked 3/15/16 and 3/16/16) based on the the ED Physician staffing record). PI # 1 presented to the ED via EMS on 3/15/16 and on 3/16/15 via private vehicle).

EI # 1 verified he was not aware of PI# 1's visit to Hospital # 1's ED on 3/15/16. PI # 1 told the physician he left the ED on 3/15/16 because he did not want to wait to be seen. On 3/16/16, EI # 1 returned to the ED with his wife. EI # 1 provided a medical screening examination to the patient. According to the physician, he remembers PI # 1 because of the patient's diagnosis of Narcolepsy.


Telephone Interview on 4/20/16 at 14:00 with ED RN / EI # 4 (Charge Nurse 19:00 - 07:00 Shift) on 3/15/16:

EI # 4 was asked who is responsible for triaging patients who present to the ED via ambulance. She said, "One of the RN's (Registered Nurse)." Patient assignments are based on room numbers. If a room is available it is the responsibility of the RN who has the room assignment to accept the patient from EMS staff.


EI # 4 was asked about the timing of triage for patients who arrive via EMS. EI # 4 stated, "As they come in the ER. We talk to EMS (staff) and know their assessment; What they told us and put the patient in a room." We (ED RN's) look at the patient and note if the patient is alert and oriented. "Sometimes ask the patient. I tell the doctor. We start treatment in the hall (if room not available) and move patient" to a room as soon as possible.

EI # 4 was asked where patients who present to the ED via ambulance are placed in the ED at Hospital # 1. The RN responded the EMS staff with a patient on a stretcher park where they can be seen from the nurses' station. "We (ED RN's) recognize EMS when they come in." EI # 4 was also asked who is responsible for keeping up with the communication from EMS to the ED regarding incoming patients. EI # 4 stated, "Whoever is close by. An RN." The RN was asked how information about a new patient arrival via EMS is communicated to the ED physician. EI # 4 said, "We let them (physicians) know. Usually when they come out of a room..." Regarding the assignment of acuity/triage prioritization of EMS patients, EI # 4 said she will ask an ED physician if she has questions regarding a patient's acuity. The Charge Nurse also stated the ED physicians usually see the patients who arrive via EMS in the hall if a room is not readily available.

The Charge Nurse / EI # 4 was asked when a patient arriving via EMS is entered into the electronic medical record system. According to EI # 4 staff can create a medical record for a patient who is not in a room (patient on a stretcher in the hall), but we, "Prefer patient to be in a room." A patient may be entered into the system, "At any point."

EI # 4 was asked if she recalled PI # 1's visit to Hospital # 1's ED on 3/15/16. The RN was advised the ED Director and the ED Manager think her signature is on the ambulance run report as the signature of the person receiving PI #1. EI # 4 was asked if she recalled providing triage services to PI # 1 on 3/15/16. EI # 4 said she, "Doesn't remember."

During a telephone call from EI # 4 on 4/22/16 at 09:00, the RN stated the signature on the EMS report regarding PI # 1 dated 3/15/16 is not her signature. According to EI # 4, she reviewed a copy of the EMS report and determined she did not sign the form.


Interview with ED Physician / EI # 6 on 4/20/16 at 16:35: (EI # 6 worked 3/15/16 based on the the ED Physician staffing record - same day PI # 1 presented to the ED via EMS):

The physician was asked to describe his responsibility when a patient presents to the ED via EMS. EI # 6 said the, "Patient is my responsibility."


Interview on 4/21/16 at 11:38 with ED RN / EI # 7 (Charge Nurse 07:00 - 19:00 Shift) on 3/15/16 (RN documented call from EMS re PI # 1's impending arrival to the ED in Hospital # 1's Communication Control Log EMS):

The Charge Nurse stated she remembered taking the call re PI # 1 from EMS staff because of the diagnosis of Narcolepsy. However, EI # 7 did not recall the arrival of the patient to the ED via EMS on 3/15/16.

According to EI # 7 it is, "Unusual for ambulance patients to leave." If there is a change in the condition of a patient who presents to the ED via EMS, EMS staff notifies us (ED staff). Patients wait if they are stable based on acuity. Staff, "Usually tells the paramedics we're really busy and they wait." The paramedics stay with the patient until they give report to ED staff.

The RN assigned to the room usually triages the patient who arrives to the ED via EMS and is placed in the room assigned to the RN. However, the charge nurse or any RN who is available may triage a patient who arrives to the ED via EMS. A quick triage starts when the RN "eyeballs" the patient and assesses the patient's orientation, skin and respiratory status. Prioritization is required. We report concerns to the ED physician.

Conclusion: PI # 1 presented to Hospital # 1's ED via EMS on 3/15/16.
Staff failed to create a medical record for PI # 1's visit to the ED on 3/15/16. Therefore, there is no documentation that the patient received a medical screening examination and/or stabilizing treatment.

Based on review of the Hospital 's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, Medical Record reviews, Security Video Review, Policies and Procedures, Plan for the Provision of Patient Care related to Emergency Services (ES), Medical Staff Rules and Regulations and interviews, it was determined Medical West Hospital failed to:

1). Maintain the ED Log by failing to enter Patient Identifier (PI) # 1's arrival, visit and/or discharge to the ED via ambulance on 3/15/16.

2). Provide a Medical Screening Examination and stabilizing treatment to PI # 1, patient who presented by ambulance post syncopal episode and has a history of Narcolepsy.

Findings include:

Please refer to findings at A2405 - Maintain a Central Log and A2406 - Medical Screening Examination.

Based on a review of Hospital # 1's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, Security Video Review, Emergency Medical Treatment and Active Labor Act Policies and Procedures and interviews, the hospital failed to document PI # 1's arrival, visit and/or discharge to the ED via ambulance on 3/15/16. This affected one of 25 sampled patients, but has the potential to negatively affect all patients who present to the ED for an evaluation.


Findings include:

Hospital # 1's Communication Control Log EMS (Emergency Medical Services) dated 3/15/16:

A review of the log maintained by Hospital # 1 revealed a call was received from EMS on 3/15/16 at 17:58 regarding the impending arrival of PI (Patient Identifier) # 1 by a staff ED (Emergency Department) RN (Registered Nurse) at Hospital # 1. Patient Information/Assessment: This 54 year old male experienced a syncopal episode and has a history of Narcolepsy.
Oxygen Saturation: 98% on room air.
Blood pressure: 134/87, Pulse 94: Respirations: 18. Blood Sugar via dextrose stick: 138.
Hospital of Patient Choice: Hospital # 1.
Hospital Patient Transported to: Hospital # 1.
ETA (Estimated Time of Arrival): 3 - 4 minutes.


Review of EMS Report Dated 3/15/16: (Incident Number: 1603-0244) Includes:

Dispatched: 17:19
Enroute: 17:19
On Scene: 17:37
Complete: 17:51 ("at ED" documented on form)
Patient Name: PI # 1
Age: 45
Allergies: ASA (Aspirin)
Medical History: Narcolepsy, TIA (Transient Ischemic Attack)
17:43 - Blood Pressure: 134/87, Pulse: 92, Respirations: 138
Glucose: 138
Narrative: "45 year old male (PI # 1) chief complaint of syncopal episode. Pt. (Patient) states he feels like his narcolepsy has caused said incident. Patient is not compliant with medication. Vital signs and monitoring enroute. Refuses IV (intravenous) therapy. Patient transported to Hospital # 1 without incident. ** Prior to arrival report was called in. Nurse stated that the hospital (Hospital # 1) was on CC (Critical Care) divert. Upon arrival at ER, crew and patient had to wait in hallway of ER for over 1 hour. Pt. Patient (PI # 1) demanded to be taken off stretcher and left ER AMA (Against Medical Advice)...Charge Nurse signed receiving patient." Documented by EMT-P / EI # 2.


EMS Incident Report regarding PI # 1 dated 3/15/16:

Date of incident: 3/15/16
Description of incident: "At approx (approximately) 17:51 hours EMS arrived at Hospital # 1 with a patient (PI # 1) who had had a narcoleptic incident at work. (Name of) EMS crew and patient proceeded to stand in hallway until 19:08 hours at which time the patient demanded to be taken off of stretcher as he wanted to leave ER. ER staff told patient he needed to sign AMA (Against Medical Advice) documents but patient proceeded to leave...Charge Nurse signed for patient.
Signature of Person Reporting: EMT-P / EI # 2


Review of Hospital # 1's ED Log:

A review of Hospital # 1's Central ED Log revealed no documentation of PI # 1's presentation to the ED on 3/15/16.


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


PI # 1's ED Medical Record Review dated 3/16/16 includes:

Comments: Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor...


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


Hospital # 1's EMTALA ("Emergency Medical Treatment and Active Labor Act") Policies and Procedures Issued 10/1/12 Includes:


...5.5.2 The triage nurse shall perform an assessment to determine the individual's chief complaint, history, medications, allergies, a description of positive and negative findings and vital signs as necessary to inform the nurse of the nature and severity of the individual's condition.

5.5.3 The information obtained from the assessment shall be documented in the ED record and shall become part of the medical record...


5.6.8 Time of screening, category of priority, time of arrival, time of placing in a treatment room, time of MSE (Medical Screening Examination)...shall be noted in the record...



Interviews:

Interview on 4/19/16 at 09:04 with EI # 3 / Hospital # 1's Chief Quality Officer (CQO):

During the interview the CQO verified there was no medical record created for PI #1's ED visit on 3/15/16.


Interview on 4/19/16 at 13:05 with EMT-P (Advanced level Emergency Medical Technician- Paramedic) / Employee Identifier (EI) # 2:

During a telephone interview on 4/19/16 at 13:05, EI # 2 confirmed he transported Patient Identifier (PI #1) to the ED (Emergency Department) at Hospital # 1 via ambulance on 3/15/16. EI # 2 states he called report via radio to the ED regarding the impending arrival of PI # 1.


According to EI # 2 the, "Charge Nurse said what you got?" EI # 2 said he told the nurse, "This is the patient (PI # 1) with Narcolepsy. We called report."

Interview on 4/19/16 at 16:00 with ED RN / EI # 8:

The RN, responsible for the triage of PI # 1 when he returned to Hospital # 1's ED on 3/16/16 said she enters / types exactly what the patient reports as their chief complaint in the medial record. According to PI # 1's ED medical record dated 3/16/16 EI # 8 documented, "Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor... "


Interview on 4/20/16 at 11:00 with ED RN / EI # 9 (Charge Nurse 07:00 - 19:00 Shift ). Called in to work in ED on 3/15/16 from 0900 - 17:00 due to increased census and ICU (Intensive Care Unit) at full capacity):

EI # 9 stated he had no knowledge of PI # 1's presentation to Hospital # 1's ED on 3/15/16.


Interview on 4/20/16 at 15:25 with the CQO (Chief Quality Officer / EI # 3:

EI # 3 verified there is no documentation regarding PI # 1's presentation to the ED at Hospital # 1 on 3/15/16. There is no evidence to include an EMS Report, a medical record and/or a face sheet to confirm PI # presented to the ED via EMS on 3/15/16.


Interview on 4/22/16 at 13:05 with PI # 1:

During a telephone interview on 4/22/16 at 10:50 AM, PI # 1 confirmed he was transported via EMS (Emergency Medical Services) to the ED at Hospital # 1 on 3/15/16. According to PI # 1, he passed out at work and when he "came to" they (co-workers) wanted to take him to the ER (Emergency Room). "I sat on the gurney (stretcher) for almost two hours (after arriving at Hospital # 1's ED)."

PI # 1 stated, "I remember waking up in the middle of the ride (EMS/ambulance transport). I don't remember anybody (ED staff) coming to see me."

Interview on 4/19/16 at 15:35 with the Director Emergency Services /EI # 5:

The Director was asked to describe the triage process to include staff responsible for the screening/triage of patients who arrive via EMS to the ED. EI # 5 was asked to define the usual procedure initiated by staff when the activity and acuity is high in the ED. According to EI # 5, patients who arrive via EMS are greeted by the Charge Nurse and the ED Physicians. Staff assignments are per room. An EMS patient is assigned to the RN who is assigned to the room. Triage of an EMS patient can began in the hall if a room is not available.

The Charge Nurse "quarterbacks" patient flow and is responsible for all patients who present to the ED in collaboration with the ED physician. EI # 5 stated staffing was increased on 3/15/16 due to the large number of ICU patients and the increased inpatient census. The Director verified EI # 7 was the charge nurse on 3/15/16 on the 07:00 to 19:00 shift.


Telephone Interview on 4/20/16 at 14:00 with ED RN / EI # 4 (Charge Nurse 19:00 - 07:00 Shift) on 3/15/16:

EI # 4 was asked who is responsible for triaging patients who present to the ED via ambulance. She said, "One of the RN's (Registered Nurse)." Patient assignments are based on room numbers. If a room is available it is the responsibility of the RN who has the room assignment to accept the patient from EMS staff.


EI # 4 was asked about the timing of triage for patients who arrive via EMS. EI # 4 stated, "As they come in the ER. We talk to EMS (staff) and know their assessment; What they told us and put the patient in a room." We (ED RN's) look at the patient and note if the patient is alert and oriented. "Sometimes ask the patient. I tell the doctor. We start treatment in the hall (if room not available) and move patient" to a room as soon as possible.

EI # 4 was asked where patients who present to the ED via ambulance are placed in the ED at Hospital # 1. The RN responded the EMS staff with a patient on a stretcher park where they can be seen from the nurses' station. "We (ED RN's) recognize EMS when they come in." EI # 4 was also asked who is responsible for keeping up with the communication from EMS to the ED regarding incoming patients. EI # 4 stated, "Whoever is close by. An RN."

The Charge Nurse / EI # 4 was asked when a patient arriving via EMS is entered into the electronic medical record system. According to EI # 4 staff can create a medical record for a patient who is not in a room (patient on a stretcher in the hall), but we, "Prefer patient to be in a room." A patient may be entered into the system, "At any point."

EI # 4 was asked if she recalled providing triage services to PI # 1 on 3/15/16. EI # 4 said she, "Doesn't remember." The RN was advised the ED Director and the ED Manager think her signature is on the ambulance run report as the signature of the person receiving PI #1.

During a telephone call from EI # 4 on 4/22/16 at 09:00, the RN stated the signature on the EMS report regarding PI # 1 dated 3/15/16 is not her signature. According to EI # 4, she reviewed a copy of the EMS report and determined she did not sign the form.


Interview on 4/21/16 at 11:38 with ED RN / EI # 7 (Charge Nurse 07:00 - 19:00 Shift) on 3/15/16 (RN documented call from EMS re PI # 1's impending arrival to the ED in Hospital # 1's Communication Control Log EMS):

The Charge Nurse stated she remembered taking the call re PI # 1 from EMS staff because of the diagnosis of Narcolepsy. However, EI # 7 did not recall the arrival of the patient to the ED via EMS on 3/15/16.

According to EI # 7 it is, "Unusual for ambulance patients to leave." If there is a change in the condition of a patient who presents to the ED via EMS, EMS staff notifies us (ED staff). Patients wait if they are stable based on acuity. Staff, "Usually tells the paramedics we're really busy and they wait." The paramedics stay with the patient until they give report to ED staff.

Conclusion: PI # 1 presented to Hospital # 1's ED via EMS on 3/15/16. There is no documentation to support the patient's arrival, stay and/or discharge because staff failed to create a medical record for PI # 1's visit to the ED on 3/15/16.

Based on a review of Hospital # 1's Communication Control Log EMS (Emergency Medical Services), the Ambulance Company EMS and Incident Reports, Hospital ED (Emergency Department) Log, PI (Patient Identifier) # 1's ED Medical Record, Security Video Review, Emergency Medical Treatment and Active Labor Act Policies and Procedures, Plan for the Provision of Patient Care related to Emergency Services (ES), Medical Staff Rules and Regulations and interviews, the hospital failed provide a Medical Screening Examination to Patient Identifier (PI) # 1 on 3/15/16 when he presented to the ED via ambulance after experiencing a syncopal episode. This affected one of 25 sampled patients and has the potential to affect all patients who present to the ED for evaluation.


Findings include:

Hospital # 1's Communication Control Log EMS (Emergency Medical Services) dated 3/15/16:

A review of the log maintained by Hospital # 1 revealed a call was received from EMS on 3/15/16 at 17:58 regarding the impending arrival of PI (Patient Identifier) # 1 by a staff ED (Emergency Department) RN (Registered Nurse) at Hospital # 1. Patient Information/Assessment: This 54 year old male experienced a syncopal episode and has a history of Narcolepsy.
Oxygen Saturation: 98% on room air.
Blood pressure: 134/87, Pulse 94: Respirations: 18. Blood Sugar via dextrose stick: 138.
Hospital of Patient Choice: Hospital # 1.
Hospital Patient Transported to: Hospital # 1.
ETA (Estimated Time of Arrival): 3 - 4 minutes.


Review of EMS Report Dated 3/15/16: (Incident Number: 1603-0244) Includes:

Dispatched: 17:19
Enroute: 17:19
On Scene: 17:37
Complete: 17:51 ("at ED" documented on form)
Patient Name: PI # 1
Age: 45
Allergies: ASA (Aspirin)
Medical History: Narcolepsy, TIA (Transient Ischemic Attack)
17:43 - Blood Pressure: 134/87, Pulse: 92, Respirations: 138
Glucose: 138
Narrative: "45 year old male (PI # 1) chief complaint of syncopal episode. Pt. (Patient) states he feels like his narcolepsy has caused said incident. Patient is not compliant with medication. Vital signs and monitoring enroute. Refuses IV (intravenous) therapy. Patient transported to Hospital # 1 without incident. Prior to arrival report was called in. Nurse stated that the hospital (Hospital # 1) was on CC (Critical Care) divert. Upon arrival at ER, crew and patient had to wait in hallway of ER for over 1 hour. Pt. Patient (PI # 1) demanded to be taken off stretcher and left ER AMA (Against Medical Advice)...Charge Nurse signed receiving patient." Documented by EMT-P / EI # 2.


EMS Incident Report regarding PI # 1 dated 3/15/16:

Date of incident: 3/15/16
Description of incident: "At approx (approximately) 17:51 hours EMS arrived at Hospital # 1 with a patient (PI # 1) who had had a narcoleptic incident at work. (Name of) EMS crew and patient proceeded to stand in hallway until 19:08 hours at which time the patient demanded to be taken off of stretcher as he wanted to leave ER. ER staff told patient he needed to sign AMA (Against Medical Advice) documents but patient proceeded to leave...Charge Nurse signed for patient.
Signature of Person Reporting: EMT-P / EI # 2


Review of Hospital # 1's ED Log:

A review of Hospital # 1's Central ED Log revealed no documentation of PI # 1's presentation to the ED on 3/15/16. However, PI # 1 returned to the ED on 3/16/16 as documented in the ED Log.


PI # 1's ED Medical Record Review dated 3/16/16 includes:

Triage:
Date: 3/16/16
Arrival Time: 16:40
Primary Triage: 16:51- Chief Complaint: Syncope
Blood Pressure: 133/73, Pulse: 92, Respirations: 18, Temperature: 98.6
Priority: Level 3 (a level in the five-level ED triage algorithm. Urgent, but stable. Multiple types of resources needed to treat patient such as lab, x-ray, etc., www.wikipedia.com)
Triage Time: 16:54
Chief Complaint: Syncope
Onset: Yesterday
Glasgow Coma Scale: 15 (A method for assessment of impairment of conscious level in response to defined stimuli, Glasgowcomascale.org).
Source of Information: Patient (PI # 1)
Arrival Mode: Walked
Comments: Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor...

Nursing Neurological Assessment 3/16/16 at 17:49:
Oriented x 4. Patient presents with complaint of multiple syncopal episodes over the last few weeks...States he can be sitting mid conversation and "pass out."


ED Physician Documentation:

Medical Screening Date: 3/16/16 Time: 17:45 (Documented by Employee Identifier (EI) # 1)
Emergent Condition: Yes. Immediate medical attention necessary and such treatment will occur immediately...
ED Provider: EI #1 / ER Physician
Time Seen: 17:46
Source of Information: Patient, Spouse
History of Present Illness:
Chief Complaint: Syncope
Stated Complaint: History of Narcolepsy
Witnessed by: Co-Workers
Onset: Yesterday
Position at time of Episode: Sitting
Character of Event: Collapsed, Became unresponsive
Duration of LOC (Loss of Consciousness): Brief
Location of Injury: None
Additional Details: Patient states continued generalized weakness as well as loss of memory to event. States prior history of Narcolepsy (Neurological disorder affects the control of sleep and wakefulness. May cause excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime, wwwwebmd.com) and TIA's (Transient Ischemic Attacks (caused by a clot; blockage is temporary, www.strokeassociation.org) in past. Does not take any medication currently for narcolepsy.

Review of Systems:
Neurological: Positive for syncope and weakness.

Past Medical History:
High Blood Pressure, TIA, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts, www.mayoclinic.org), Narcolepsy and Diabetes.

Home Medications:
Lantus Insulin 40 units BID (twice daily)
Metformin 50-500 milligrams (mg.) one tablet BID

Physical Examination:

General Appearance: Alert, no evidence of trauma.
Cardiovascular: Regular rate and rhythm; Heart sounds normal.
Respiratory: Breath sounds normal. Clear to auscultation bilaterally.
Neurologic: Oriented x 4 (person, place, time and event).

EKG (Electrocardiogram, a test that checks for problems with the electrical activity of the heart shown as line tracings on paper, www.webmd.com).

3/16/16 at 18:03: Normal sinus rhythm. Normal rate, axis, intervals, p-waves and QRS complex. Nonspecific T wave (Spikes and dips in the tracings are called waves (www.webmd.com) and represent repolarization of the ventricles, www.cardionetics.com).

Lab Results 3/16/16:

Creatinine Kinase: 796 H (High). Normal: 55-170 U/L (Units per Liter).

CK-MB (CK-2): 4.95 (H). Normal: 0.0 - 3.38 ng/mL (Nanogram per milliliter).

RBC (Red Blood Cells): 4.13 Low (L). Normal: 4.70 - 6.10 10^6/u/L (units per Liter).

Hemoglobin: 11.6 (L). Normal: 14.0 - 18.0 G/DL (grams per deciLiter).

Hematocrit: 36.0 (L). Normal: 42.0 - 52.0 %.

Chest X-ray:
3/16/16 at 18:18
Impression: Heart size and vasculature normal. No pleural collection or pneumothorax seen. Lungs are clear.

CT Scan (Computerized Tomography):
3/16/16 at 6:33 PM
Impression: Negative non - contrast cranial CT.

Primary Impression: Syncope.

Condition: Stable.

Work Release: Return to work on 3/21/16.

Additional Instructions: Keep appointment with your neurologist tomorrow.

ED Nursing Departure Note 3/16/16:

Disposition: Home at 20:15.


Review on 4/20/16 at 14:15 of Security Video of Ambulance Bay Area at Hospital # 1:

The security video of the ambulance bay at Hospital # 1's ED was reviewed beginning at 18:00 on 3/15/16 to determine if the ambulance transporting PI # 1 could be seen. The date and time documented on the EMS report was used as a reference. The surveyor was unable to see the name of EMS Company on the ambulance that arrived in the bay at 18:03. A male figure was seen transporting what appeared to be a patient on a stretcher from the back of the ambulance to the side of the ED where the ambulance bay is located. The same ambulance left the bay at 19:21.


Hospital # 1's EMTALA ("Emergency Medical Treatment and Active Labor Act") Policies and Procedures Issued 10/1/12:

"1. Purpose: To establish guidelines for persons presenting to Hospital # 1 for unscheduled procedures or evaluation in accordance with the Emergency Medical Treatment and Active Labor Act.

3.1 Definitions:

...3.1.3. Medical Screening Examination (MSE) refers to the medical evaluation required to reach with reasonable confidence the point at which it can be determined whether an individual has an Emergency Medical Condition (EMC).

3.1.5. Stabilize means to provide such medical treatment of the Emergency Medical Condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility or that, in the case of a woman in labor, the woman has delivered the child and the placenta.

4. Standards:
4.1. It is the policy of this hospital that all persons presenting to the Hospital Campus for unscheduled procedures or evaluation shall receive a MSE by a Qualified Medical Professional to determine if an EMC exists or if the patient is in active labor...

5. Procedure:
5.1...All persons presenting to the Hospital Campus requesting treatment or examination shall be provided a Medical Screening Examination.

...5.4 Persons presenting by ambulance with an Emergency Medical Condition shall be taken directly to the Emergency Department...

5.5 Emergency Department Assessment / Triage

5.5.1 A designated triage nurse shall be stationed in the triage area of the ED on all shifts.

5.5.2 The triage nurse shall perform an assessment to determine the individual's chief complaint, history, medications, allergies, a description of positive and negative findings and vital signs as necessary to inform the nurse of the nature and severity of the individual's condition.

5.5.3 The information obtained from the assessment shall be documented in the ED record and shall become part of the medical record.

...5.5.5 The triage nurse shall assign a priority category to each individual utilizing the Emergency Severity Index (ESI) Algorithim.

5.6 Medical Screening Examination (MSE)

5.6.1 Medical Screening Examinations shall be performed as promptly as possible in accordance with the Emergency Service Index as assigned by the triage nurse.

5.6.1.1 Where individuals' priorities permit, in the judgement of the RN, or by the determination of a physician, ambulance patients shall be provided a MSE prior to others in order to make treatment facilities and capabilities available more rapidly to all individuals.

5.6.2 The purpose of the MSE shall be determine whether the individual has an Emergency Medical Condition (EMC).

5.6.2 The scope of further treatment shall be based on the Qualified Medical Professional's determination of whether the patient has an EMC...

5.6.8 Time of screening, category of priority, time of arrival, time of placing in a treatment room, time of MSE...shall be noted in the record.

5.7 Treatment and Stabilization

5.7.1 Necessary definitive care to stabilize the individual's condition shall be rendered in the hospital.

5.7.3 Individuals refusing examination, treatment, or transfer shall be documented with the appropriate portion of the Patient Transfer Policy..."

Plan for the Provision of Patient Care related to Emergency Services (ES) Includes:

Written: 2/10/03
Revised 2/6/14

Scope of Service: ES provides care to patients seeking treatment for unanticipated illness or injuries...

Goals of Service:
1. Patients presenting for emergency services for treatment of unanticipated illnesses / injuries shall be provided age-appropriate care...

2. All patients presenting for emergency services shall receive the highest quality emergency medical care in a timely and efficient manner...

Medical Staff Rules and Regulations (Revised and Approved 4/25/13:

...6. Medical Records...

7. Short-Stay Records

c. Such records must establish the diagnosis and show the results of physical examination of the vital organ system, in addition to any other examinations pertinent to the case.

d. Short-stay records must be signed, dated, timed by the responsible practitioner...

e. Short-stay record documentation may be made in the following manner:

1)...a comprehensive Emergency Department record...


Interviews:

Interview on 4/19/16 at 09:04 with EI # 3 / Hospital # 1's Chief Quality Officer (CQO):

During the interview the CQO verified there was no medical record created for PI #1's ED visit on 3/15/16.


Interview on 4/19/16 at 13:05 with EMT-P (Advanced level Emergency Medical Technician- Paramedic) / Employee Identifier (EI) # 2:

During a telephone interview on 4/19/16 at 13:05, EI # 2 confirmed he transported Patient Identifier (PI #1) to the ED (Emergency Department) at Hospital # 1 via ambulance on 3/15/16. EI # 2 states he called report via radio to the ED regarding the impending arrival of PI # 1. The EMT -P was notified Hospital # 1 was on Critical Care diversion, not ED diversion.

According to EI # 2 the, "Charge Nurse said what you got?" EI # 2 said he told the nurse, "This is the patient (PI # 1) with Narcolepsy. We called report." EI # 2 was unable to recall the nurse's name. The EMT- P said shift change occurred while they were waiting with the patient. EI # 2 said he and the EMS driver stood next to an empty room near the ambulance bay entrance and PI # 1 remained on the stretcher. PI # 1 was fully awake and remained on the stretcher until he (PI # 1) decided to leave.

According to the EMT-P, the wait in the ED was greater than one hour. EI # 2 said the patient's vital signs were not taken by ED staff. PI # 1 said, "I'm leaving...I want down. We (EI # 2 and EMS driver) let our stretcher down and the patient released the straps." He (PI # 1) said he was getting his wife and leaving. PI # 1's wife was in the waiting room. "I had to get a nurse." EI # 2 was asked if ED (Emergency Department) staff approached PI # 1. EI # 2 replied, "No one (ED staff) approached the patient." No vital signs were taken.

EI # 2 stated he notified the Chief at the EMS Station about the incident and the Chief notified the Medical Control Officer. According to EI # 2, he was advised the Medical Director said to make sure he (EI # 2) obtained signatures of the ED staff on the EMS report.

At 13:45 on 4/19/16, the EMT-P called and "corrected" the times that he previously documented on the EMS report dated 3/15/16. Arrival time was 18:01 and return to service time was 19:23.


Interview on 4/19/16 at 16:00 with ED RN / EI # 8:

The RN, responsible for the triage of PI # 1 when he returned to Hospital # 1's ED on 3/16/16 said she enters / types exactly what the patient reports as their chief complaint in the medial record. According to PI # 1's ED medical record dated 3/16/16 EI # 8 documented, "Patient states syncopal episode yesterday at work. Came here (ED) by ambulance last night but left before seeing doctor... "


Interview on 4/20/16 at 09:50 with Director Emergency Services / EI # 5:

The Director was asked to describe patient tracking in the ED. According to EI # 5, the chart rack serves as a visual cue to let the physicians know the order in which patients are to be seen based on the triage assessment. There is also a system on the computer, "Physician Unassigned Tracker." Two large electronic display boards in the center of the ED display current patients who are in ED rooms and patients in waiting status. The ESI (Five-level ED triage algorithm, www.wikipedia.com) levels are also displayed on the board.

According to the Director, "It is not our (Hospital # 1's ED staff) practice to put a patient on the board until the patient is assessed by an RN and/or placed in a room" in the ED. The patient is triaged by the Charge Nurse and the physician. EMS patients are in the ED's "internal" waiting room as these patients are always in the visual line of staff.


Interview on 4/20/16 at 11:00 with ED RN / EI # 9 (Charge Nurse 07:00 - 19:00 Shift ). Called in to work in ED on 3/15/16 from 0900 - 17:00 due to increased census and ICU at full capacity):

EI # 9 stated he had no knowledge of PI # 1's presentation to Hospital # 1's ED on 3/15/16. The RN said everytime an EMS patient arrives he always gets report from the EMS crew. ED staff tries to clear EMS patients, but sometimes a noncritical patient who arrived via ambulance may have to wait to be seen by the staff/physician. Staff follows the triage process.


Interview on 4/20/16 at 11:35 with ED Manager / EI # 10:

EI # 10 was asked to identify staff responsible for a patient who arrives via EMS to the ED. The Manager said a charge nurse or a "floater" (RN not assigned to a room) can provide triage to a patient who arrives via ambulance to the ED. A floater worked on 3/15/16, but EI # 10 could not identify the floater based on the nursing schedule.

EI # 10 was asked to describe the triage process. He said triage involves talking to and visualizing the patient and getting report from the EMS crew. Patients triaged at a high acuity level are placed in a room. A patient with a lesser triage level may have to be moved out of a room and into the hall. The process fluctuates. Treatment may begin when the patient is on a stretcher in the hall if necessary. Nursing staff notifies the ED physician.

EI # 10 was asked to explain what would happen if a a patient arrives via EMS and is not "on the board" via the creation of an electronic medical record and no paper record is created, how is the ED physician notified about the patient. The ED Manager said staff would verbally notify the physician about the patient.


Interview on 4/20/16 at 15:25 with the CQO (Chief Quality Officer / EI # 3:

EI # 3 verified there is no documentation regarding PI # 1's presentation to the ED at Hospital # 1 on 3/15/16. There is no evidence to include an EMS Report, a medical record and/or a face sheet to confirm PI #1 presented to the ED via EMS on 3/15/16.


Interview on 4/22/16 at 13:05 with Patient Identifier (PI) # 1:

During a telephone interview on 4/22/16 at 10:50 AM, PI # 1 stated, "I suffer from Narcolepsy and I'm a diabetic." PI # 1 confirmed he was transported via EMS (Emergency Medical Services) to the ED at Hospital # 1 on 3/15/16. According to PI # 1, he passed out at work and when he "came to" they (co-workers) wanted to take him to the ER (Emergency Room). "I sat on the gurney (stretcher) for almost two hours (after arriving at Hospital # 1's ED)."

PI # 1 stated, "I remember waking up in the middle of the ride (EMS/ambulance transport). I don't remember anybody (ED staff) coming to see me."

PI # 1 said, "I checked myself out." PI # 1 was asked if he recalled ED staff asking him to sign any forms when he left the ED. He responded, "I don't." According to PI # 1, the ED (Hospital # 1) was crowded. He went to another ED, but did not present for treatment because the wait time was too long. PI # 1 stated he went home and slept. The patient stated he returned to the ED at Hospital # 1 on 3/16/16 in a private vehicle with his wife. PI # 1 suggested the state surveyor speak with his wife and he called his spouse to the telephone.

According to the PI # 1's wife, she followed the ambulance from PI # 1's work place and met him at Hospital # 1's ED. She stated the ED was "too crowded" and she noted the patient was on the stretcher when she arrived. PI # 1's wife said she went to the waiting room. "I had to ask the triage nurse to let the doctor know he (PI # 1) can't take aspirin." She also reported the patient PI # 1 has a history of stroke and TIA's. According to PI # 1's spouse, "When he (PI # 1) passes out and wakes up he is a little discombobulated and ready to go."

According to the patient's wife, PI # 1 was not seen in the ED by a physician at Hospital # 1 on 3/15/16. While in the waiting room, the patient's wife stated she asked a security guard to check to see if the PI # 1 was still in the hall (not in a room). PI # 1's wife said a security guard returned to the waiting rooms with "papers." The patient's wife was asked if she signed the forms. She said, "No. I was concerned no doctor talked to me." PI # 1 and his wife returned to the ED at Hospital # 1 on 3/16/16 and he was seen by a physician. PI # 1's wife voiced no concerns about PI # 1's visit on 3/16/16.


Interview on 4/18/16 at 14:00 with CQO (Chief Quality Officer / EI # 3):

According to the CQO / EI # 3, a total of fifteen patients arrived in the ED at Hospital # 1 between 17:00 and 18:00 (including patients presenting via ambulance) on 3/15/16 (PI # 1 arrived via ambulance on 3/15/16 at 16:40):

- Thirteen patients were assigned an ESI Level 3 (five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from least to most urgent based on patient acuity and resource needs. A Level 3 is a patient with a chief complaint that requires an in-depth evaluation, but felt to be stable in the short term, ahrq.gov).

- Two patients were determined to be ESI Level 4 (Likely to require one resource, ahrq.gov).

There were 18 patient arrivals to the ED between 18:00 and 19:00 on 3/15/16 to include:

- One emergent ESI Level 1 (Needs immediate treatment involving the airway, emergency medicines, or hemodynamic support, tomwademd.net).

- Seven ESI Level 3 patients; and

- Ten ESI Level 4 patients.

Hospital # 1's ED has 21 beds. Seven patients were in the process of
being admitted to the hospital. The ED went on diversion at 18:37 until 22:26 on 3/15/16 (same day PI # 1 arrived in the ED via EMS).


Interview on 4/19/16 at 15:35 with the Director Emergency Services /EI # 5:

EI # 5 was asked for a copy of the ED Nursing assignment sheet dated 3/15/16. The Director was also asked to describe the triage process to include staff responsible for the screening/triage of patients who arrive via EMS to the ED. EI # 5 was asked to define the usual procedure initiated by staff when the activity and acuity in the ED is high. According to EI # 5, patients who arrive via EMS are greeted by the Charge Nurse and the ED Physicians. Staff assignments are per room. An EMS patient is assigned to the RN who is assigned to the room. Triage of an EMS patient can began in the hall if a room is not available.

The Charge Nurse "quarterbacks" patient flow and is responsible for all patients who present to the ED in collaboration with the ED physician. EI # 5 stated staffing was increased on 3/15/16 due to the large number of ICU patients and the increased inpatient census. The Director verified EI # 7 was the charge nurse on 3/15/16 on the 07:00 to 19:00 shift.


Interview with ED Physician/EI # 1 on 4/19/16 at 16:25: (EI # 1 worked 3/15/16 and 3/16/16) based on the the ED Physician staffing record). PI # 1 presented to the ED via EMS on 3/15/16 and on 3/16/15 via private vehicle).

EI # 1 verified he was not aware of PI# 1's visit to Hospital # 1's ED on 3/15/16. PI # 1 told the physician he left the ED on 3/15/16 because he did not want to wait to be seen. On 3/16/16, EI # 1 returned to the ED with his wife. EI # 1 provided a medical screening examination to the patient. According to the physician, he remembers PI # 1 because of the patient's diagnosis of Narcolepsy.


Telephone Interview on 4/20/16 at 14:00 with ED RN / EI # 4 (Charge Nurse 19:00 - 07:00 Shift) on 3/15/16:

EI # 4 was asked who is responsible for triaging patients who present to the ED via ambulance. She said, "One of the RN's (Registered Nurse)." Patient assignments are based on room numbers. If a room is available it is the responsibility of the RN who has the room assignment to accept the patient from EMS staff.


EI # 4 was asked about the timing of triage for patients who arrive via EMS. EI # 4 stated, "As they come in the ER. We talk to EMS (staff) and know their assessment; What they told us and put the patient in a room." We (ED RN's) look at the patient and note if the patient is alert and oriented. "Sometimes ask the patient. I tell the doctor. We start treatment in the hall (if room not available) and move patient" to a room as soon as possible.

EI # 4 was asked where patients who present to the ED via ambulance are placed in the ED at Hospital # 1. The RN responded the EMS staff with a patient on a stretcher park where they can be seen from the nurses' station. "We (ED RN's) recognize EMS when they come in." EI # 4 was also asked who is responsible for keeping up with the communication from EMS to the ED regarding incoming patients. EI # 4 stated, "Whoever is close by. An RN." The RN was asked how information about a new patient arrival via EMS is communicated to the ED physician. EI # 4 said, "We let them (physicians) know. Usually when they come out of a room..." Regarding the assignment of acuity/triage prioritization of EMS patients, EI # 4 said she will ask an ED physician if she has questions regarding a patient's acuity. The Charge Nurse also stated the ED physicians usually see the patients who arrive via EMS in the hall if a room is not readily available.

The Charge Nurse / EI # 4 was asked when a patient arriving via EMS is entered into the electronic medical record system. According to EI # 4 staff can create a medical record for a patient who is not in a room (patient on a stretcher in the hall), but we, "Prefer patient to be in a room." A patient may be entered into the system, "At any point."

EI # 4 was asked if she recalled PI # 1's visit to Hospital # 1's ED on 3/15/16. The RN was advised the ED Director and the ED Manager think her signature is on the ambulance run report as the signature of the person receiving PI #1. EI # 4 was asked if she recalled providing triage services to PI # 1 on 3/15/16. EI # 4 said she, "Doesn't remember."

During a telephone call from EI # 4 on 4/22/16 at 09:00, the RN stated the signature on the EMS report regarding PI # 1 dated 3/15/16 is not her signature. According to EI # 4, she reviewed a copy of the EMS report and determined she did not sign the form.


Interview with ED Physician / EI # 6 on 4/20/16 at 16:35: (EI # 6 worked 3/15/16 based on the the ED Physician staffing record - same day PI # 1 presented to the ED via EMS):

The physician was asked to describe his responsibility when a patient presents to the ED via EMS. EI # 6 said the, "Patient is my responsibility."


Interview on 4/21/16 at 11:38 with ED RN / EI # 7 (Charge Nurse 07:00 - 19:00 Shift) on 3/15/16 (RN documented call from EMS re PI # 1's impending arrival to the ED in Hospital # 1's Communication Control Log EMS):

The Charge Nurse stated she remembered taking the call re PI # 1 from EMS staff because of the diagnosis of Narcolepsy. However, EI # 7 did not recall the arrival of the patient to the ED via EMS on 3/15/16.

According to EI # 7 it is, "Unusual for ambulance patients to leave." If there is a change in the condition of a patient who presents to the ED via EMS, EMS staff notifies us (ED staff). Patients wait if they are stable based on acuity. Staff, "Usually tells the paramedics we're really busy and they wait." The paramedics stay with the patient until they give report to ED staff.

The RN assigned to the room usually triages the patient who arrives to the ED via EMS and is placed in the room assigned to the RN. However, the charge nurse or any RN who is available may triage a patient who arrives to the ED via EMS. A quick triage starts when the RN "eyeballs" the patient and assesses the patient's orientation, skin and respiratory status. Prioritization is required. We report concerns to the ED physician.

Conclusion: PI # 1 presented to Hospital # 1's ED via EMS on 3/15/16.
Staff failed to create a medical record for PI # 1's visit to the ED on 3/15/16. Therefore, there is no documentation that the patient received a medical screening examination and/or stabilizing treatment.