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Based on interview and record review, the hospital failed to ensure that the central Emergency Department (ED) Log, provided to the survey team, contained information regarding when patients were triaged and when they received a medical screening examination (MSE). This failure had the potential to affect the health and safety of all patients requiring emergency services.

Findings:

On September 28, 2015 at 8:45 AM, during the entrance conference, the facility management team was asked for the ED Log for the previous 6 month period (April 1, 2015 to September 28, 2015).

A review of the 328 page ED log on September 28, 2015 revealed the following:

1. No date and time when patients are triaged
2. No date and time when the MSE was performed

On September 28, 2015 at 10:30 AM, an interview was conducted with the Chief Nursing Officer (CNO). During the interview, the CNO was informed that triage and MSE dates and times were not observed on the ED Log. The CNO stated, "The information could be located in the individual patient record."

Based on interview and record review, the hospital failed to ensure when one of 31 sampled patients (Patient 1) presented to the hospital's Emergency Department, an appropriate medical screening examination (MSE) was provided to the patient. This failure created the potential to result in the increased risk of harm to the patient, by the patient not receiving treatment for an emergency medical condition.

Findings:

During a complaint investigation conducted on September 22, 2015, Patient 1 presented to the Emergency Department (ED) via ambulance Code 3 (lights and sirens) escorted by the local fire department on July 8, 2015 with the chief complaint of respiratory distress. The complaint stated the ambulance and the fire department personnel were met at the ED ambulance bay by a ED staff member who informed ambulance and fire crew, "We have no beds." No attempt was made by the hospital staff to examine the patient or provide necessary treatment. On two (2) seperate attempts, after verifying the lack of available beds with the ED Charge Registered Nurse (CRN 1), the patient was transported Code 3 to a second local hospital, where an "Emergency Dept STAT Admit," was conducted, which resulted in the patient requiring an emergent intubation with an admission to the intensive care unit.

On September 28, 2015 at 9:40 AM, an interview was conducted with the Emergency Medical Technician (EMT). During the interview with the EMT, the EMT stated he recalled the incident on July 8, 2015, further stating he remembered it was a busy night.

As the interview continued, the EMT stated he met the ambulance in the ambulance bay and opened the double doors of the ambulance and stated, "Were full, we have no beds." The EMT stated, it was "Strictly on me to go out to the ambulance bay and meet the ambulance." The EMT was asked to describe the condition of the patient in the back of the ambulance, the EMT stated, "The patient was diaphoretic, was wearing an oxygen mask and the medics were trying to start an IV on him and get an EKG."

On September 28, 2015 at 2:30 PM, an interview was conducted with the ED physician on duty on July 8, 2015. The ED physician stated he was not aware that Patient 1 was enroute to the hospital or had arrived Code 3 via ambulance. The ED physician stated he did not learn of the patient's arrival until July 9, 2015 at 2 AM, when he heard the EMT and CRN 1 talking about the ambulance leaving, at which time he stated, "What ambulance."

On September 29, 2015 at 8:20 AM, an interview was conducted with CRN 1. CRN 1 stated, "We were busy at the time." A member of the ambulance crew was asking for the charge nurse, they asked me if we were full, I stated, "Yes," at which time the ambulance crew member was observed to go out the ambulance entry door and returned to the ambulance that Patient 1 remained in. A few minutes later, a second person (a fire crew member) came in asking for the charge nurse and asked are you full, I stated, "Yes."

CRN 1 was asked at the time the ambulance/fire crew each entered the ED, if she informed them that a bed available soon, CRN 1 stated, "I could not make conversation with them, they turned around." CRN 1 was asked if she attempted to regain the ambulance/fire crews attention, CRN 1 again stated, "I could not make conversation with them, they turned around."

On September 29, 2015 at 11:05 AM, a telephone interview was conducted with the Engineer from the fire truck, who responded to Patient 1's 911 call and escorted the ambulance from the scene (patient's home) to the hospital Code 3. The fire engineer (FE) stated, when we arrived at the hospital, the hospitals EMT informed the ambulance crew "Were not ready for you, we don't have a bed." As the interview continued, the FE stated the ambulance driver/medic went inside the ED and spoke with the charge nurse and she said the same thing (we don't have any beds). I said to myself wait this isn't good, I went inside the ED and spoke with the charge nurse myself and she said, "We don't have any beds."

The FE further stated, they knew we were coming, we called from the scene and informed them that we needed respiratory upon our arrival. The FE was asked during his conversation with the charge nurse, if the charge nurse stated that a bed would soon be available for Patient 1, the FE stated, "No," she just said, "We don't have any beds." We (ambulance and fire crew) interpreted it as were not ready and no beds would be available anytime soon. The FE stated, "The patient was rapidly deteriorating, we saw an impending code situation."

On September 29, 2015 at 12:55 PM, an interview was conducted with the firefighter/paramedic (FFP) who was in the back of the ambulance treating Patient 1. The FFP stated upon arrival to the hospitals ambulance bay, the ambulance doors were opened by the ED EMT who told us "Were not ready to receive the patient," I said "What do you mean were not ready." The FFP was asked to interpret what the comment meant, the FFP stated, "Means the care will not be at that facility at that time," further stating, "Were not ready," was perceived as go somewhere else.

The FFP was asked if any ED staff other than the EMT observed the patient or performed an assessment of the patient who arrived in respiratory distress, the FFP stated, "No." The FFP was asked if CRN 1 or the physician saw the patient, the FFP stated, "No."

A review of the AMR run sheet dated July 8, 2015 under "Summary of Events" revealed patient had a sudden onset of an asthma attack, used his inhaler twice with no relief before calling EMS. Oxygen saturation 82....lung sounds wheezing in all fields....present in a tripoding position, unable to speak in complete sentences, gasping for air.

Further review of the AMR run sheet revealed the following:

"Patient transported to hospital for further care and eval, Doctors Hospital (previous name of facility) contacted directly by fire medic....No relief with breathing treatment....Original destination was Doctors Montclair, but had no beds available. Patient was not unloaded from ambulance, when arrived at Doctors Montclair EMS crew was met outside by ER staff stating they had no beds available."

A review of the fire department run sheet dated July 8, 2015 under "Summary of Events" revealed the following:

"Arrived on scene to find listed patient standing in front of house, standing tripodding on chair, in severe respiratory distress. Patient is unable to speak more than one word a breath....patient moved immediately to gurney and placed on nebmed treatment...Uponal arrival to (initials of facility), hospital employee meets at back of ambulance and opens ambulance doors and stated, "We do not have any beds available." While treating patient both AMR EMT and Fire Engineer to speak with charge nurse. Charge nurse stated, "We do not have any beds available, we are not ready." Immediately diverted to (second hospital name) due to patient's condition.

A review of the ED Log book, revealed no ED record for Patient 1 when he presented to the hospital on July 8, 2015 to indicate that the ED staff had triaged and/or performed a medical screening examination on the patient.

A review of the hospital's policy and procedure (P & P) dated May 2014, titled, "Triage and Treatment of Patients in the Emergency Department," under the "Purpose" section revealed the following:

"To ensure that any individual presenting to the emergency department requesting examination or treatment for a medical condition receives an appropriate medical screening examination within the capability of the emergency department, including ancillary services routinely available the emergency departments, to determine whether or not an emergency medical conditon exists.

Further review of the P & P under the "Definition" section documentation revealed the following:

"Triage is the process by which a patient is assessed to determine the urgency of the problem and the appropriate health care resource(s) needed to care for the identified problem and the ranking of individuals who may or may not have an 'emergency medical condition,' as defined by EMTALA, by a registered nurse, according to the seriousness of their condition to determine the order in which they will be seen in the emergency room.

Medical Screening Exam-an exam done by a qualified physician or practitioner to determine whether or not the individual has an emergency medical condition."

A review of the undated hospital "New Employee General Orientation" booklet, page 81, topic "EMTALA" revealed the following documentation:

"....Medical screening and stabilization: EMTALA states that all patients must have a medical screening to determine status and that any emergency medical conditions must be stabilized. This must occur prior to collection of any financial information. This must also occur prior to the patient being discharged home or transferred to another hospital, clinic or doctor's office. If the patient requires immediate follow-up, it is a trnasfer and not a discharge."

Further documentation of the undated hospital "New Employee General Orientation" booklet, page 81, topic "EMTALA" revealed the following:

"These regulations apply to any person on the hospital's property requesting medical care.

Based on interview and record review, the hospital failed to ensure that a timely triage, full medical examination and treatment was provided for one of 31 sampled patients (Patient 1). This delay in treatment created the potential to affect the patients' health and safety by not providing a timely triage, full medical examination and treatment for an emergency medical condition.

Findings:

On July 8, 2015, Patient 1 presented to the Emergency Department (ED) via ambulance Code 3 (lights and sirens) escorted by the local Fire Department with the chief complaint of respiratory distress. Upon the patient's arrival, the ambulance and the fire department personnel were met at the ED ambulance bay by the ED Emergency Medical Technician (EMT) who informed the ambulance and fire crew "We have no beds."

Following the conversation with the ED EMT, a member of the ambulance crew entered the ED looking for the Charge Registered Nurse (CRN). The CRN was asked if the ED was full, the CRN stated, "Yes." A few minutes later, a second person (a fire crew member) came in asking for the charge nurse and asked the CRN if the ED was full, the CRN stated, "Yes."

On September 29, 2015 at 8:20 AM, an interview was conducted with CRN 1. CRN 1 stated, "We were busy at the time." A member of the ambulance crew was asking for the charge nurse, they asked me if we were full, I stated, "Yes," at which time the ambulance crew member was observed to go out the ambulance entry door and returned to the ambulance that Patient 1 remained in. A few minutes later, a second person (a fire crew member) came in asking for the charge nurse and asked are you full, I stated, "Yes."

On September 29, 2015 at 11:05 AM, a telephone interview was conducted with the Engineer from the fire truck, who responded to Patient 1's 911 call and escorted the ambulance from the scene (patient's home) to the hospital Code 3. The fire engineer (FE) stated, when we arrived at the hospital, the hospitals EMT informed the ambulance crew "Were not ready for you, we don't have a bed." As the interview continued, the FE stated the ambulance driver/medic went inside the ED and spoke with the charge nurse and she said the same thing (we don't have any beds). I said to myself wait this isn't good, I went inside the ED and spoke with the charge nurse myself and she said, "We don't have any beds."

The FE further stated, they knew we were coming, we called from the scene and informed them that we needed respiratory upon our arrival. The FE was asked during his conversation with the charge nurse, if the charge nurse stated that a bed would soon be available for Patient 1, the FE stated, "No," she just said, "We don't have any beds." We (ambulance and fire crew) interpreted it as were not ready and no beds would be available anytime soon. The FE stated, "The patient was rapidly deteriorating, we saw an impending code situation."

A review of the AMR and Fire Department run sheets revealed the patient was diaphoretic, wearing a high flow oxygen mask and the medics were trying to start an IV and get an EKG on the patient.

The FFP was asked if any ED staff other than the EMT laid eyes on the patient, the FFP stated, "No." The FFP was asked if CRN 1 or the physician saw the patient, the FFP stated, "No."

A review of the ED Log book, revealed no ED record for Patient 1 when he presented to the hospital on July 8, 2015 to indicate that the ED staff had triaged and/or performed a medical screening examination on the patient.

The patient was taken to a second local hospital where a STAT emergency admission was conducted, followed by the patient having an emergent intubation and admission to the Intensive Care Unit.