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Based on a review of the clinical record, interviews with facility personnel, review of facility documentation and a review of the facility policies, the facility failed to ensure that one patient who presented to the emergency department (ED) with the chief health complaint of a headache was provided a medical screening and stabilized prior to being removed from the ED and/or that a central log on each individual who came to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged was maintained.

Please refer to A-2405 and A-2406

Based on a review of the clinical record, interviews with facility personnel, review of facility documentation and a review of the facility policies, the facility failed to ensure that one patient who presented to the ED with the chief health complaint of a headache was entered into the central log. The finding includes the following:

1. Review of a triage form time stamped and dated 5/1/11 at 12:37 AM identified a handwritten first name of an "individual" (Patient #1) who presented to the ED and an unidentified phone number. Review of the triage form and interview with Greeter #1 on 5/16/11 at 7:40 AM identified that when this patient entered the Emergency Room (ED) he/she asked "How can I help you?". Patient #1 responded "headache" and provided his/her first name, however, was unable to provide his/her last name and date of birth. Greeter #1 stated that when he/she asked the patient a second time for his/her last name, the patient yelled profanities. Greeter #1 indicated that he/she time stamped and wrote the patient's first name on the triage form as provided by the patient.

2. The ED log indicated that Patient #1 was entered onto the log at 1:02 AM at the time of his/her second presentation to the ED and was discharged to "home/self-care". The log identified Patient #1 by name, time of entry, and time of discharge, however failed to reflect nature of complaint and an accurate disposition.

3. Review of the facility policy indicated that a computerized list is maintained for all patients who present to the emergency department. The log should include the following information, name, age, sex, nature of complaint, disposition, the time of discharge, and discharge diagnosis.

Based on a review of the clinical record, interviews with facility personnel, review of facility documentation, and a review of the facility policies, the facility failed to ensure that one patient who presented to the emergency department (ED) with a chief health complaint of a headache was provided a medical screening by qualified medical personnel although numerous opportunities to do so existed prior to the patient being removed from the ED and while in police custody. The finding includes the following:

1. Review of a triage form time stamped and dated 5/1/11 at 12:37 AM identified a handwritten first name of an "individual" (Patient #1) who presented to the ED. Review of the triage form and interview with Greeter #1 on 5/16/11 at 7:40 AM identified that when this patient entered the Emergency Room (ED) he/she asked "How can I help you?". Patient #1 responded "headache" and provided his/her first name, however, was unable to provide his/her last name and date of birth. Greeter #1 stated that when he/she asked the patient a second time for his/her last name, the patient yelled profanities, "I already gave it to you b ....., what the f ...." as Patient #1 leaned in towards him/her (the greeter) throwing his/her hands up. As Greeter #1 utilized the desk phone to call security, Security Guard #1 rounded the corner of the ED desk. Greeter #1 identified that Security Guard #1 asked the patient to "leave", the patient replied, "You're a big dude; I'm not f .....with you". The Greeter stated he/she could not recall the triage nurse (RN#1) coming out of the triage room located directly behind the desk. Greeter #1 failed to seek out direction from RN #1 when Patient #1 was attempting to register and unable to provide the required information (last name and date of birth).

2. Interview with Security Guard #1 on 5/16/11 at 9:15 AM stated that he/she was assigned the post in the ED on 5/1/11. Security Guard #1 stated Greeter #1 had called security just as he/she was heading back to the triage desk. Security Guard #1 stated he/she observed an "irate person" who was yelling and using foul language. Security Guard #1 requested him/her to "stop yelling". The patient replied, "f .... you", Security Guard #1 asked the patient to leave, who replied, "make me" as he/she began to disrobe and put fists up to fight saying, "come on". Security Guard #1 stated the patient was subsequently restrained by Security Guards #1 and 2 in a take-down, Security Guard #3 arrived to the scene and applied handcuffs with the assistance of Security Guard #2. Security Guard #1 stated that they picked Patient #1 up and walked him/her to the side room and had the patient sit in a chair to await police arrival. Security Guard #1 stated that the local police were called for assistance. Patient #1 remained in handcuffs and detained in an open room under the supervision of Security Guards #1, #2, and #3 until the local police arrived. Security Guard #1 stated that the cuffs were switched out by the police without incident. Patient #1 was subsequently removed from the ED by police and placed in the police cruiser absent any medical presence or intervention.

3. Review of Patient #1's RN triage assessment dated 5/1/11 at 1:01 AM and the physician's note indicated that Patient #1 had previously presented to the ED with complaints of headache and had a question of psychiatric history. The triage assessment indicated that Patient #1 became argumentative and very threatening, the police were called and the patient had been arrested. The triage assessment indicated that the patient had no respirations and was unresponsive. Review of the clinical record indicated that the facility attempted to resuscitate the patient during the period of 1:01 AM through 2:04 AM. Facility documentation identified that the patient expired at 2:04 AM.

4. Interviews with Security Guards #1, #2, and #3 on 5/16/11 at 9:15 AM identified they were unsure why this patient presented to the ED, that the behavior exhibited by the patient was not considered "normal" behavior and although stated they take direction from nursing staff, all Guards failed to inquire as to the reason for the visit and/or sought out direction from nursing/medical personnel in accordance with facility policy. Security Guards #1 and #3 further stated during interviews on 5/16/11 that their understanding was the patient was being taken to jail. Security Guard #2 identified that the patient stated, "I want to go home, and don't want to go to jail".

5. Interview with RN #1 on 5/3/11 at 10:15 AM stated while triaging a child, he/she heard someone yell profanities in a loud tone, "b ..... " . RN #1 instructed Greeter #1 to call security, while continuing to triage other patients. RN #1 stated that she further instructed the Greeter to "call the police". Approximately 15-20 minutes following the patient being taken into police custody, RN #1 stated a security guard requested that he/she come outside to evaluate Patient #1 while in the back of the police car. RN #1 stated that he/she assessed the patient to be pulseless and unresponsive and the patient was immediately brought to the trauma room.

Review of RN #1's written statement dated 5/1/11 at 7:10 AM, identified that RN #1 heard the security guard request that the patient leave, however, failed to intervene to assess or monitor the patient and/or request assistance from other medical personnel. RN #1 stated that no medical personnel evaluated the patient prior to the patient leaving the ED in the custody of police.

RN #1 failed to ensure that Patient #1 had been triaged and/or that the Charge Nurse, Nursing Supervisor or the Physician had been notified.

6. Interview with the Nurse Director of the ED on 5/4/11 at 2:00 PM indicated that the physician on duty or the Charge Nurse had not been notified of Patient #1 and stated that the Triage nurse was responsible to ensure patient's entering the ED were assessed and should have requested assistance from the charge nurse and/or physician if busy with another patient.

7. Review of the Charge Nurse's (RN #2) written statement dated 5/1/11 at 8:31 AM identified that he/she was not aware of the circumstances that occurred in the ED waiting room until Patient #1 was brought into the trauma room unresponsive.

8. Interview with MD #1 on 5/18/11 at 12:00 PM stated that he/she first became aware of Patient #1 when brought into the trauma room pulseless and unresponsive.

9. Interview with the Director of Security on 5/19/11 at 9:30 AM indicated that security staff should not have asked Patient #1 to leave hospital grounds without first determining the reason for the visit and then to work with nursing as appropriate.

10. Tour of the ED on 5/3/11 and 5/18/11 identified that the ED is comprised of 21 medical treatment areas, 7 fast track areas, and a 5 bed behavioral health unit. The behavioral health area is staffed with a RN, Technician and a Security Guard at all times.

11. Review of the "Security Procedures for the ED" directed that the Security Guard assigned post in the ED will "properly (politely) greet, assist, and check those entering the ED. Ensuring all patients register and visitors are directed to their destination".

12. Review of the "Disorderly Patient Policy" identified that "in the event a disorderly person enters the hospital for treatment he/she shall be seen by a physician and/or an RN before being arrested, discharged or escorted from the hospital property". "It is imperative that no person or persons arriving at the hospital for medical treatment not be offered treatment".

13. The "Triage Nurse Responsibilities" policy directed that "no patient may be sent out of the ED unless evaluated by the triage nurse and a medical screening is completed by the ED physician and/or PA". The policy identified that the triage nurse should complete an "initial evaluation of the all patients presented to the triage area for treatment". The policy further indicated that "if patient at risk to self or other, or of elopement, the patient is placed directly in a treatment area and psychiatric protocols are to be followed".

14. Review of the "Greeter Orientation" education identified that "ED greeters need to understand that they should not interrupt the Triage nurse unless they have an actual issue that needs immediate attention".