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Based on observation, interview and record review, the hospital failed to comply with the provisions of CFR 489.24 when:

1) Patient 1 did not receive a timely MSE and the hospital did not determine whether or not Patient had an emergency medical condition to the best of the facility's capability. This failure resulted in a delay of stabilization and treatment. (refer to A 2406)

2) Patients 9 and 13 did not receive a timely MSE which contributed to both patients leaving without being seen prior to a complete MSE being completed. (refer to A 2406)

3) Patient 5 did not receive appropriate treatment and stabilization which resulted in multiple unnecessary vists to the ED and caused Patient 5 unnecessary pain and suffering. (Refer to A 2407)

The cumulative effect of these problems resulted in the hospital failing to provide care in a safe setting in the Emergency Department.

Based on observation, interview and record review, the hospital failed to provide a timely Medical Screen Exam (MSE) and determination of whether or not there existed an Emergency Medical Condition within the hospital's capabilities when:

1. Patient 1 presented to the Emergency Department on 3/28/18 at 5:40 am with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure and the first contact with the qualified medical professional (QMP) was at 8:04 am. The triage Registered Nurse (RN 1) assessed Patient 1 and obtained the blood pressure of 186/120, determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 1 to be seen by the QMP and had Patient 1 wait in the lobby.

These failures resulted in delay in the MSE by the QMP, delay in stabilizing measures such as placing Patient 1 on a cardiac monitor, obtaining laboratory results, administration of medications and establishing intravenous access. These failures resulted in the potential harm of not identifying and acting on an emergent cardiac situation in a timely manner. The delay in prioritizing care and permitting Patient 1 to wait in the lobby unmonitored contributed to Patient 1 eloping from the ED and caused ED personnel to call Patient 1 to return to the hospital after receiving the critical value for Troponin of 3.3. Patient 1 returned to the hospital at 12:49 pm on 3/28/18 and was immediately triaged, prioritized and seen by the QMP, stabilizing measures implemented and subsequently hospitalized.

2. Patient 9 presented to the Emergency Department on 2/6/18 at 10:44 am with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN9) assessed Patient 9 and determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 9 to be seen by the QMP and had Patient 9 wait in the lobby. The first contact with a QMP for the MSE was on 2/6/18 at 3:02 pm (almost 4 ½ hours after walking into the ED).
These failures resulted in delay in the MSE by the QMP, delay in stabilizing measures such as placing Patient 9 on a cardiac monitor, or establishing intravenous access for the administration of medications. D Dimer (a blood test that measures a substance released when a blood clot breaks up) results returned elevated resulting in the order for a CT Chest (a scan that is more detailed type of chest X ray) with contrast (a liquid used in a CT scan that makes any injury or disease visible to the physician.) The delay in prioritizing care and having Patient 9 wait in the lobby unmonitored contributed to Patient 9 becoming upset with wait times, refusing to have the Chest CT and leaving AMA at 5:43 pm before identifying a potential blood clot. Patient 9 left AMA without having vital signs taken again since triage.

3. Patient 13 presented to the Emergency Department via ambulance on 1/25/18 at 10:13 am with the chief complaint of suicidal ideation with depression. Patient 1 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The standardized protocol for psychiatric evaluation was initiated but was not fully implemented. The MSE by the QMP was not done by the time the patient left without being seen (LWBS) at 11:22 am.
This failure resulted in delay in MSE by the QMP, delay in stabilizing measures such as IV access and environmental safety features and contributed to Patient LWBS and the potential harm of having a patient leave the ED with an emergent medical condition.

Findings:

1. On 4/10/18 at 8 am, a review of Patient 1's medical record with RN Clinical Informaticist (CI) 1 indicated: Patient 1 arrived via private car to the ED on 3/28/18 and checked in with RN 1 at 5:40 am. Patient 1 provided RN 1 the chief complaint that she had been experiencing chest pain for three days described as burning, tightness and intermittent. Patient 1 described her current pain level as 8 on a scale of 0 to 10. RN 1 assigned Patient 1 an ESI of 3. RN 1 initiated the following orders from the Chest Pain Standardized Procedures: Blood sample for Troponin I (a protein released when the heart muscle is damaged), CBC (complete blood count), Metabolic panel; 12-lead EKG, Chest X-ray (PA and Lateral views); and a urine test for pregnancy. At 5:45 am, RN 1 obtained the following Vital Signs from Patient 1: temperature of 96.8 degrees Fahrenheit, a pulse of 75 bpm, respiratory rate of 20, oxygen saturation of 98 per cent and a blood pressure of 186/120. RN 1 documented next to the blood pressure value: "history of hypertension, took meds prior to arrival". The clinical record indicated Patient 1 had an EKG and Chest X-ray soon after the vital signs were obtained.
The next entry in the electronic clinical record was at 6:07 am when MD 1 reviewed the EKG and marked on the EKG form "no STEMI" (STEMI= ST elevation myocardial infarction). The clinical record indicated the EKG automated interpretation was "left axis deviation, ventricular hypertrophy with QRS widening and repolarization abnormality, inferior infarct, age undetermined, anterolateral infarct age undetermined, abnormal ECG."
After the EKG was completed, Patient 1 waited in the lobby. The clinical record indicated that sometime after 7 am Patient 1 was in Rapid Medical Evaluation (RME) area room 2 with RN 2.

At 7:38 am, RN 2 documented that she obtained a blood sample and sent it to the lab at 7:42 am.

At 7:45 am, RN 2 obtained blood pressure of 128/93 and pulse of 109 for Patient 1.

At 7:54 am PA 1 started the clinical record review, obtained a brief history from Patient 1 in the Rapid Medical Evaluation area Room 2 and documented: "Patient 1 has a history of hypertension ... presents to the ED for evaluation of intermittent left sided chest pain for three days described as burning and tightness with shortness of breath on inspiration. Reports episodes of chest pain this morning that lasted approximately 1.5 hours. Reports being awoken by chest pain ..."

At 8 am, RN 2 obtained the blood pressure of 128/108.
At 8:02 am, the clinical record indicates Patient is in registration and completed this process at 8:10 am.

Following registration, Patient 1 was sent to the lobby.

At approximately 8:04 am the clinical record indicated PA 1 discussed the EKG results with MD 2 and documented: "no STEMI but concerning findings". The clinical record also indicates PA's plan to place Patient 1 "with a bed in the back" (bed in the ED core) and the clinical record shows a bed was reserved for Patient 1 (at 8:11 am).
At 8:38 am, a critical lab result for troponin was reported to PA 1; the troponin level was 3.3 (range is 0.00 to 0.05)
8:42 am, RN 2 documented " ...attempted to take to room in main ED, patient not found, lobby, bathrooms; multiple attempts to locate patient unsuccessful. Called phone number on chart, no answer at this time ... PA aware; charge nurse aware."
8:45 am, RN 2 documented "...attempted to find patient in lobby X 2; unable to find patient or boyfriend.
10:15: Record indicated Patient 1 as discharged.
11:10 am RN 3 documented "[local law enforcement] called to make me aware of patient welfare check unsuccessful; states grandmother answered the door. Patient usually stays there but has not come home."
12:49 pm RN 11 documented "Patient arrived in ED" while in triage area and ESI was documented as 2. BP obtained was 136/86.
12:53 pm Patient placed in Room 37. 12:59 Patient was placed on cardiac monitor, placed on non-invasive blood pressure monitor and continuous pulse oximetry.
At 1:01 pm an EKG was done. Automated interpretation noted as "Sinus tachycardia, T-wave abnormality, Abnormal ECG". Pain assessment was 3 out of 10. Chest X-ray was done.
At 1:18 pm, MD 2 started the MSE and documented Patient 1's history of methamphetamine use, last use yesterday. Also noted family history of cardiac disease; father had MI at 40 y/o.
From 1:19 pm until 2:45 pm the care of Patient 1 included blood draw for lab tests, placement of intravenous access and administration of medications including Aspirin, Ativan, Clonidine, nitroglycerin, diltiazem, potassium chloride and heparin.

At 2:05 p.m. a critical lab value of TROPONIN 8.55 (range 0.00-005) was reported, as well as PRO-BRAIN NATRIURETIC PEPTIDE (PROBNP- a protein present in heart failure) of 1,270 pg/ml (Optimized diagnostic cutoff for CHF age < 50 years 0-450 pg/ml)
At 2:45 p.m., MD 2 noted decision to admit. Diagnosis: Non-STEMI (non-ST elevated myocardial infarction). MD 2 discussed patient with admitting Hospitalist (MD 4) who will assume care with consulting cardiologist.

At 4:04 p.m. Patient 1 was admitted to the telemetry unit on the second floor, attending physician was MD 4.

On 4/11/18 at 7:22 am, during an interview held in the Board Conference Room of the hospital and concurrent record review, PA 1 stated on 3/28/18 his shift started at 6 am PA 1 stated his usual pattern is to arrive in the ED to start his shift, to get his phone and check in with the charge nurse for direction. PA 1 stated the decision about which patient to see first depends on many factors. PA 1 stated Patient 1 arrived in ED before his shift started and he was not given any information about her. PA stated he started his Medical Screening Exam (MSE) for Patient 1 at 8:04 a.m. and had no contact with her prior to that. PA 1 stated before he went in to see Patient 1, he looked at her record briefly to familiarize himself but did not have any knowledge of her at all before that time. PA 1 stated he spoke with Patient 1 and briefly examined her. PA 1 stated he then obtained a copy of the EKG and went back to discuss it with MD 2 who said Patient 1 needed a cardiac work up. PA 1 stated he told the RN that Patient 1 needed a bed in the back. PA 1 explained this was the extent of his contact with Patient 1.

On 4/11/18 at 8 am, during an interview held in the Board Conference Room of the hospital and concurrent record review, RN 1 stated she was the triage nurse working in the ED on the morning of 3/28/18 when Patient 1 came in. RN 1 stated her shift started at 6:45 pm on 3/27/18 and ended at 7:15 a.m. on 3/28/18. RN 1 stated as Triage RN her role is to obtain the patient's chief complaint, ("describe their story"), take a set of vital signs, assess patient's pain level, assign an ESI level, and enter the patient into the computer (electronic health record). RN 1 stated she followed a checklist for this process. RN 1 stated the triage process determined whether a patient can wait to see the provider; if they can wait, the tracking board will show the patient is in the waiting room, which means the lobby. RN 1 stated orders are placed for lab work and other tests based on the chief complaint per the Standardized Procedure (SP). The SPs are in the computer so they (RNs) know what to order. Asked if standardized procedures are initiated most of the time or only if a provider is not available at that time to see the patient, RN 1 stated at that time (referring to Patient 1's 5:40 am arrival), there is no available provider available in triage area and the SP is not initiated. RN 1 stated she placed orders for an EKG and chest x-ray for Patient 1 per the standardized procedure for chest pain. RN 1 stated the EKG is done by the tech in the ED. After the tech completes the EKG they carry the printed copy to the ED physician in back to review it immediately. RN 1 stated she does not know what the EKG showed for Patient 1. RN 1 stated she placed orders for STAT lab tests per the SP at 5:43 a.m. RN 1 stated there is no phlebotomist in the ED during that time of morning so the lab draw would wait until the phlebotomist is there on day shift. RN 1 stated the RNs can draw labs and sometimes she does draw the labs if she has the time. When asked whose decision it is whether or not the RN draws the labs or waits, RN 1 stated she did not know. RN 1 was asked, when a SP is initiated by an RN, should all of the orders be implemented. RN 1 stated all of the orders are supposed to be activated and followed. Asked about her decision not to implement the order for cardiac monitoring for Patient 1 when she initiated the SP, RN 1 stated the patient was waiting in the lobby and they don't have monitoring in the lobby so she did not implement that order.

On 4/12/18 at 9:22 am, during a telephone interview, ED MD (MD 1) stated he was working in the ED core (Pods) on 3/28/18 and had provided the EKG review at 6:07 am for Patient 1. MD 1 stated when an EKG is presented to the ED physician on duty, it is only for the purpose of identifying if there is an ST Elevation Myocardial Infarction (STEMI) in order to facilitate activation of the cath lab team for timely intervention. MD 1 stated this was the extent of his involvement in Patient 1's case. MD 1 stated the ED physician reviewing the EKG has no information about the patient in terms of history or clinical presentation and has no role in the management of the patient. MD 1 stated if there was critical information regarding a patient he would expect the RN or tech to communicate that directly to him when they bring the EKG for review. MD 1 also stated it was his expectation the standardized procedure for chest pain would have been followed for Patient 1.

On 4/12/18 at 9:45 am during an interview with the Client Services Supervisor (CSS), Lab Supervisor (LS), and ED Manager, the CSS stated during the hours of 4:30 am to 8 am each day two phlebotomists are assigned to do morning lab draws for the inpatient areas in the hospital. CSS stated no phlebotomists are assigned to the ED during these hours each day. During these hours the phlebotomists can be reached on their cell phone if they are needed in the emergency department. The CSS stated the RNs in ED are responsible for drawing any labs during those hours or contacting the phlebotomist if the lab is needed urgently and/or the ED RN cannot draw the blood. The CSS stated the lab remains open during this time to process specimens per their usual practice. The CSS stated this process has been in place for at least 10 years and is well known to the ED staff. The CSS stated per the lab records on the morning of 3/28/18, no calls for assistance from the ED were received by the lab staff. The LS stated the expectation for STAT orders received by the lab is the lab staff will draw the specimen within 15 minutes of receiving the order, and the lab will process and submit the result within an hour. LS stated the turnaround time for processing and resulting STAT labs drawn by nursing staff is the same.

On 4/10/18 at 1:55 pm, during an interview, RN 3 stated when there is no provider up front (meaning the triage area) there is a standardized procedure that RNs should follow. RN 3 stated she had the opportunity to review the presenting symptoms, history and chief complaint for Patient 1. RN 3 stated the ESI should have been a 2 rather than a 3.
On 4/10/18 at 3 pm, during an interview, MD 2 (ED Medical Director) stated she had the opportunity to review the clinical record for Patient 1. MD 2 stated that what had occurred to Patient 1 should not have occurred, meaning Patient 1 should have been seen by the QMP more promptly and the standardized procedure should have been fully implemented when Patient 1 first arrived.

On 4/12/18 at 4 pm, during an interview, the ED Manager (RN) stated she had the opportunity to review the clinical record for Patient 1. ED Manager stated that the ESI should have been 2 rather than 3, the chest pain standardized procedure should have been fully implemented and the QMP should have been notified in order to start the MSE more promptly.

The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, " ...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...."

The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP ... 4. Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI) ...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for age 35 years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view ... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry ...IV access: IV normal saline or saline lock ...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI ...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older ...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ..."

The hospital policy and procedure titled "RME (Rapid Medical Evaluation) Guidelines" dated 5/11/16, indicated, " ...During periods that RME is staffed, patients that cannot immediately be moved to an ED examination room will be assessed by an ED provider in order to complete the Medical Screening Exam (MSE). Patients will be assessed in order of arrival or as determined by clinical staff or provider ...RME is a process in which the patient has a rapid medical examination by a provider. The basic goal of RME is to eliminate barriers and bring patients to providers as quickly as possible upon arrival at the emergency department ...the initial provider evaluation will occur as quickly as possible upon patient arrival and appropriate orders will be initiated ...Patient presents to RN Greeter who will obtain chief complaint ...the greeter RN will determine if a life threatening or time-sensitive condition exists and ...will take appropriate action ...standardized procedures may be initiated during the RME process in order to expedite care ...immediate bedding will be utilized when beds available in the ED ...."
The hospital policy and procedure titled "Left Without Being Seen" dated 4/18/16, indicated, " ...Patients that are observed leaving or that request to leave without being seen by a provider will be offered medical screening by a provider prior to leaving ...Quality RN will review the LWBS report every 24-72 hours and will conduct a callback in the following situations: patient has left after any diagnostic studies have been conducted (i.e. ED Standardized Procedures), at the request of the ED provider, at the discretion of the Quality RN ...Quality RN will complete the QA ED Follow-up form for all abnormal diagnostic results and will submit to an ED physician for review ...RN shall make an effort to speak to patient and encourage the patient to stay ...identify reason for delay ...attempt alternatives to leaving ...document the condition of the patient and the time last seen ...."

2. On 4/11/18 at 3:00 p.m. a concurrent clinical record review and interview with RN 4 and RN 5 in the Board Conference Room was conducted. Patient 9 arrived to the Emergency Department by way of car on 2/6/18 at 10:44 am and presented to the triage nurse (RN 9) with the chief complaint of chest pain, level of 10 on a scale of 0 - 10. Blood Pressure at triage was 133/63, pulse 66 and Temp 36.4 degrees Celsius. RN 4 stated the clinical record indicated Patient 9 waited in the lobby after triage and prior to the MSE. When asked, RN 4 stated there was no indication that Patient 9 had cardiac monitoring. At 2:27 pm, Patient 9 was taken to the RME (Rapid Medical Exam) room to have a MSE performed. At 3:02 pm, Patient 9 had her MSE by MD 3. RN 4 stated the clinical record indicated that after being seen by MD 3 Patient 9 received an albuterol breathing treatment (medication used to prevent and treat breathing difficulties, shortness of breath and coughing) then returned to the lobby with no indication cardiac monitoring per the CP standardized procedure was started.

On 2/6/18 at 3:21 pm, the D Dimer (blood sample that measures whether or not there is blood clots present in the blood) lab results returned elevated (597 with reference range less than 250). At 3:39 pm Chest CT with contrast was ordered by MD 3. At 3:55 pm the Chest CT with contrast order was acknowledged by RN 6. At 4:41 pm, RN 6 indicated Pt 9 wanted to go home prior to the Chest CT exam. RN 4 stated the clinical record indicated that RN 6 informed MD 3 Pt 9 wanted to go home. At 5:43 pm, RN 6 indicated that Pt 9 was upset at wait times, refused CT of the chest and requested to leave AMA. MD 3 was notified via phone. Pt 9 signed AMA form using language line interpreter # 183500 and Pt 9 left with her son.

When asked if there was any indication that Pt 9 ever had a cardiac monitor in place, or if there is any indication her vital signs were ever checked after triage, RN 4 said there was no indication in the clinical record that Pt 9 ever had a cardiac monitor in place and there is no indication that Patient 9 ever had her vital signs taken after triage.

The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP ... 4. Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI) ...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for age 35 years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view ... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry ...IV access: IV normal saline or saline lock ...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI ...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older ...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ..."

The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, " ...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...."

The hospital policy and procedure titled "Left Without Being Seen" dated 4/18/16, indicated, " ...Patients that are observed leaving or that request to leave without being seen by a provider will be offered medical screening by a provider prior to leaving ...Quality RN will review the LWBS report every 24-72 hours and will conduct a callback in the following situations: patient has left after any diagnostic studies have been conducted (i.e. ED Standardized Procedures), at the request of the ED provider, at the discretion of the Quality RN ...Quality RN will complete the QA ED Follow-up form for all abnormal diagnostic results and will submit to an ED physician for review ...RN shall make an effort to speak to patient and encourage the patient to stay ...identify reason for delay ...attempt alternatives to leaving ...document the condition of the patient and the time last seen ...."


3. On 4/11/18 at 11:20 a.m. a concurrent clinical record review and interview with Clinical Informaticist (CI) 1 in the Board Conference Room was conducted. Patient 13 arrived in the Emergency Department via Emergency Medical Services (EMS - or ambulance) on 1/25/18 at 10:13 a.m. Patient 13 was triaged at 10:19 a.m. and given an ESI of 2, and was placed in hallway bed 7. CI 1 was asked to comment regarding what standardized procedures for Patient 13 were implemented. CI 1 stated that the standardized procedure for Psychiatric complaints should have been fully implemented. CI 1 stated the clinical record for Patient 13 did not have documented evidence that all of the interventions for the standardized procedure were implemented. CI 1 stated the clinical record for Patient 13 did not show that Patient 13 was started with an IV access and the cardiac monitor was not placed.

When asked what is the process of obtaining a sitter for a patient exhibiting the type of psychiatric problems similar to Patient 13, CI 1 stated "A CNA would be floated from another department, and be assigned to sit with the patient." When asked if a sitter was assigned to PT 13, CI 1 stated as noted in the chart " ... No plans of hurting himself at this time per pt." and CI 1 stated "a sitter was not assigned during that time" according to the clinical record.
CI 1 stated the clinical record indicated that on 1/25/18 at 10:54 am a QMP was assigned to PT 13, but an MSE was not performed. When asked to clarify, CI 1 stated, "That is the time the provider assigned themselves to the patient, not when they saw the patient."
CI 1 stated the clinical record for Patient 13 indicated on 1/25/18 at 11:22 am, a clinical notation by charge nurse was documented and states "Pt unable to find in bed, Public safety informed. Pt not in lobby. [first name of RN] Charge Nurse informed and aware." Clinical documentation was requested regarding if a provider was notified of PT 13 missing, CI 1 was not able to locate documentation. CI 1 was asked what actions were implemented to locate PT 13, CI 1 stated as noted in the chart, "Attempted to call pt's cell phone listed ...[local town] PD contacted to notify them of patient elopement."

Based on observation, interview and record review, the facility failed to provide within the capabilities of the facility and staff at the hospital, further medical examination and treatment as required to stabilize an emergency medical condition when:

Patient 5 arrived in Hospital 1 Emergency Department (ED) on 3/16/18 at 4:32 p.m. with complaints of severe abdominal pain and loss of appetite. Patient 5 returned to Hospital 1 ED on 3/19/18 with unrelieved abdominal pain and worsening symptoms. Hospital 1 was aware Patient 5 was seen and treated at hospital 2 for the same symptoms on 3/15/18 on Patient 5's visit of 3/16/18.

These failures resulted in delay in stabilizing treatment for Patient 5 and resulted in Patient 5's unnecessary pain and suffering as a result of the delay.

Findings:

4/11/18 at 11:20 a.m. a concurrent interview and record review (EHR) was completed with Clinical Informaticist and former ED RN (CI) 2.
The clinical record indicated Patient 5 is a 42 year old female who arrived in the ED on 3/16/18 at 4:32 pm by private car, accompanied by a family member. The clinical record indicated triage of Patient 5 was completed at 4:35 pm and an ESI of 3 was assigned. The clinical record indicated the chief complaint was abdominal pain for 2 days. The clinical record indicated the initial triage Vital Signs were 36.8 degrees Celsius, Pulse 86, Blood Pressure 116/77. The clinical record indicated the pain level stated by patient 5 as 10 on a scale of 0-10. Patient 5's face sheet indicated her primary language was Spanish and that an interpreter would be needed. Orders were placed by the triage RN using the standardized procedure for abdominal pain, and the clinical record indicated Patient 5 waited in the lobby.

At 4:37 p.m. PA 3 entered a note (scribed). The note indicated Patient 5 was in RME (room not specified). The PA's note documented the chief complaint and triage vital signs. In the top section of the note the following is documented "MSE INITIATED at 4:37 p.m.; in the bottom portion of the note under the "Plan" section the PA indicated "Medical Screening Exam (MSE) Initiated at: 5:02 p.m. Patient awaiting further evaluation." The PA signed this note on 3/24/18 at 6:36 p.m.

At 5:16 pm, labs were drawn for a complete blood count (CBC), Comprehensive Metabolic Panel (CMP), and Lipase. The results for the lab samples were provided to the ED at 6 pm and were noted to be within normal limits.

At 5:50 pm a urine specimen was collected and sent to the lab for a urinalysis. Urinalysis results were abnormal, presence of red and white blood cells noted. The urine sample was sent for culture according to the clinical record.

At 6:31 pm the clinical record event log indicated Patient 5 was moved to ED room 19. CI 2 was asked if the record indicated where the patient was between 4:32 pm and 6:31 pm and stated the record does not specifically indicate that information.

At 7:51 pm the record indicated PA 3 spoke with Patient 5 and documented the history of present illness. Patient 5 explained to PA 3 she lived in Sonora and was seen at hospital 2 the previous day with the same symptoms. PA 3 noted Patient 5 had a past medical history of chronic back pain and had an ileus 10 years ago. PA 3 documented a physical exam which included findings of diffuse abdominal tenderness and diffuse back tenderness with costovertebral angle tenderness.

At 7:51 pm in the same provider note, PA 3 indicated under the heading ED COURSE/Medical DECISION MAKING, that the MSE was initiated at 7:51 p.m. and indicated she will order meds and discuss the case with the ED physician. CI 2 was asked about the documentation in this record of the Medical Screening Exam being initiated at 3 different times: 4:47 p.m., 5:02 p.m., and 7:51 p.m. CI 2 stated there should be only one time documented and that he has no explanation for the 3 different entries in this case.

At 8:27 pm Patient 5's pain level is documented as 8 (0-10 scale). An IV was started and Morphine 4 mg was given IV for pain.

At 9:17 pm the nurse's notes indicated Patient 5 was taken to have a CT.

At 9:36 pm the nurse's notes indicated patient returned from CT and cardiac monitoring was reestablished. Patient 5's pain level was noted to be 8 (0-10), and the note indicated patient 5 was extremely anxious.

At 10 pm the ED provider note indicated PA 3 "consulted with [MD 6] who reviewed the CT scan results and said patient can be discharged home."

At 10:06 pm the nurse's notes indicated PA 3 was at bedside to reassess patient.
At 10:13 pm PA 3 documented her discussion with Patient 5 about the workup: "likely ileus, advised fluids, pain and nausea control and rest. Return precautions discussed. Patient instructed to follow up with PCP in 1-2 days. Patient understands and agrees with plan."
Review of PA 3 chart entry summarizing the medical decision making indicated "Patient improved after morphine in the ED. Symptoms consistent with ileus and UTI, although urine sample is contaminated and patient has no urinary symptoms ...patient suitable for outpatient care ...patient discharged with prescription for Keflex, Zofran, and Norco."

At 10:20 pm - 4 mg Zofran given IVP for nausea.
At 10:34 pm water provided to patient for PO challenge.
At 10:51 pm the nurses notes indicated patient able to keep water down but patient stated it makes her feel slightly sick to her stomach. PA 3 aware.
At 11:19 pm Patient 5 discharged home.

The Clinical Informaticist was asked about documentation regarding use of an interpreter for this patient at any time during her stay from 4:32 pm until 11:19 pm since it is indicated on Patient 5's face sheet that her primary language is Spanish and that an interpreter would be needed. CI reviewed the entire record for evidence that an interpreter was used during any communication with Patient 5 and no documentation was found in any form in this record. CI 2 stated there was no documentation that the provider or any of the nurses spoke Spanish fluently. CI 2 stated that the clinical record indicated there was no documentation that a bilingual family member acted as an interpreter for the patient, or that an interpreter was considered or offered.

The clinical record and concurrent interview continued with CI 2. On 3/19/18 at 3:51 pm Patient 5 arrived in the ED (3 days after the first visit). CI 2 stated the clinical record indicated that triage of Patient 5 was completed at 3:56 pm; an ESI of 3 was assigned. CI 2 stated the clinical record documented the Chief complaint as: "Abdominal pain- Patient seen here on Friday (3/16/18) for abdominal pain and diagnosed with an ileus. Patient is now vomiting. Patient states pain medication is not working." CI 2 stated the clinical record indicated the vital signs at triage were stable and the pain level for Patient 5 was listed as 10 out of scale from 0-10.

CI 2 stated the clinical record for this visit indicated Patient 5 was provided services and interventions similar to the visit of 3/16/18 with the exception of obtaining a comprehensive history and physical including a history of medication prior to the visit. The hospitalist was called to assess Patient 5 on 3/19/18 and agreed with decision to admit patient. The hospitalist obtained a GI consult who provided a plan for the care of Patient 5.

The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at the hospital Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP.
1. Abdominal Pain ...Obtain nursing history and physical exam: Vital signs ...Focused abdominal assessment and HPI ...Brief history including abdominal surgery, ulcers, similar pain, alcohol abuse, use of pain medications or NSAIDs or histamine blockers ...Current medications ...Diagnostic Studies: CBC, CMP (Complete Metabolic Panel), Lipase and liver panel, urine dip and analysis ...urine pregnancy test if potential for pregnancy ...Obtain order from physician for abdominal x-rays if bowel obstruction likely or significant abdominal distention ...12-lead EKG for ACS (Acute Coronary Syndrome)-associated symptoms or atypical signs of ACS ...fingerstick glucose for diabetics ...Treatment in the treatment area: IV access ...Place on cardiac monitor and monitor rhythm and rate, blood pressure, continuous pulse oximetry ...Medications: Oxygen as needed to keep oxygen saturation greater than 95%...obtain order from physician for analgesia ..."