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Based on review of hospital documents, the emergency department (ED) central log, medical records, and policies and procedures and interviews, the hospital failed to enforce its policies and procedures to comply with the requirements of 42 CFR 489.24. The hospital did not enforce its policies and procedures for triage classification to ensure patients were provided a medical screening examination in a timely manner. For fourteen of fifteen patients (Patients #1, 2, 3, 6, 7, 8, 9, 26, 27, 29, 31, 32, 33, and 35 of Patients #1, 2, 3, 6, 7, 8, 9, 26, 27, 29, 31, 32, 33, 35, and 36), whose medical records were reviewed for triage level accuracy, the patients were not classified according to the hospital's triage policy.

Findings:

1. The hospital uses the ESI (emergency severity index) triage algorithm. The algorithm has five (5) levels with Level 1 as the highest level, most acute.

2. According to the hospital's policy and procedure for triage classification, Policy #1202, entitled "Triage", with an effective date of 9/30/03, lists Level 1 as patients presenting with any of the following symptoms/conditions, but not limited to: airway and breathing difficulty or arrest; cardiac arrest; acute chest pain with dyspnea; status seizure; and testicular pain. Level 2 conditions included: chest pain, sharp non-cardiac, headaches, and patients with cardiac histories, regardless of complaint.

3. Review of the ED central log showed the majority of patients were classified as a Level 3, irregardless of their presenting complaint, including those presenting unresponsive and in cardiac arrest.

4. The presenting symptoms for Patients #1, 2, 3, 6, 7, 8, 9, 26, 27, 29, 31, 32, 33, and 35 showed the patients should have been classified as ESI 1 or ESI 2. The patient's were classified as ESI 3 or 4.

5. On 02/23/2015 at 0930, Staff M told the surveyor that he had reviewed Patient #1's medical record and he had incorrectly classified the patient as ESI 3 when it should have been charted as ESI 1.

Based on review of policies and procedures, hospital documents and medical records, and interviews with hospital staff, the hospital failed to provide an appropriate medical screening examination by a qualified medical person in order to determine whether an emergency medical condition existed for one (Record #1) of twenty-one patients who presented to the emergency room department (ER) requesting examination/treatment and whose medical records were reviewed.

Findings:

1. According to Patient #1's medical record, the patient presented at 2037 as a walk-in, ambulatory through the ambulance entrance with complaints of chest pain.

2. The medical record documented, confirmed by staff interviews, the patient was directed to registration. While Patient #1 was in registration, the patient collapsed.

3. The physician documentation recorded, "The patient or guardian reports chest pain that is located primarily in the anterior chest wall" with an onset today and pain that "radiated to the left arm, neck. There has been no movement or pain ...The patient or guardian reports a single episode, that is still ongoing ...Pt (patient) presents via private vehicle with reports of chest pain that began several hours prior to arrival ...Upon presentation to the ER (emergency department) waiting room, pt promptly collapsed and was wheeled to ER room 6 - trauma bay. Pt was found to be pulseless and dusky upon arrival to the ER 6 ... " When the surveyors interviewed Staff C on the afternoon of 02/19/2015, he told the surveyors that his notes were charted after the patient's death and the documentation of pain and patient presentation were obtained from Patient #1's friend.

4. According to the Medical Screening (MSE) requirements, the hospital must screen individuals to determine if an emergency medical condition (EMC) exists. It is not appropriate to merely "log in" an individual and not provide a MSE. A MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage.

Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel. If the medical screening is not timely, it's not an appropriate medical screening.