HospitalInspections.org

Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2405 - Emergency Room Log:
The facility failed to ensure that it maintained a log of all patients presenting to the Emergency Department seeking a Medical Screening Examination (MSE). Specifically, the hospital's obstetrics department did not maintain a complete log that indicated the disposition of women presenting to the obstetrics (OB) department for medical screening examination.

Refer to findings for Tag A 2406 - Medical Screening Examination:
The facility failed to ensure that sample Patient #1 was provided an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department (ED), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition (EMC) existed prior to discharging the patient to his/her home. The hospital failed to utilize diagnostic equipment that the hospital had available and did not transfer the patient to a hospital that could perform the diagnostic testing to rule out an EMC.

Refer to findings for Tag A 2408 - Delay in Examination or Treatment:
The facility failed to ensure that its policies/procedures allowed for the provision of an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section without a delay in order to inquire about the individual's method of payment or insurance status of patients presenting to the Dedicated Emergency Department (DED) seeking a Medical Screening Examination (MSE) for their Emergency Medical Condition (EMC). Additionally, the facility had policies/procedures that were in effect that may have unduly discouraged individuals from remaining for further evaluation. Specifically, the facility inquired about patients' insurance status, asked for copayment, and had uninsured patients sign a form indicating that they would be charged for the visit if the visit was later determined to not be an emergency all before a MSE. This failure had the potential to deter patients with EMCs to stay at the DED for a MSE and stabilizing treatment.

Based on staff interview and review of the facility's documents the facility failed to ensure that it maintained a log of all patients presenting to the Emergency Department seeking a Medical Screening Examination (MSE). Specifically, the hospital's obstetrics department did not maintain a complete log that indicated the disposition of women presenting to the obstetrics (OB) department for medical screening examination.

The findings were:

On 2/9/2012 at approximately 12:30 PM, a request was made for the facility to provide the "Emergency Department/OB log for the past 6 months."

A review of the logs provided for the OB department revealed that the department maintained three binders/logbooks. One logbook contained all births at the facility and was titled "Labor and Delivery Register." The logbook did not contain women that had presented for MSEs, only women who had delivered at the hospital. A second logbook contained all children born at the facility. A third binder was provided when the facility's staff was asked where women seeking MSEs in the facility's OB department. The binder contained a section labeled "Observations" which contained entries that pertained to women who presented to the OB department for medical complaints rather than to the Emergency Department since they were pregnant. The sections of the pages included areas for the date, name, physician name, medical record number, time in, time out, reason, assessment and treatment, gestation, and charges. The pages did not have a place to indicate the disposition of each patient (i.e. discharge, admission, transfer, etc.) nor did the sheets indicate the disposition of any patient in the log. An additional section of the binder was labeled "Transports". The most current page in the section included five entries which ranged from 12/18/2010 through 12/25/2011. Sections of the log were incomplete for one of the entries dated "12/3?" which included the "time in", "time out", "gest[ation]", and "reason."

An interview with an OB Department Staff Nurse was conducted on 2/9/2012 at approximately 3:45 PM. S/he confirmed that there was not a way to tell from the logs available the disposition of each patient that presented for an MSE in the OB department.

Based on medical record review, staff interview, review of the facility's policies/procedures and Medical Staff Bylaws, Rules/Regulations the facility failed to ensure that sample Patient #1 was provided an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department (ED), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition (EMC) existed prior to discharging the patient to his/her home. The hospital failed to utilize diagnostic equipment that the hospital had available and did not transfer the patient to a hospital that could perform the diagnostic testing to rule out an EMC.

The findings were:

Facility Policies/Procedures, Medical Staff Bylaws, Rules/Regulations:
The facility's Medical Staff Bylaws, Rules and Regulations, were last reviewed and approved 1/27/2009. The Rules and Regulations included a Medical Staff policy titled "Emergency Services" which was last approved by the Governing Body and Medical Staff on 1/26/2010. The policy stated, in pertinent parts:
"1. All patients presenting to the Emergency Department will be evaluated. Only licensed physicians can perform medical screening exams to rule out emergent medical conditions. In addition, OB nurses who have completed OB unit competency requirements are authorized by the medical staff to perform assessment of active labor ...
3. a) All patients presenting to the Emergency Department will have a nursing triage. After the emergency room nurse has performed a nursing assessment, the appropriate physician will be contacted ...
11. Medical Staffing of the Emergency Department will be as follows:
a) There will be a physician on duty in the Emergency Department twenty-four (24) hours per day, seven (7) days per week ...
c) The Emergency Department physician shall remain in house and be available to the Emergency Department at all times ...
k) If the Emergency Department is excessively busy, the Emergency Department physician may, on occasion, ask for backup assistance by a qualified physician ..."

A facility policy titled, "Function of the Emergency Department", stated in pertinent parts:
"Policy
The primary function of the Emergency Department is preliminary or complete examination and/or treatment of ill or injured persons coming to the hospital, especially those of an emergent nature.
All patients who present to the Emergency Department, when a request is made on the individual's behalf for examination and/or treatment, will receive a medical screening exam to determine whether or not an emergency condition exists, and a disposition will be made by a physician.
If it is determined that the individual has an emergency condition, Southwest Memorial Hospital will either provide such further medical care as may be required to stabilize or treat the medical condition, or provide for the treatment of labor or transfer to an appropriate medical facility ..."

A facility policy titled, "Emergency Department Routine Protocol", stated in pertinent parts:
" ...Procedure:
1. Patients will be triaged upon arrival to the ED. This will include vital signs, chief complaint and classification of patient (per Triage policy) ...
2. After medical triage, the Admissions Clerk will obtain all pertinent information for ED admission ...
6. A Triage Sheet shall be completed and the ED physician notified.
7. Vital signs will be repeated hourly (more often if the patient's condition warrants) and recorded ..."

A facility policy titled, "Emergency Department Outpatient Policies and Procedures", stated in pertinent parts:
" ...Procedure ...
Staffing
A. Patients who present to the ED will be seen by the ED Physician. The exception will apply if a primary physician has arranged to meet the patient in the ED
Emergency Department Records ...
C. Check vital signs (blood pressure, temperature, pulse, respirations, pulse oximetry and pain scale) and record on ED form. Also make any nursing notes that are significant (i.e., patient's appearance, color, state of consciousness, etc.). Follow Triage Policy ...
Transferring Patients ...
C. Patients to be transferred or referred to another facility are done so only after the attending physician confirms this with the consulting physician who in turn makes the arrangement at the hospital or institution to which the patient is to be sent.
1. No patient may be arbitrarily transferred.
2. The mode of transportation is determined by the attending physician after he has determined that the patient's condition is stable and all life-saving measures have been accomplished for the patient's safety and comfort (such as immobilization of fractures, clear airway, control of hemorrhage and pain, IVs started, etc.).
3. COBRA forms will be completed in detail ...
Physician Office Hours
During physician office hours, if physician requests, a patient may be sent to the office for primary care if, and only if, the ED Registered Nurse's examination reveals that the patient's condition is stable and will tolerate the transfer by private car. The ED Registered Nurse must contact the office by phone for consult before referring the patient. A "Patient's Emergency Room Release Form" must be signed by the patient or representative to release the hospital from liability of not treating the patient in the ED ...

A facility policy titled, "Triage of Emergency Patients", stated in pertinent parts:
" ...Procedure:
When the patient arrives at the registration desk, the clerk shall inform the Registered Nurse on duty that a patient has presented for emergency care. All persons presenting to the Emergency Department will be triaged within 20 minutes of arrival to the area, and before the registration clerk elicits financial information. Ideally, this triage interview should be performed by a Registered Nurse; but at times, due to patient volume and/or acuity, thin interview may be performed by an EMT, EMT-I, or Paramedic trained in emergency care. The EMT or Paramedic will immediately report to the RN on duty, as verified as part of the EMT competency.
If the patient is not emergent and is able to wait in the waiting area, the patient will be assessed every 15 minutes while in the waiting area ...
...Patients waiting in the ED should be reassessed on a timely basis to identify the deterioration of an urgent or non-urgent patient ..."

A facility policy titled, "Guidelines for Discharging Patients from the Emergency Department", stated in pertinent parts:
"Policy:
Assist in the discharge process of Emergency Department (ED) patients.
Purpose:
To discharge patient according to condition - satisfactory, fair, poor, or critical.
To assist the ED staff (Registered Nurse) in ascertaining the readiness of a patient to be discharged.
Definitions:
1. Critical condition
a. Immediate life-threatening illness or injury.
b. Vital signs are not within normal range and fluctuate:
1) + or - 20 points for blood pressure;
2) + or - 20 points for pulse;
3) + or - 10 respirations/minute; and
4) + or - 2 degrees for temperature.
2. Poor condition
a. Possible life-threatening illness or injury.
b. Vital signs are not within normal limits but stable.
c. Needs frequent observation by trained personnel.
3. Fair condition
a. Injury or illness is serious but not likely to be life-threatening.
b. Vital signs fluctuate within 10% of patient's normal limits and are stable.
c. Observation is needed but may be done by untrained personnel.
4. Satisfactory condition
a. No life-threatening illness or injury.
b. Vital signs within normal limits and stable.
c. Requires no observation by other personnel.
Procedure:
The Emergency Room staff registered nurse shall assess a patient for discharge according to the above definitions. If the patient is in a critical or poor condition, the registered nurse shall inform the patient's personal physician. If the personal physician wishes to discharge the patient after being notified that the patient is in a critical or poor condition, the staff registered nurse shall inform the Medical Chief of Service about the case. The Chief of Service and the personal physician shall confer and determine the patient's disposition ..."


1. Sample patient #1
Medical Record Review
A review on 2/9/2012 of sample patient #1's medical record revealed the following, in pertinent parts:
On 12/29/2011 (Sample #1), the patient presented to the hospital's ED at approximately 8:49 AM. The patient was triaged by an ED nurse. The triage assessment stated that the patient had left lower extremity pain, swelling, and erythema for approximately 24 hours. The patient presented with a pulse of 110 and had oxygen saturations of 94% on room air. The patient was categorized by the triage nurse as a "3" which represented the least emergent category of "non-urgent". The nurse documented that the patient was "pale, diaphoretic, cool, clammy" and had a "cough". The nurse further documented that the patient was "ill-appearing" and "in distress". The nurse also documented that the patient exhibited "tachycardia".
The nursing notes reflected that at approximately 8:56 AM, the patient walked into the ED patient room. The nurse documented that the patient was "pale, cool, clammy, diaphoretic. MD aware." At approximately 9:24 AM, blood samples were collected for laboratory studies and were started for the patient which included a D-Dimer. The laboratory report for the D-Dimer result reflected that it was resulted at approximately 10:12 AM and was 5.24 which was stated on the report to correlate with an "increased possibility of DVT or PE". The next note was at approximately 10:20 AM which stated that "MD in room with patient." The record reflected that at approximately 10:30 AM, the patient was started on supplemental oxygen via a nasal cannula of 2 liters per minute. The patient was given pain medications at approximately 10:32 AM, and 11:45 AM. The patient was taken to the radiology department at approximately 12:10 PM for an ultrasound of his/her affected extremity and returned to the ED at approximately 1:11 PM. The patient was given additional pain medication at approximately 1:20 PM. The nursing notes documented that the ED physician returned to the patient's room at approximately 1:29 PM to notify the patient that s/he had a Deep Vein Thrombosis. The notes also reflected that the patient received a chest x-ray that s/he returned from at approximately 2:24 PM. The physician returned to the patient's room at approximately 2:38 PM after Lovenox had been administered and teaching had been performed. The patient was discharged home with his/her parent at approximately 2:50 PM. The medical record did not reflect if the patient was removed from the supplemental oxygen or what his/her vital signs were upon discharge. The medical record did reflect that the patient's pulse was 105 at both 11:40 AM and at 1:17 PM. The last set of vital signs were recorded at 1:46 PM which reflected that the patient's pulse was 98 and his/her oxygen saturations were 95% (on an unknown amount of supplemental oxygen or room air). The chest x-ray that was performed had a radiologist's report that was signed at approximately 4:44 PM, which stated that the "evaluation [was] limited due to patient's body habitus". The patient's medical record did not reflect any studies performed to evaluate if the patient had pulmonary emboli (PE).
The patient presented to an acute care hospital after being discharged from the ED. The Emergency Department Report from the acute care hospital stated that the patient presented to the ED at the acute care hospital for "further treatment and evaluation" "due to familial concerns regarding his/her medical safety and ability to be treated as an outpatient". The patient presented with a pulse of 130. The emergency department report further stated that "CT angiogram of the chest was done due to concerns of possible pulmonary embolus due to patient's history of recently diagnosed DVT as well tachycardia" and showed that "patient to have pulmonary emboli with moderate clot load". The admission history and physical examination report dictated on 12/29/2011 at approximately 11:16 PM stated, in pertinent part:
" ...The day prior to admission s/he developed left lower extremity swelling and redness and subsequently presented to [Critical Access Hospital]. They diagnosed him/her with DVT that goes from his/her foot up into his/her groin, gave him/her a dose of Lovenox and a dose of warfarin, and subsequently sent him/her home. His/her family felt uncomfortable with him/her going home and s/he subsequently presented to [Acute Care Hospital] for evaluation and treatment. Here at [Acute Care Hospital], it was found that s/he has bilateral pulmonary emboli ..."

Staff/Physician Interview:
An interview with the Medical Director of the Emergency Department was conducted via telephone on 2/14/2012 at approximately 3:45 PM. S/he stated that s/he spoke with the physician that cared for sample patient #1. The Medical Director stated that according to the physician's documentation PE was not considered based on H&P (history and physical). DVT (deep vein thrombosis) was entertained and diagnosed and treated for. The medical director had concerns regarding nursing notes which stated that the patient had tachycardia, was cool, clammy, pale, and diaphoretic. S/he stated that it was "hard to say what [the physician] was thinking, while s/he provided the full H&P and the necessary ancillary testing." When asked why a chest x-ray was performed rather than a CT scan or V/Q scan to rule-out a pulmonary embolism, /she stated "I did not ask him/her why the chest x-ray was completed. The chest x-ray was not for PE, was for underlying lung problems." S/he stated that the case was going to be reviewed by the hospital's medical staff to determine if the appropriate level of therapeutic care was met.

Based on staff interview, review of the facility's policies/procedures, review of the Medical Staff Bylaws, medical record review and observations the facility failed to ensure that its policies/procedures allowed for the provision of an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section without a delay in order to inquire about the individual's method of payment or insurance status of patients presenting to the Dedicated Emergency Department (DED) seeking a Medical Screening Examination (MSE) for their Emergency Medical Condition (EMC). Additionally, the facility had policies/procedures that were in effect that may have unduly discouraged individuals from remaining for further evaluation. Specifically, the facility inquired about patients' insurance status, asked for copayment, and had uninsured patients sign a form indicating that they would be charged for the visit if the visit was later determined to not be an emergency all before a MSE. This failure had the potential to deter patients with EMCs to stay at the DED for a MSE and stabilizing treatment.

The findings were:

Facility Policies/Procedures, Medical Staff Bylaws, Rules/Regulations:

On 2/14/2012 at approximately 10:25 AM the Registration Supervisor was interviewed in the presence of the facility's Risk Manager. S/he stated that the ED registrars followed a written procedure (which was produced and is presented below) when registering patients in the ED.
"Emergency Room Registration
? Patient presents to Emergency room
? Patient will be triaged by qualified Emergency Room Staff, prior to being seen by ER registrar.
? ER registrar will promptly notify ER staff if patient's condition appears to be severe or life threatening.
? Patient or representative of patient will present to ER registration after triage to give the following information:
o Date of birth
o Name
o Address
o Phone Number
o Social Security Number
o Chief complaint
o Emergency contact information
o Insurance information
o Signature on all applicable documents ..."

The facility's Medical Staff Bylaws, Rules and Regulations, were last reviewed and approved 1/27/2009. The Rules and Regulations included a Medical Staff policy titled "Emergency Services" which was last approved by the Governing Body and Medical Staff on 1/26/2010. The policy stated, in pertinent parts:
"1. All patients presenting to the Emergency Department will be evaluated. Only licensed physicians can perform medical screening exams to rule out emergent medical conditions. In addition, OB nurses who have completed OB unit competency requirements are authorized by the medical staff to perform assessment of active labor ...
3. a) All patients presenting to the Emergency Department will have a nursing triage. After the emergency room nurse has performed a nursing assessment, the appropriate physician will be contacted ...
11. Medical Staffing of the Emergency Department will be as follows:
a) There will be a physician on duty in the Emergency Department twenty-four (24) hours per day, seven (7) days per week ...
c) The Emergency Department physician shall remain in house and be available to the Emergency Department at all times ...
k) If the Emergency Department is excessively busy, the Emergency Department physician may, on occasion, ask for backup assistance by a qualified physician ..."

A facility policy titled, "Function of the Emergency Department", stated in pertinent parts:
"Policy
The primary function of the Emergency Department is preliminary or complete examination and/or treatment of ill or injured persons coming to the hospital, especially those of an emergent nature.
All patients who present to the Emergency Department, when a request is made on the individual's behalf for examination and/or treatment, will receive a medical screening exam to determine whether or not an emergency condition exists, and a disposition will be made by a physician.
If it is determined that the individual has an emergency condition, Southwest Memorial Hospital will either provide such further medical care as may be required to stabilize or treat the medical condition, or provide for the treatment of labor or transfer to an appropriate medical facility ..."

A facility policy titled, "Emergency Department Routine Protocol", stated in pertinent parts:
" ...Procedure:
1. Patients will be triaged upon arrival to the ED. This will include vital signs, chief complaint and classification of patient (per Triage policy) ...
2. After medical triage, the Admissions Clerk will obtain all pertinent information for ED admission ...
6. A Triage Sheet shall be completed and the ED physician notified.
7. Vital signs will be repeated hourly (more often if the patient's condition warrants) and recorded ..."

A facility policy titled, "Emergency Department Outpatient Policies and Procedures", stated in pertinent parts:
" ...Procedure ...
Staffing
A. Patients who present to the ED will be seen by the ED Physician. The exception will apply if a primary physician has arranged to meet the patient in the ED
Emergency Department Records ...
C. Check vital signs (blood pressure, temperature, pulse, respirations, pulse oximetry and pain scale) and record on ED form. Also make any nursing notes that are significant (i.e., patient's appearance, color, state of consciousness, etc.). Follow Triage Policy ...

A facility policy titled, "Triage of Emergency Patients", stated in pertinent parts:
" ...Procedure:
When the patient arrives at the registration desk, the clerk shall inform the Registered Nurse on duty that a patient has presented for emergency care. All persons presenting to the Emergency Department will be triaged within 20 minutes of arrival to the area, and before the registration clerk elicits financial information. Ideally, this triage interview should be performed by a Registered Nurse; but at times, due to patient volume and/or acuity, thin interview may be performed by an EMT, EMT-I, or Paramedic trained in emergency care. The EMT or Paramedic will immediately report to the RN on duty, as verified as part of the EMT competency.
If the patient is not emergent and is able to wait in the waiting area, the patient will be assessed every 15 minutes while in the waiting area ...
...Patients waiting in the ED should be reassessed on a timely basis to identify the deterioration of an urgent or non-urgent patient ..."

Physician/Staff interviews/Observations:
On 2/8/2012 at approximately 1:26 PM a tour of the Emergency Department (ED) was conducted with the Director of Emergency Services as part of the validation recertification survey being conducted. S/he stated during the tour that the RN performed triage if available, otherwise patient triage was being performed by EMTs. When asked to clarify, s/he stated that all levels of EMTs within the ED (Basics, Intermediates, and Paramedics) "all are qualified" to perform triage. S/he stated that if the EMT has questions the EMT would consult the RN or physician. S/he stated that the MSE (medical screening examination) is only "done by a physician." S/he stated that when patients present to the ED, they will knock on the triage door as instructed by a sign outside the triage door. The nurse or staff present would open the door and triage a patient if they were not currently triaging a patient. If the nurse or staff present were currently triaging a patient, the patient would present to the registration desk and the registrar would page into the ED that a patient was awaiting triage. S/he stated that after triage was performed, patients were redirected to the registrar where the patient was "asked demographics and insurance information." S/he confirmed that often the registration was completed prior to the MSE. S/he stated that the ED was staffed 24/7 with a physician, 1-2 nurses (2 nurses from 10AM-10PM, and one nurse from 10 PM-10AM.), and a hospital based ambulance crew (2 EMTs on 24 hours shifts - with alternating downtime, essentially having one EMT available when the crew is not on a call).

A subsequent interview with the Director of Emergency Services was conducted on 2/14/2012 at approximately 9:42 AM. S/he stated that the ED utilized a 3 tier triage acuity scale that included 1. Emergent, 2. Urgent, and 3. Non-Urgent. When asked if there was any follow-up with patients that left without being seen by an ED physician, s/he stated that sometimes the facility would contact the patient at the phone number provided, but that it was not done on a regular basis. S/he stated that if a patient was contacted after leaving without being seen , then it would be documented in the patient's record. S/he then stated that, "Our patients are a bit spoiled. If they can't be seen within 20-30 minutes, then they leave."

On 2/14/2012 at approximately 10:25 AM the Registration Supervisor was interviewed in the presence of the facility's Risk Manager. S/he stated that the ED registrars follow a written procedure when registering patients in the ED. S/he stated that during the registration process, patients that are part of the Colorado Indigent Care Program (CICP, program for uninsured individuals that do not qualify for Medicaid) are asked to sign a letter that stated that the patient could be responsible for the full cost of the visit if the visit is later determined to not be an emergency. S/he stated that the letter had been generation from the PFS (patient financial services) department and had been around for 2-3 years. S/he confirmed that the patient's insurance information is asked for prior to the ED physician seeing the patient. S/he also stated that a co-payment may be requested at the time of registration but that it was "not pushed hard."

An interview with a member of the PFS department was conducted on 2/14/2012 at approximately 10:35 PM in the presence of the facility's Risk Manager. S/he stated that the CICP letter had been presented to patients for 3-4 years, and that the letter was only given to ED patients. S/he also stated that the letter had not changed in the 3-4 years it had been given out to patients.

An interview with a staff nurse in the Emergency Department was conducted on 2/14/2012 at approximately 3:00 PM. S/he confirmed what had been said of how patients were triaged and presented to the ED staff. S/he stated that "nurses typically do triage, EMTs assist" and further stated that EMTs usually get there first and will take the patient's vital signs. S/he stated that the nurse was ultimately responsible for the patient's triage though. S/he stated that if the patient was stable enough to go to registration, the patient would be sent there, otherwise they would go back to a room immediately.

A telephone interview was conducted on 2/14/2012 at approximately 3:45 PM with the Medical Director of the ED. The interview revealed the following:
"My plan is to do bedside registration; the physician would have the opportunity to see the patient prior to registration information." S/he stated that s/he shared our "Same concerns that patients are discouraged from being seen by registration information collection. At my last facility, we would provide MSE, if non-emergent, then would notify them of charges, after the physician had determined the EMC did not exist. It is my plan to streamline that process."

A subsequent interview, in person, was conducted with the Medical Director of the ED on 2/15/2012 at approximately 7:45 AM. Medical records were reviewed with the Medical Director of the ED during the interview. The Risk Manager and Director of Medical Staff Services were present as well. S/he stated that immediately the hospital was going to stop having patients sign the CICP form and especially prior to the MSE.
He was asked about the care of sample patient #6, who had a documented pulse of 138 upon triage, but was given an acuity rating of "3" which indicated the lowest acuity of "non-urgent" and did not have any other documentation of further monitoring. The patient "left without being seen" by the physician, but the physician documented giving the patient instructions to increase his oral fluid intake. The Medical Director of the ED stated that utilizing a 5 level triage scale was more appropriate to avoid triaging patients into the lowest level with unstable vital signs.
S/he was then asked about the care of sample patient #7, who presented with neck pain, and was documented as having "left without being seen" as well as "against medical advice" (AMA) but did not have AMA paperwork completed. The Medical Director of the ED stated s/he was "not sure what to make of it, appropriate call-back will be implemented."
S/he was then asked about the care of sample patient #9, who was a two year old patient that presented to the ED at 3:55 PM with "pediatric illness" and "left thumb" (the triage documentation did not elaborate on the issue with the patient's thumb or pediatric illness). The patient's record did not include a triage acuity nor a pain rating for the patient. The chart did not indicate the patient was placed in a room, or rechecked at any point. The record stated in full that at 6:20 PM "pt LWBS [left without being seen]." The Medical Director of the ED stated that the record "spoke for itself" and that s/he was "not pleased with nursing" care for the case of this patient. Especially the lack of documentation for 2 ? hours and the lack of an acuity assignment from triage. S/he stated that the care was not consistent with the expected "culture" and that it was not "okay to let people leave." When asked if s/he felt that the nursing staff was overwhelmed, s/he stated that in his/her discussions with the staff it was not an issue.
S/he was then asked about sample patient #10 who presented to the ED with a "shoulder problem" and pain of 9/10. The patient was not assigned a triage acuity, nor did the triage documentation completely describe the patient's complaint and mechanism of injury. The patient's blood pressure upon triage was 183/101. The patient was placed in a room upon arrival, but no further care was documented. There was no physician documentation in the record. The patient "LWBS" at approximately 2 ? hours later. The Medical Director of the ED stated that the physician should have checked in on the patient and started a work-up. S/he stated that s/he was working on having some symptom driven standing orders, so that patients receive appropriate diagnostic studies rather than sitting in the department receiving no care.
The care of sample patient #11 was next discussed. The patient was a five year old that presented to the ED at 5:21 PM with hip pain after a fall from 5 feet. It was determined by staff present in the interview that the patient was triaged by an EMT upon arrival. The triage documentation did not include any vital signs and did not include a triage acuity determination. There was no indication that the patient was placed in a room nor was the patient monitored or given any care. The patient "LWBS" at approximately 6:45 PM. There was no physician documentation. The Medical Director of the ED stated that s/he was "perturbed by the lack of vital signs" and was not pleased by the lack of documentation and care.
The Medical Director of the ED stated that his/her expectation was that there would be increased reviews and call backs of patients that left without being seen.

Medical Record Review:
In addition to the records reviewed with the Medical Director of the ED as discussed above, additional medical records were reviewed. A sample of 20 medical records were reviewed of patients that had presented to the hospital's ED seeking a medical screening exam. Four (sample records #1, 2, 5, and 15) of the 20 records contained the CICP form as described above. Sample patient #5 signed the CICP form and left without being seen after waiting in the ED for 1 hour. Sample patient #15 signed the CICP form and left against medical advice.