HospitalInspections.org

Based on findings from document review and interview, the hospital failed to comply with requirements at 489.24 and related requirements at 489.20. Please reference findings at Tag A2406.

Based on findings from observation and interview, the hospital failed to post EMTALA (Emergency Medical Treatment and Labor Act) signage in all areas likely to be noticed by all patients arriving to the emergency department (ED). Specifically, EMTALA signs were not posted in the ambulance entrance area of the ED. This lack of notification could affect patient's rights.

Findings include:

-- During a tour of the ED on 2/8/17 at 10:15 am, there was no EMTALA signage posted in the entrance to the ED where patients arrive via ambulance. Staff A (ED Director) acknowledged this finding at the time of observation.

Based on findings from interview and document review, the hospital did not ensure all individuals presenting to the Emergency Department (ED) or other areas (Maternal Child Health [MCH] unit) that provide ED care, are entered into a central log. Also, the hospital's policy and procedure (P&P) for care of pregnant patients that present to the ED does not address central log documentation.

Findings include:

-- Per interview of Staff A (ED Director) on 2/8/17 at 10:50 am, patients presenting to the ED who are 20 weeks gestation or greater and their complaint is related to pregnancy (and not in acute distress) are directed to the MCH unit for a medical screening exam (MSE) by a Qualified Medical Provider (QMP). These patients are not entered into the ED Central Log.

-- During interview of Staff B (Director of MCH unit) on 2/8/17 at 8:30 am, patients presenting to the MCH unit from the ED (who are greater than 20 weeks gestation) are transported to the MCH unit. However, the MCH unit does not maintain a central log of patients presenting from the ED.

-- Per review of hospital's P&P titled "ED and MCH Joint Management Protocol Ver 3," published 11/12/13, it was identified it lacked instruction to staff to document and maintain a central log.

Based on findings from document review, medical record (MR) review, video file review, interview and observation, (a) in 1 of 21 MRs reviewed, the hospital did not ensure a patient (Patient #1) presenting to the emergency department (ED) was triaged, monitored or provided a medical screening examination (MSE) in a timely manner. (b) In 4 of 4 MRs (Patients #2, #3, #4 and #5) reviewed of patients who left without being seen (LWBS), no reassessments/monitoring of the patients in the waiting room were documented. This lack of triage, a MSE and reassessment could result in an emergency medical condition or change in patient's condition not being identified and treated.

Findings regarding (a) include:

-- Review of the hospital's policy and procedure (P&P) titled "Triage Policy Ver 5," dated 11/19/15, indicated the ED Registered Nurse (RN) should triage each presenting patient to prioritize and optimize ED flow by assessing, identifying and expediting those patients that require immediate care. Patients that come in by ambulance can either be placed in an open ED bed or placed in a wheelchair and sent to the triage area for an initial triage assessment as indicated. If no open beds are available, patients with ESI (Emergency Severity Index) level 3 (urgent), 4 (semi-urgent) and 5 (non-urgent) can be placed in the waiting area after the initial triage assessment is completed until a treatment space becomes available. The triage nurse should round in the waiting area hourly to complete vital signs on all waiting patients and assess for any change in the patients' condition.

-- Per MR review, Patient #1, a 52-year-old male, presented to the ED on 1/19/17 at 6:09 pm via Emergency Medical Services (EMS). Upon arrival to the ED, Patient #1 was transferred from the stretcher to a wheelchair and placed in the waiting room by EMS. Report and transfer of care was given to the RN in triage. A nurse documented a triage assessment and vital signs (temperature - 98.7 Fahrenheit (F), pulse - 64, respirations -18, blood pressure -122/82) at 6:15 pm. Patient #1 was triaged as a level 4 on the ESI.

Nursing next documented on 1/19/17 at 8:43 pm (2 1/2 hours later) " ... patient came to ED willingly, was in wheelchair in waiting room, speaking with receptionist when he slumped over in wheelchair. Pt (patient) immediately brought to room 14, placed on stretcher and cardiac monitor. Pt had no pulse, entire body mottled, no respirations. CPR (cardiopulmonary resuscitation) was started, ABC (emergency code) alert called, MD (physician) in room immediately. No pulse recovered, no spontaneous respirations, time of death 20:37 (8:37 pm)."

-- On 2/8/17 at 9:40 am, two Department of Health surveyors viewed the hospital's surveillance video files dated 1/19/17 from 6:06 pm - 8:26 pm (approximately 2 hours and 20 minutes). The video files showed Patient #1 entering the hospital through the ED ambulance entrance via stretcher with EMS personnel. (There was a brief time frame, approximately 2 ½ minutes, the patient is not on video as there was no camera in that area.) Per interview of hospital staff Patient #1 was transferred from the EMS stretcher to the wheelchair with assistance from hospital staff. Patient #1 is then seen being wheeled out to the reception window (past the triage area) where the receptionist obtains paperwork and applies a bracelet. Patient #1 is then wheeled into the waiting area by EMS and placed facing the reception window. EMS personnel relayed report to the nurse assigned to triage. The remainder of the video files revealed Patient #1 sitting in the waiting area facing the reception desk. He is seen handling a plastic bag, attempting to stand or adjusting himself in the wheelchair and turning his head. Patient #1's last movement was noted at 6:58 pm.

-- Per interview of Staff C (ED Receptionist) on 2/10/17 at 2:20 pm, Patient #1 arrived to the ED via ambulance on a stretcher. He/she helped Patient #1 from the stretcher to a wheelchair. EMS wheeled Patient #1 to the waiting area facing the reception window. Staff C was with the patient during the 2 1/2 minute time frame where there is no video feed. At approximately 8:15 pm or 8:20 pm, Staff C went to bring another patient from the waiting area into the ED and noticed Patient #1 looked deceased. He/she informed the triage nurse. Staff C stated he/she did not see anyone obtain vital signs or assess Patient #1 when he arrived to the ED or in the waiting area.

-- Per interview of Staff D (ED Charge Nurse) on 2/10/17 at 1:15 pm, he/she revealed taking the ambulance call from EMS that they were bringing in Patient #1. He/she mistakenly thought Patient #1 was another patient who frequently is seen in the ED and is disruptive and went to look for a room to put the patient in. When he/she returned to the desk the paramedic informed him/her Patient #1 was out front (the triage area). Staff D never laid eyes on Patient #1.

There was no evidence on the video files Patient #1 was triaged, had his vital signs taken or was assessed upon arrival to the ED or in the waiting area. Additionally, there was no evidence Patient #1 was reassessed while in the waiting area.

-- Per interview of Staff E (ED RN assigned to triage) on 2/14/17 at 2:00 pm, he/she was in the ED when Patient #1 arrived and EMS put him in the waiting area. He/she went to the triage area and EMS gave him/her a quick report. Staff E looked out the reception/triage window at Patient #1 and he didn't look to be in any distress and appeared stable. He/she approached Patient #1, explained he/she needed to obtain vital signs and asked him a few questions. Patient #1 refused having his vital signs checked at that time. Staff E went back to the triage area and tried to document in Patient #1's MR but could not (vital signs must be entered for staff to continue to document). Staff E made a second attempt to check Patient #1's vital signs. They were obtained at approximately 7:00 pm to 7:15 pm. In addition, Patient #1 denied chest pain, dizziness and didn't know why he was at the hospital. Staff E obtained and documented the vital signs in the computer located in the triage area next to reception but "back timed" the vital signs in the computer to 6:00 pm - 6:20 pm, nearer to the time Patient #1 presented to the ED. Staff E obtained Patient #1's vital signs with a stethoscope and manual blood pressure cuff stored in the reception area, used a portable temporal thermometer he/she had in his/her pocket and obtained a portable oxygen saturation machine from the clean utility room in the main ED. Staff E stated Patient #1 was wearing a jacket and he/she pulled up his sleeve to get his vital signs. At approximately 8:00 pm another patient presented to the ED with shortness of breath and Staff E brought him into the ED. When he/she returned to the triage area the receptionist told him/her Patient #1 looked dead. Staff E went to Patient #1 noted a color change and checked for a pulse. Patient #1 was immediately taken into the ED for resuscitation.

Although Staff E indicated he/she assessed Patient #1, this could not be corroborated by video files or other staff interviews.

Findings regarding (b) include:

-- Review of the hospital's policy and procedure (P&P) titled "Triage Policy Ver 5," dated 11/19/15, indicated patients with ESI level 3, 4, and 5 can be placed in the waiting area after the initial triage assessment is completed until a treatment space becomes available. The triage nurse should round in the waiting area hourly to complete vital signs on all waiting patients and assess for any change in the patients' condition.

-- Per review of Patient #2's MR, she presented to the ED on 12/7/16 at 12:02 pm with a chief complaint of knee pain. Nursing triaged the patient at 12:56 pm with an ESI level of 4. The next documentation by nursing was at 9:00 pm (8 hours later) indicating Patient #2 LWBS.

-- Per review of Patient #3's MR, she presented to the ED (sent from Urgent Care) on 10/8/16 at 1:23 pm with a chief complaint of back pain. Nursing triaged the patient at 1:26 pm with an ESI level of 3. An electrocardiogram (EKG) was performed at 1:34 pm, the patient was then placed in the waiting room. The next documentation by nursing is at 4:36 pm (3 hours later) indicating Patient #3 LWBS.

-- The same lack of reassessment documentation was noted for Patient #4 (ESI level of 3 and 4 hours later LWBS) and Patient #5 (ESI level of 4 and 2 1/2 hours later LWBS).

-- Per interview of Staff A (ED Director) on 2/7/17 at 11:50 am, he/she revealed the triage nurse is to monitor the waiting area.

-- Per interview of Staff F (ED RN) on 2/8/17 at 8:30 am, he/she revealed the triage nurse reassesses patients in the waiting area every hour or more frequently if needed.

-- Per interview of Staff E on 2/14/17 at 2:00 pm, he/she reassesses patient's in the ED waiting area by looking at them. He/she assumes the triage RN is to monitor the waiting area in collaboration with the Charge Nurse.

-- During interview of Staff A on 2/8/17 at 2:00 pm, he/she acknowledged the above findings.