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Based on review of the facility's policies/procedures, documents, medical records, and interviews, it was determined that the facility failed to have a patient seen by a physician for four hours who presented to the emergency department (ED) with an ESI score of two (2). This deficient practice poses a potential risk to the health and safety of patients when there is insufficient staff coverage to provide essential emergency services to patients arriving to the ED.

Findings include:

Policy titled "Performance Improvement Plan" revealed "...6.0 Scope of Care/Service...6.2 The Emergency Room is an 8-bed unit. All levels of emergency care are rendered. Trauma patients and other critically ill patients are stabilized and transferred to tertiary care facilities, either by helicopter or ground ambulance...."

Document titled "Benson Hospital Medical Staff Bylaws" revealed "...Professional Conduct Review Committee. While all committees are deemed Peer Review in nature...a smaller Professional Conduct Review Committee may be formed on an ad hoc basis when specific, in depth provider review is necessary. The Chief of Staff in consultation with hospital leadership will assess the necessity of such a committee relative to the facts and circumstances surrounding the review, particularly given the nature of these Bylaws, which allow many Staff categories voting status...."

Document titled "ED Daily Log, 02/07/2020" revealed one doctor working a 12 hour shift from 0700 to 1900. Patient #3's visit began at 1736 and ended at 2135. With shift change occurring at 1900, the patient had opportunity to be seen by two providers, and at least two nurses. During the 3 hours and 59 minutes that Patient #3 was in the ED, 13 patients arrived before or left later than Patient #3. Two of those patients had an ESI score of 2, like Patient #3. One of those patients arrived at 14:58 with a breathing difficulty and was transferred out at 20:09; another patient arrived at 17:32 with chest pain and was transferred out at 22:25. The other 11 patients had a score of 3 (urgent) or 4 (semi-urgent).

Patient #3's medical record dated 02/07/2020 identified the patient arrived at 17:36, was triaged at 18:29 by an RN and given an ESI score of 2 (Emergent). The patient's vital signs were taken at 18:30 and the nursing assessment was documented at 18:36. Patient #3 signed the "Conditions of Treatment" and "Patient Rights" at 18:46. At 19:13 Employee #50 gave report of Patient #3 to the night shift. Employee #51 documented at 21:35 that patient was discharging self as s/he had waited 4 hours without being seen. There were no provider notes or assessment in the patient's medical record.

Employee #1 confirmed during an interview conducted on 11/18/2020 that the facility has no policy or document that addresses the issue of how quickly a patient, regardless of their ESI score, should be seen by a provider in the ED. Additionally it was confirmed that there are no policies or documents addressing how a provider is to obtain help in the event there is not sufficient staff to provide services to patients. Employee #1 confirmed that there had been no peer review of either of the ED providers on shift on 02/07/2020 from 1736 to 2135.

Employee #4 confirmed during an interview conducted on 11/17/2020 that it was unusual for a patient to wait for 1 hour to be triaged. It was further confirmed that an ESI score of 2 is considered emergent, it is the second highest score. It is unusual for a patient not to be seen by a provider for 4 hours. Employee #4 did their own audit because the patient left without being seen, and concluded the ED was very busy that night. It was also confirmed there is always only one provider on at a time in the ED. There is a Hospitalist in the hospital daily who could be back-up for the emergency department, however the time of day that the Hospitalist is there would depend on their patient load. There is a nurse practitioner (NP) that sees wound patients and if the NP is in-house they could be used as back-up. Employee #4 is not aware of any back-up help being requested that day. No nurses are trained to conduct a specific medical screening examination.

Provider #8 confirmed in an interview conducted on 11/18/2020 that it is their expectation if a provider has emergent or urgent patients that they cannot evaluate, the provider should reach out to the hospital administration to get more help. It was further confirmed there is no policy instructing a provider how to obtain additional help. An NP or another physician could be called in to help; that is the instruction that is given to the providers. Patient's can contact the facility or providers so a second physician can be sent to help. Provider #8 confirmed that an occurrence of a patient with an ESI of 2, leaving after waiting 4 hours without being seen by a provider, should go to peer review.

Based on review of the facility's policies/procedures, documents, medical records, and interviews, it was determined that the facility failed to provide policies/procedures that include guidelines for the medical management of the varying ESI scores of patients presenting to the ED; or for the periodic review and evaluation of the services furnished. These deficient practices pose a potential risk to the health, and safety of patients, when they present to the ED.

Findings include:

Policy titled "Performance Improvement Plan" revealed "...6.0 Scope of Care/Service...6.2 The Emergency Room is an 8-bed unit. All levels of emergency care are rendered. Trauma patients and other critically ill patients are stabilized and transferred to tertiary care facilities, either by helicopter or ground ambulance...."

Patient #3's medical record reveals the patient was seen by a nurse approximately 1 hour after arrival and was triaged as an ESI of 2. Vital signs were taken. There is no other clinical documentation on the patient until the night shift nurse documents Patient #3 leaving without being seen.

Employee #1 confirmed in an interview on 11/18/2020 that their scope of care or scope of service is contained in their policy titled "Performance Improvement Plan". It was further confirmed there is no other policy that addresses the scope of care/service of the facility; only what is written in the Performance Improvement Plan. Each department in the hospital has a brief description under the Scope of Care/Service section of the Performance Improvement Plan policy. There is no other written Standard of Care or Scope of Service for the facility.

Employee #4 confirmed in an interview on 11/17/2020, that Patient #3's medical record identifies that the patient had one nursing assessment at the time of triage and vital signs were taken. There is no other nursing note revealing care for this patient by the nursing staff. There is no documentation by a provider for assessment of this patient. Employee #4 further confirmed that an ESI of 2 is emergent. There is nothing written that suggests how frequently vitals should be taken on a patient with an ESI of 2. There is nothing written that addresses how frequently a patient with an ESI of 2 who is waiting for an MSE should be seen, assessed, or monitored by a nurse. There is no Standard of Care policy or document other than that contained in the Performance Improvement Plan.