HospitalInspections.org

Based upon medical record review, interview and document review, the facility did not comply with all of the provisions for conducting a medical screening exam.

Please reference findings under Tag # A2406.

Based upon medical record review, interview and document review, the hospital does not ensure all patients presenting to the emergency department (ED) receive a medical screening examination (MSE) in a timely manner, along with ongoing monitoring and beginning with triage, to determine if an emergency medical condition (EMC) exists in 7 of 24 records reviewed. A lack of a medical screening exam could result in an emergency medical condition not being identified and treated in a timely manner.

Findings Include:

Review on 10/08/15 of policies ED-30 "Assessment of the Emergency Department Patient" last revised 2/14 and ED-34, " ER Staff Responsibilities " last revised 4/15 revealed all patients presenting to the ED will be triaged and categorized as: Level 1- critical, Level 2- Emergent, Level 3- Semi emergent, Level 4- urgent and Level 5 non urgent. Timeframe's for triage to MD/PA for non-urgent patients is 60 minutes, urgent patients is 45 minutes, semi-urgent patients is 40 minutes, emergent patients is 30 minutes and critical patients is 15 minutes.

Review on 10/8/15 of policy A-28 " EMTALA/COBRA " last revised 12/10 revealed a medical screening examination for all patients who present to the ED is to be performed by a physician upon the patient ' s arrival to determine whether an emergency medical condition exists.

Review on 10/8/15 of policy ED-34, "ER Staff Responsibilities" last revised 4/15 revealed the triage nurse performs a "quick triage" for all patients and assesses the waiting room in between patients to identify any patients in distress, explain delays and answer questions.
Patient partners greet and perform a quick registration process on patients. They will check on patients who return to the waiting room after triage due to a lack of ED beds. They will document their observations at least every 30 minutes, obtain vital signs, oxygen saturation, pain scale rating and report significant findings to the RN.

Medical record review on 10/8/15 for Patient A revealed on 7/27/15 at 10:22pm the patient presented to the ED and reported to the Patient Partner that they were experiencing general weakness and loss of appetite. The patient was sent to the waiting room and on 7/28/15 at 1:45am the RN documents the patient was called from the waiting room (for triage) but was found to be unresponsive with no pulse. Resuscitative efforts were initiated at 1:45am and at 2:36am the patient was pronounced. No evidence was found to indicate the patient had been triaged or monitored during the three and a half hours that had elapsed between presentation to the ED and being found unresponsive in the waiting room.

Interview on 10/7/15 at 2:10pm with Staff # 28 revealed the ED is divided into 3 zones: zone 1 is assigned to the charge nurse and includes the code room, zone 2 includes the fast track and zone 3 includes triage. The Patient Partners check on patients in the waiting room. Most of them are Emergency Medical Technicians. They do not obtain vital signs.

Interview on 10/7/15 at 1:00pm with Staff # 30 revealed she does patient intake and keeps an eye on the patients in the waiting room. After triage, if a patient comes back out to the waiting room, we are supposed to check on them every 30 minutes." Eyeball" them but we don't do vital signs. The triage nurse starts at 9:30am and is usually the Zone 3 nurse. She is located in the back, not in the triage room.

Interview on 10/6/15 at 3:45pm with Staff # 12 revealed Patient Partners perform pre-triage screening of patients who present to the ED waiting room. She is responsible to obtain intake information on a patient but does not obtain vital signs. She "eyeballs" patients in the waiting room. There is not always a triage nurse, usually "whoever is up next to take a patient will triage them".

Medical record review on 10/8/15 revealed no evidence to indicate the following patients were triaged in a timely manner or monitored following their arrival in the ED.
- Patient R presented to the ED on 9/30/15 at 12:53pm with a complaint of facial swelling. At 3:17pm the RN documents "not in waiting room".
-Patient S presented to the ED on 9/4/15 at 10:13am with a complaint of diarrhea, vomiting and syncope. At 1:30pm the patient leaves without being triaged.
-Patient W presented to the ED on 9/5/15 at 4:05 PM via ambulance with a complaint of syncope. At 7:24pm the RN documents Patient R "left without being seen".
- Patient X presented to the ED at 10:09am with a complaint of abdominal pain and nausea. At 11:46am the patient was triaged as an ESI(Emergency Severity Index) Level 3.

Medical record review on 10/08/15 revealed no evidence the following patients received a MSE in a timely manner:
-Patient C presented to the ED on 8/14/15 at 11:02am with a complaint of taking an overdose of pills and was triaged as ESI Level 2. An MSE was not conducted until 1:04pm.
-Patient U presented to the ED via ambulance and was triaged as an ESI Level 3 at 7:46pm with complaints of status post seizure and head injury. At 10:45pm the RN documents the patient "left without being seen" by a physician.

Interview on 10/08/15 at 1:50pm with Staff #2 verified the above noted findings.

Review on 10/08/15 of Emergency Room/Stroke Quality Assurance committee meeting minutes revealed the following data:
July 2015:
- 212 patients who presented to the ED left before triage.
- 122 patients were triaged but left before being seen by the physician.
August 2015:
- 124 patients who presented to the ED left before triage.
- 126 patients were triaged but left before being seen by the physician.
September 2015:
- 151 patients who presented to the ED left before triage.
- 124 patients were triaged but left before being seen by the physician.

No evidence was found to indicate the facility has implemented actions to address the number of patients who leave before triage or before being seen by a physician.