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Based on observation, staff interview, record review, the hospital failed to comply with 42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency Services, by not fulfilling the requirements for an appropriate screening for two (Patient 1, 19) of 49 sampled patients reviewed. This failure has the potential to adversely affect patient safety and quality healthcare for these patients and for other patients who require a medical screening exam.

Findings:

During the EMTALA survey conducted from 9/15/14 to 9/16/14, the survey team determined Patients 1 and 19 were not appropriately screened for an emergency medical condition. (Refer to A-2406)

Based on observation, interview, record and document review, the hospital failed to follow their policies and procedures to timely initiate an appropriate triage assessment and medical screening examination by a qualified medical professional to determine whether a medical emergency existed for two (Patients 1, 19) of 49 sample patients arriving to the emergency department (ED) by ambulance. The hospital's delay in providing an initial triage and assessment necessitated emergency medical services (EMS) ambulance personnel to remain with the patient for time periods up to and greater than one hour as follows:

1. Patient 1 remained in the care of EMS personnel for a period greater than one hour after arrival to the ED.

2. Patient 19 remained in the care of EMS personnel for a period greater than thirty minutes after arrival to the ED.

This failure had the potential to adversely affect patient safety and quality healthcare for Patients 1, 19, and other patients arriving to the ED by ambulance.

Findings:

1. On 9/15/14, Review of the hospital policy "Triage Policies and assessment of Acuity Levels", last revised date 2/13 showed "All patients who present to the ED will be assessed by the ED Triage Nurse to prioritize their need for medical care unless they are roomed immediately or at [Hospital] campus present only for a Legal Blood draw." Triage Nurses will determine the patient's triage acuity level as described below in "Guidelines for Setting Priorities for Care." "Triage consists of a brief assessment that determines the level of acuity. This will included a history of the present illness/injury, and exam of involved systems, past medical history, current medications and allergies, and a complete set of vital signs per protocol.

During an unannounced visit to the hospital on 9/15/14, observation at 10:19 a.m. showed five ambulance rigs parked outside the ambulance entrance to the ED. At 10:30 a.m., observation showed a patient (Patient 19) on a gurney in the ambulance entrance hallway inside the ED and three EMS staff of the local fire department. EMS 1 stated her team had been at the ED for 50 minutes, had come code 2 (no siren, no lights), the patient had been pretty sick and was able to get a bed, and now the EMS team was ready to go.

EMS 1 stated EMS staff gives a brief report to the charge nurse when they arrive, but there is no ED staff assessment. EMS 1 stated they keep patients on cardiac monitors if applied when answering the emergency call, non-re-breather masks when necessary, even going to the ED storage room to obtain larger oxygen tanks when wait times might be long. EMS 1 stated one of the EMS personnel was required to remain with the patient at all times until the ED was ready to room the patient. EMS 1 stated "it's not the way to work, but that's what we have to do."

EMS 2 stated the problem of EMS personnel having to park and monitor their patients waiting for a bed to open happened even before an adjacent county hospital's ED closed to ambulance traffic on 8/7/14 and the waits could occur any hour of the day. EMS 1 stated since the closure of that ED (on 8/7/14), it was hoped that nearby EDs could increase their staffing to handle the additional patients from the adjacent county.

On 9/15/14 at 11:08 a.m., ED nurse managers (NM 1 and NM 2) confirmed there were occasionally wait times for ambulance patients not coming in Code 3 (life-threatening emergencies). NM 1 indicated the "wall" (the inside hallway of the ambulance entrance) allowed enough space for two EMS gurneys inside the ED and any other patients would have to remain in the EMS rigs that brought them. NM 1 stated the ED had 22 monitored rooms and three hallway beds. According to NM 1, all beds were not available at all hours of the day and night, but all beds were open and available at 11 a.m. when enough nurses would be available to staff all the beds.

On 9/16/14 at 9:30 a.m., the hospital's vice-president for medical affairs (VPMA) and the ED's medical director (EMD) stated during interview, the hospital was was aware of the adjacent county's pending ED closure, but the actual announcement caught them by surprise. According to VPMA, the hospital's ED had experienced a 15 to 25% increase in ambulance traffic since the closure on 8/7/14 to ambulance traffic by the adjacent county's ED. VPMA also stated the hospital ED had experienced an increase of 25 to 30% of "walk-ins" [not arriving by ambulance, but by other means] from the adjacent county as well. When asked if the hospital increased ED staffing as a result of the increased patients seeking care, VPMA stated an extra AM (morning) and PM (evening) nurse staffing position were formally requested of the regional board, but confirmed the extra positions were yet to be approved.

At 10:10 a.m., VPMA stated the ED staffing matrix was based on a historical patient volume of 130 patients a day and not changed. According to VPMA, "We're on the upper end of our capacity." According to EMD, "We've had some exceptionally busy days." EMD clarified the patient census could reach the 170's.

On 9/16/14 at 12:55 p.m., NM 1 and NM 2 were asked how ED staff triaged patients brought in Code 2 by ambulance. NM 1 stated "EMS [personnel] will go to the charge nurse, the charge nurse will ask what is the chief complaint and will ask more [questions] if EMS has more info. The charge nurse will look at the ED flow; if we don't have a room, our average wait is 45 minutes. If we're near the 60 minutes [wait time], the charge nurse may get an EMT [ED tech] and ask the tech to do vital signs or could get an EKG. It's not a formal process." NM 1 was asked if the charge nurse did a triage assessment to determine the ambulance patient's acuity. NM 1 stated when the charge nurse obtained the information from EMS, the charge nurse "visually looks at the patient" and "we ask EMS for the vital signs." According to NM 1 this was an informal triage and the formal triage would be done by the assigned primary nurse when the patient was roomed. At 1:10 p.m., NM 2 stated she agreed that the patients arriving by ambulance were the hospital's responsibility even if ED staff were not assessing and monitoring them.


Review of the ambulance record on 8/25/14 and 9/15/14 showed Patient 1 was brought by ambulance to the hospital's emergency department (ED) on 8/20/14 at 9:55 a.m. He had been seen earlier that morning in a private medical office in another city for complaints of weakness and shortness of breath. Emergency services were contacted and an ambulance dispatched to take Patient 1 to one of three EDs located within approximately 20 miles. Review of the ambulance EMS "Patient Care Report" showed the "Destination Decision" to go the the hospital's ED was "Patient/Family Request."

According to the Patient Care Report, Patient 1's chief complaint was gradual onset of weakness over the past five days and sudden onset of shortness of breath on exertion. According to the Patient Care Report, Patient 1's medical history included hypertension and a kidney transplant nine years ago following dependence on dialysis for his kidney failure. Vital signs taken by the ambulance personnel at 9:45 a.m. showed Patient 1's heart rate was 120, a fast heart rate for an adult (normal is less than 100), his blood pressure elevated at 140/100 (normal is less than 140/90) respiratory rate was 20 (normal is less than 20) and oxygen saturation initially on room air was 93% (normal is more than 94%) for which he was placed on 4 liters of oxygen. EMS personnel determined Patient 1's condition was not life-threatening so he was transported without lights and siren (Code 2) to the hospital. Review of the ambulance Dispatch Information showed "Time Transport Arrived" as 9:55 a.m. and "Time Care Transferred" as 11:05 a.m.

According to the ED's Triage -ED Arrival Information, Patient 1 arrived in the ED at 11:05 a.m. with an acuity level of 2, a number defined by the ED as potentially high risk if any vital signs were in the "danger zone" e.g., heart rate exceeding 100 or respiratory rate exceeding 20. Review of the ED record showed at 11:18 a.m., Patient 1's initial vital signs were recorded and essentially the same as the EMS measurements except for an increase in respiratory rate to 25 and the ED physician was "at bedside." The ED physician documented "ED Course: I assessed pt when he was roomed, appeared to be mild-to-moderate distress. He was noted to be tachycardic [heart rate over 100] with a flutter in 2-1 block [an abnormal heart rhythm]. nursing staff was unable to gain IV access....Lab tests were unable to be performed by the laboratory. 1330 [1:30 p.m.]: femoral [vein in the groin] line placed; labs sent. 1440 [2:40 p.m.]: pt became bradycardic [heart rate less than 60], lost pulses while I was at bedside. CPR was begun...."

Continued review showed Patient 1 experienced bradycardia with pulselessness at 2:20 p.m. after receiving an antiarrythmic medication for his abnormal heart rhythm. After his initial resuscitation (restoration of heart rate), Patient 1 experienced two more episodes of pulselessness. Hospital staff was unable to resuscitate him after the last episode and he expired on 8/20/14 at 4:23 p.m.

Review of Patient 1's record showed ED staff did not initiate any interventions for Patient 1, and vital signs by staff were not done until 11:18 a.m., after Patient 1 was roomed at 11:06 a.m.

On 9/16/14 at 1:28 p.m., the hospital's director of risk management (RM) stated "We changed the policy because it didn't reflect ambulance patients." RM agreed the triage nurse was not assessing ambulance patients and neither was the charge nurse. According to RM, the ED had no policy or procedure to address ambulance patients who come into the ED not through the waiting room; what the ED had was "our practices."


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2. On 9/15/14 at 10:40 a.m., by observation and interviews, Patient 19 was sitting up on the gurney in the emergency department (ED) hallway, just inside the ambulance entrance doorway. He was alert and responsive to verbal questions. Patient 19 said he was not in pain and came to the hospital because he had blood in his colostomy bag. (Colostomy is a surgical procedure that brings one end of the large intestine out through an opening made in the abdominal wall. Stools moving through the intestine drain through the opening into a bag attached to the abdomen). Emergency Medical Services (EM 3), attending to Patient 19, said that he brought Patient 19 into the hospital from a dialysis center when the dialysis nurse saw dark blood in Patient 19's colostomy bag. EMS 3 said he and Patient 19 arrived about 30 minutes ago and they were waiting for a room.

At 10:50 a.m., an ED nurse beckoned for EMS 3 to wheel Patient 19, on the gurney, into an ED exam room. EMS 3 gave a report to registered nurse (RN 3). EMS 3 said that Patient 19 was thirty minutes into a three-hour dialysis treatment when bloody dark stool was noted in the colostomy bag. (Dialysis is a mechanical means of purifying the blood when kidneys fail.) Patient 19 was taking Coumadin (an anticoagulant which prolongs clotting) daily and it was recently increased. Patient 19 reported blood in the colostomy bag for four days.

At 11:05 a.m., Patient 19's vital signs on the monitor showed a blood pressure of 104/80, a heart rate of 91, a respiratory rate of 11 and oxygenation level of 99% all within normal limits. At 11:07 a.m., Physician 1 came in the room and began to examine Patient 19. By observation there was approximately one cup of dark red liquid in the colostomy bag. Physician 1 performed a bedside test of the fluid and it tested positive for blood. Physician 1 told Patient 19 he would be admitted to the hospital. By record review, Physician 1 wrote in the ED record that upon reexamination, Patient 19's systolic (upper number) blood pressure dropped to the "90's."

RN 3 said his shift was 11 a.m. to 8 p.m. and he happened to come in a little early and was asked to triage Patient 2. (Triage is a brief focused clinical assessment of the patient's presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the patient should be seen by the physician. Triage begins the medical screening process for patients who present with emergency medical conditions.)

On 9/15 14 at 11:15 a.m., during an interview, Nurse Manager 2 (NM 2) said that "...when they [patients] hit the door, clearly they are our [ED staff's] responsibility. NM 2 also said Emergency Medical Service staff (Emergency Medical Technicians or Paramedics employed by the ambulance companies and under contract by EMS) will let the charge nurse know if the status of the patient changes while waiting in the hallway. NM 2 said that recently a nearby hospital closed its' doors to ambulance traffic and on August 7, 2014, the EMS eliminated diversion status for all hospitals in the area. (Diversion status exists when EMS redirects ambulances from one hospital emergency room to another upon an ED's request and usually occurs when bed spaces and staffing resources are overwhelmed.) NM 2 said information from the EMS initially projected an increase in ambulances of four to five per day. NM 2 said that the hospital did not increase ED staffing in anticipation of the projected increase in ambulance traffic.

On 9/16/14 at 1:30 p.m., during mutual review of Patient 19's ED electronic medical record (EMR) and concurrent interview, RN 4 who was the Charge Nurse on 9/15/14, said she entered the arrival time as 10:35 a.m. That was the time she did a "Quick Look" of Patient 19 from "across the way." RN 4 said she knew that Patient 19 had blood in his colostomy bag from the EMS staff report but she didn't have a room for Patient 19 until she could open four more beds when the 11 a.m. nurse, RN 3, was scheduled to arrive.

RN 4 said she didn't perform a triage assessment of Patient 19. RN 4 said the ED practice was that once the patient was placed in a room then the nurse assigned to the room would perform the triage assessment as described above with Patient 19. In the EMR there was no triage assessment and no acuity level entered. RN 4 said that Patient 19's condition warranted an acuity level 2. She said RN 3 probably forgot to chart. There was a medical screening exam entered by Physician 1, dated 9/15/14.

RN 4 also said that the staffing matrix (a document showing core staffing requirements per shift per day) in the ED changed at the end of July (2014.) RN 4 said that 2 nurses used to come in at 10 a.m., whereas now; one started at 10 a.m. Three nurses used to start a shift at 11 a.m. and now four started at 11 a.m. Also there was a nurse who used to work 9 a.m. to 9 p.m. on high patient volume days, like the weekend and Monday or Friday. (9/15/14 was a Monday.) The 9 a.m. position was eliminated on the day shift. RN 4 said the difference she experienced since the staffing matrix changed was that the ED is overwhelmingly busy by 11 a.m. The ambulances line up and the waiting room backs up with patients to be seen. "...I like to be ahead of the game so I really miss that extra 10 a.m. nurse..."

Review of the ED's policy entitled "Triage Policies and Assessment of Acuity Levels," dated 2/13, had an attachment, "ESI Triage Algorithm." (ESI is emergency severity index which is five level triage tool used to quickly rated the acuities of patients. Level 1 indicates the most serious condition and Level 5 is the least serious. Algorithm is a step by step reasoning process.) Level 1 on the hospital's ED algorithm was described as "requires immediate life-saving intervention" and level 2 was described as a "high risk situation..."