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Based on interview and record review, the facility failed to verify, evaluate and update policies and procedures for emergency medical services on an ongoing basis for all patients presenting to the emergecy department (ED). Findings include:

During tour of the facility on 05/08/24 at 0920, Staff C was questioned which triage acuity system was used in the ED. Staff C reported, "ESI" (Emergency Severity Index).

On 05/08/24 at 1300, review of policy titled "Triage", (no policy #), reviewed 2017, demonstrated that the triage acuity rating system was not "ESI". The policy demonstrated a system of Priority 1 through Priority 5. Each priority level is defined as "Immediate" (1); "Emergent" (2); "Urgent" (3); "Non-Urgent" (4); and no definition is provided for Priority 5. Each Priority level lists approximately a dozen examples of patient complaints that fit that level. Unique to the ESI Triage system, is that "resources needed" and "vital signs" are used to establish the acuity rating. The triage policy does not state that the facility uses ESI for Triage acuity rating. A single reference to ESI is found in the policy 'Reference' footnote, "ESI- A Triage Tool for Emergency Department Care Version 4 (2012) AHRQ Agency For Healthcare Research and Quality."

An interview was conducted with Chief Nursing Officer Staff B on 05/09/24 at approximately 1010. Staff B was questioned why the Triage policy does not reflect current Triage practice in the EC. Staff B stated, "We will need to update that policy. All policy is updated at the corporate level."

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the Medical Screening Exam responsibilities.

See tags:
A2405 Failure to have a complete Emergency Room Log.
A2406 Failure to provide a Medical Screening Exam.

Based on interview and record review, the facility failed to maintain a central log for all 20 of 20 patients reviewed for documentation in the Central Log for the Emergency Department (ED), resulting in inaccurate documentation of patient arrivals to the ED. Findings include:

On 05/08/24 at 0900, the required ED Central Log was requested from Director of ED (Staff C) for additional documentation of patients' arrival times. Staff C explained that the Central Log was moved from a previous electronic medical record platform to our new electronic medical record platform and we have incorporated portions of the ED Central Log into it.

On 05/08/24 at 1137, Staff C provided a copy of the facility's "Daily ED Summary Log" in lieu of the required ED Central Log requested. Staff C stated that "(The new electronic medical record platform) was able to duplicate the Central Log and the report is pending." Staff C returned a short time later and presented a spreadsheet titled "ED Daily Log" displayed on his computer screen.

A comparison and review of facility's policy "EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act", (no policy #) revised 03/2016, demonstrated, "Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following:

Patient's name

DOB

Sex

Chief complaint

Arrival time

Triage time

Registration time

MSE time

Medical record/ Account number

Mode of arrival

Name of LIP (Licensed Independant Practicioner) who provided MSE (Medical Screening Exam)

If admitted Name of admitting LIP

Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged."



The facility's report "Daily Summary" reviewed on 05/08/24 at 1137 demonstrated that the log did not include registration time, mode of arrival, or name of LIP who provided MSE, as stated in the policy above. Further review of the "Daily Summary" on 05/10/24 at 1440 failed to demonstrate documentation of P-1 as presenting to the facility ED on 02/15/24 at 1600. The "Daily Summary" demonstrated a time gap with no patients logged between 02/15/24 at 1408 until 02/15/24 at 1744. A review of the facility's "ED Registrations" report provided by the facility's Director of Registrations (Staff O) on 05/10/24 at 1445, did not match the "Daily Summary Log." It demonstrated the registration of 37 patients between 1408 and 1744, on 02/15/24.

An interview was conducted on 05/08/24 with Registration Manager Staff N. Staff N was questioned about the many discrepancies with the data. Staff N stated, "The registration history report pulls data from another emergency center, which is under the same CCN (facility registration number)." Staff N stated that a second attempt at the report would be made the following morning. No other report was provided.

Based on interview and record review the facility failed to ensure a medical screening exam (MSE) was performed for 1 of 20 patients (P-1) requesting services of the Emergency Department (ED) resulting in P-1 not receiving an MSE. Findings include:

During review of P-1's medical record with ED Director Staff C, on 05/07/24 at 1300, Staff C was questioned if P-1 received a triage evaluation and Medical Screening Exam (MSE). Staff C replied "No, he left before being seen." Staff C was next asked why he thought P-1 left the facility after seeking treatment. Staff C replied, "The triage nurse chose a chest pain over him first." During chart review for P-1 it was noted that the medical record contained "depart" information showing "Discharged at 1602." Staff C was requested to provide the "Discharge Instructions" that were provided to P-1. Staff C stated that "P-1 was not provided discharge instructions because he left before being seen."

Review of facility's document "Facesheet", dated 02/15/24 demonstrated P-1's "Arrival Date/Time" as 1658, and "Admit Date/Time" as 1707 (P-1 was not admitted).

Review of document, "Registration History for the Patient Encounter," dated 02/15/24 from 1602 through 1616 demonstrated that P-1 was registered at the facility approximately one hour prior to the documented "arrival time" indicated on the "Facesheet". Review of documents "Registration History for the Patient Encounter" dated 02/15/24, revealed the following information in timeline format:

Date/Time:

02/15/24 at 1602: P-1 arrived at ED (registration) and "Patient Encounter" created.

02/15/24 at 1616: Hospital account verified, and Confirmation Error was recorded.

02/15/25 at 1625: Patient Disposition documented as "Dismissed."

Documentation of P-1's presenting to Facility A was not located in either the "ED Summary Log" nor the "ED Registrations" file. The "Registration History for the Patient Encounter" was the only documentation of P-1's arrival or registration on 02/16/24 at 1604.