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Based on interview and record review, the facility failed to complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for two of 29 randomly selected patients (Patient 9 and Patient10) and evaluate those two patients for an Emergency Medical Condition (EMC - a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, with serious impairment, and or with serious dysfunction of any bodily organ or part), when these patients (Patient 9 and Patient 10) presented in the emergency department with chest pain, and were not seen by a physician within 15 minutes after being assigned an ESI (Emergency Severity Index, tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of 2. Patient 9 left the ED without being seen/evaluated by a physician almost 3 hours after arriving in the ED, while Patient 10 left the ED without being seen/evaluated by a physician after waiting almost 7 hours from ED arrival.

This deficient practice resulted in Patient 9 and Patient 10 not receiving complete MSE and evaluation for an EMC, which had the potential for the patients to not be provided treatment in a timely manner and may result in complications such as cardiac arrest (when the heart stops beating).

Findings:

During a record review on 11/14/2024 at 11:40 a.m. with the Assistant Director of Regulatory, Licensing and Accreditation Services (ARLCS), Patient 9's Emergency Department (ED, provides immediate care for patients with severe illnesses and injuries) Nursing Notes - Patient Care Timeline, dated 11/12/2024, was reviewed. ARLCS stated the following:

1. Patient 9 arrived at the ED on 11/12/2024, at 6:28 p.m., with a Chief Complaint, "Someone spiked my drink. I feel jittery in my stomach and feel drunk."

2. Patient 9 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) on 11/12/2024, at 6:31 p.m., with an Emergency Severity Index (ESI - tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of level 2 acuity (severity of illness).

3. Vital Signs (VS - measurements of the body's most basic functions which includes heart rate, respiratory rate, temperature, blood pressure) were Temperature (T) 97.8 degrees Fahrenheit (F, a unit of measurement- normally 97 to 99 degrees F); Pulse rate (HR) 98 beats-per-minute (BPM - normally 60 to 100); Respiration rate (RR) 18 breaths-per-minute (normally 12 to 20); Blood Pressure (BP) 131/89 (normally 120/80); Oxygen Saturation of 99% on room air (measurement of the amount of oxygen in the blood). Pain assessment was not documented and should have been assessed and documented.

Concurrently, during a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 6:31 p.m., ARLCS stated the following:
1. Patient 9's general appearance/distress level was moderate.
2. Patient 9's mental status/ level of consciousness/awareness was oriented to person and place.
3. Patient 9's mobility indicated patient had Dizziness/Generalized Weakness.

During a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:13 p.m., ARLCS stated Laboratory ordered for complete blood count (CBC - a blood test that measures the number and types of cells in the blood), glucose (blood sugar), and electrolytes (a blood test that measures the levels of minerals in the blood that help the body function normally).

During a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:52 p.m., ARLCS stated Patient 9 was called multiple times in the ED, lobby, and front entrance, with no answer. ED disposition indicated patient Left Without Being Seen (LWBS) by the physician.

During a review of the facility's emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following:

1. ED registered nurses (RN's) may initiate condition-based orders based on patient's chief complaints and presenting symptoms, prior to an evaluation of the ED physician.
2. Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient's bedside immediately.
3. Acuity with ESI level 2 (emergent - high risk situation) -patients shall be seen within 15 minutes.
4. Acuity with ESI level 3 patients have urgent needs.
5. Acuity with ESI level 4 are patients with non-urgent complaints.
6. Acuity with ESI level 5 are patients with minor complaints.

During a review of the facility's reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, the document indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following:

1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient's presentation to the ED.

2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable.

3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body's basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination.

4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination.

5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.


2. During a concurrent interview and record review on 11/14/2024 at 11:54 a.m. with ARLCS, Patient 10's Emergency Department (ED) Nursing Notes - Patient Care Timeline, dated 10/1/2024, was reviewed. ARLCS stated the following:

1. Patient 10 arrived at the ED on 10/1/2024 at 1:08 p.m.

2. At 1:09 p.m., patient's (Patient 10) Chief Complaint was intermittent chest pain on the left-side for three days, after patient ran out of maintenance medication.

3. patient (Patient 10) was triaged at 1:11 p.m. with an ESI level 2 acuity.

4. At 1:13 pm, patient's (Patient 10) Vital Signs (VS - measurements of the body's most basic functions) were: Temperature 98.1 degrees Fahrenheit (normally 97 to 99); HR 70 BPM (beats per minute; normally 60 to 100); RR 18 BPM (normally 12 to 20); BP 131/91 (normally 120/80); Oxygen saturation 98% on RA. Pain Score was 3 out of 10. Pain Location was at left Chest.

5. At 2:42 p.m., VS: T 98.1 degrees F; HR 65; RR 17 BPM; BP 138/95. Oxygen saturation 98% on RA.

Concurrently, during review of Patient10's ED Nursing Notes - Patient Care Timeline, dated 10/1/2024, with ARLCS, ARLCS stated the following:

1. At 1:21 p.m., a 12-lead electrocardiogram (EKG - a medical test that measures the heart's electrical activity that compares the strength of signals between twelve different pairs of electrodes/leads, attached to the body) was done.

2. At 2:31 p.m., labs were ordered for CBC, electrolytes, Troponin I (a heart-specific protein that is part of the constitutive heart function), glucose, and B-type natriuretic peptide (BNP - hormone produced by the heart to diagnose and monitor the heart's condition).

3. At 4:12 p.m., indicated patient was three-hours post ESI.

4. At 6:12 p.m., indicated patient was five hours post ESI.

5. At 8 p.m., indicated patient was dismissed and the ED diagnosis was LWBS (Left Without Being Seen)

During a review of facility's emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following:

- ED registered nurses (RN's) may initiate condition-based orders based on patient's chief complaints and presenting symptoms, prior to an evaluation of the ED physician.
- Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient's bedside immediately.
- Acuity with ESI level 2 (emergent - high risk situation) patients shall be seen within 15 minutes.
- Acuity with ESI level 3 patients have urgent needs.
- Acuity with ESI level 4 are patients with non-urgent complaints.
- Acuity with ESI level 5 are patients with minor complaints.

During A review of the facility's reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following:

1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient's presentation to the ED.

2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable.

3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body's basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination.

4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination.

5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.

Based on observation and interview, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) requirement posting signage for informing patients of their right to receive a medical screening examination (an initial exam performed by a qualified medical professional to determine if a patient has an emergency medical condition), stabilizing treatment (to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability), and an appropriate transfer, regardless of their ability to pay, when the EMTALA signage was not posted conspicuously (attracts notice or attention, a place or places likely to be noticed by all individuals) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma).

This deficient practice had the potential for patients arriving in the ED to not be aware of their rights for a medical screening exam and necessary stabilizing treatment, which may lead to negative patient outcomes.

Findings:

During an observation on 11/12/2024 at 1:00 p.m.; Emergency Medical Treatment and Labor Act (EMTALA) signage was not found in a conspicuous area at the ED entrance, admitting area, or patient waiting area.

During a concurrent observation and interview on 11/12/2024 at 1:05 p.m. with he Director of Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma); stated there was no signage posted in the waiting room, the EMTALA signage was posted on the wall at the entrance of treatment area which was located at the end corner of the ED waiting room, the treatment area was behind the ED waiting area. Observed the EMTALA signage was not readily visible in the sitting area.

During an interview on 11/12/2024 at 1:25 p.m. with the Director of Emergency Department (ED), the Director of the ED stated the EMTALA signage should be posted in an area that was accessible to the patients, so patients can see and read the notice and be informed of their rights. They will put the EMTALA signage today (11/12/2024) at the nurse check in area.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 1/08/2023, the P&P indicated the following: Signage: "Conspicuous signs will be posted at hospital entrances and in places likely to be noticed by all individuals who entered the Emergency Department (ED) (e.g., parking garage, entrance, admitting area, waiting room, treatment area). Signage will specify the rights of individuals to examination and treatment for emergency medical conditions regardless of the ability to pay, and the rights of women in labor for health care services, and whether the hospital participates in the Medicaid (a government program that provides health insurance for adults and children with limited income and resources) program ..."

Based on interview and record review, the facility failed to complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for two of 29 randomly selected patients (Patient 9 and Patient10) and evaluate those two patients for an Emergency Medical Condition (EMC - a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, with serious impairment, and or with serious dysfunction of any bodily organ or part), when these patients (Patient 9 and Patient 10) presented in the emergency department with chest pain, and were not seen by a physician within 15 minutes after being assigned an ESI (Emergency Severity Index, tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of 2. Patient 9 left the ED without being seen/evaluated by a physician almost 3 hours after arriving in the ED, while Patient 10 left the ED without being seen/evaluated by a physician after waiting almost 7 hours from ED arrival.

This deficient practice resulted in Patient 9 and Patient 10 not receiving complete MSE and evaluation for an EMC, which had the potential for the patients to not be provided treatment in a timely manner and may result in complications such as cardiac arrest (when the heart stops beating).

Findings:

During a record review on 11/14/2024 at 11:40 a.m. with the Assistant Director of Regulatory, Licensing and Accreditation Services (ARLCS), Patient 9's Emergency Department (ED, provides immediate care for patients with severe illnesses and injuries) Nursing Notes - Patient Care Timeline, dated 11/12/2024, was reviewed. ARLCS stated the following:

1. Patient 9 arrived at the ED on 11/12/2024, at 6:28 p.m., with a Chief Complaint, "Someone spiked my drink. I feel jittery in my stomach and feel drunk."

2. Patient 9 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) on 11/12/2024, at 6:31 p.m., with an Emergency Severity Index (ESI - tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of level 2 acuity (severity of illness).

3. Vital Signs (VS - measurements of the body's most basic functions which includes heart rate, respiratory rate, temperature, blood pressure) were Temperature (T) 97.8 degrees Fahrenheit (F, a unit of measurement- normally 97 to 99 degrees F); Pulse rate (HR) 98 beats-per-minute (BPM - normally 60 to 100); Respiration rate (RR) 18 breaths-per-minute (normally 12 to 20); Blood Pressure (BP) 131/89 (normally 120/80); Oxygen Saturation of 99% on room air (measurement of the amount of oxygen in the blood). Pain assessment was not documented and should have been assessed and documented.

Concurrently, during a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 6:31 p.m., ARLCS stated the following:
1. Patient 9's general appearance/distress level was moderate.
2. Patient 9's mental status/ level of consciousness/awareness was oriented to person and place.
3. Patient 9's mobility indicated patient had Dizziness/Generalized Weakness.

During a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:13 p.m., ARLCS stated Laboratory ordered for complete blood count (CBC - a blood test that measures the number and types of cells in the blood), glucose (blood sugar), and electrolytes (a blood test that measures the levels of minerals in the blood that help the body function normally).

During a review of Patient 9's ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:52 p.m., ARLCS stated Patient 9 was called multiple times in the ED, lobby, and front entrance, with no answer. ED disposition indicated patient Left Without Being Seen (LWBS) by the physician.

During a review of the facility's emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following:

1. ED registered nurses (RN's) may initiate condition-based orders based on patient's chief complaints and presenting symptoms, prior to an evaluation of the ED physician.
2. Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient's bedside immediately.
3. Acuity with ESI level 2 (emergent - high risk situation) -patients shall be seen within 15 minutes.
4. Acuity with ESI level 3 patients have urgent needs.
5. Acuity with ESI level 4 are patients with non-urgent complaints.
6. Acuity with ESI level 5 are patients with minor complaints.

During a review of the facility's reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, the document indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following:

1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient's presentation to the ED.

2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable.

3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body's basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination.

4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination.

5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.


2. During a concurrent interview and record review on 11/14/2024 at 11:54 a.m. with ARLCS, Patient 10's Emergency Department (ED) Nursing Notes - Patient Care Timeline, dated 10/1/2024, was reviewed. ARLCS stated the following:

1. Patient 10 arrived at the ED on 10/1/2024 at 1:08 p.m.

2. At 1:09 p.m., patient's (Patient 10) Chief Complaint was intermittent chest pain on the left-side for three days, after patient ran out of maintenance medication.

3. patient (Patient 10) was triaged at 1:11 p.m. with an ESI level 2 acuity.

4. At 1:13 pm, patient's (Patient 10) Vital Signs (VS - measurements of the body's most basic functions) were: Temperature 98.1 degrees Fahrenheit (normally 97 to 99); HR 70 BPM (beats per minute; normally 60 to 100); RR 18 BPM (normally 12 to 20); BP 131/91 (normally 120/80); Oxygen saturation 98% on RA. Pain Score was 3 out of 10. Pain Location was at left Chest.

5. At 2:42 p.m., VS: T 98.1 degrees F; HR 65; RR 17 BPM; BP 138/95. Oxygen saturation 98% on RA.

Concurrently, during review of Patient10's ED Nursing Notes - Patient Care Timeline, dated 10/1/2024, with ARLCS, ARLCS stated the following:

1. At 1:21 p.m., a 12-lead electrocardiogram (EKG - a medical test that measures the heart's electrical activity that compares the strength of signals between twelve different pairs of electrodes/leads, attached to the body) was done.

2. At 2:31 p.m., labs were ordered for CBC, electrolytes, Troponin I (a heart-specific protein that is part of the constitutive heart function), glucose, and B-type natriuretic peptide (BNP - hormone produced by the heart to diagnose and monitor the heart's condition).

3. At 4:12 p.m., indicated patient was three-hours post ESI.

4. At 6:12 p.m., indicated patient was five hours post ESI.

5. At 8 p.m., indicated patient was dismissed and the ED diagnosis was LWBS (Left Without Being Seen)

During a review of facility's emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following:

- ED registered nurses (RN's) may initiate condition-based orders based on patient's chief complaints and presenting symptoms, prior to an evaluation of the ED physician.
- Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient's bedside immediately.
- Acuity with ESI level 2 (emergent - high risk situation) patients shall be seen within 15 minutes.
- Acuity with ESI level 3 patients have urgent needs.
- Acuity with ESI level 4 are patients with non-urgent complaints.
- Acuity with ESI level 5 are patients with minor complaints.

During A review of the facility's reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following:

1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient's presentation to the ED.

2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable.

3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body's basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination.

4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination.

5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.