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Based on policy review, document review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

Review of the facility's "ED (Emergency Department) STANDARDS OF CARE" document (July 2020) revealed, "...The triage system is based on the 5 level Emergency Severity Index (ESI) ...emergency room nurse triages each patient to obtain pertinent and objective data while providing physical, emotional and psychosocial support for the patient ...VITAL SIGNS ...ESI 4: reassessed per acuity and clinical assessment but no less frequently than four (4) hours..."

Medical record review revealed Patient #1 presented to the hospital's ED via private vehicle on 1/29/2024 at 8:30 PM with complaint of hearing loss. A triage assessment was performed at 8:40 PM. There was no documentation Patient #1 was re-assessed or monitored by hospital staff after triage assessment was performed at 8:40 PM. (Patient #1 was determined to be an ESI level 4 during triage, which required reassessment of vital signs at a minimum of every 4 hours). There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1's total time in the ED from arrival to being determined Left Without Being Seen (LWBS) was 6 hours.

Refer to A-2406

Based on policy review, document review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "TRIAGE PROCESS" policy (August 2022) revealed, " ...Classifications for purposes of triage assessment include... ESI [Emergency Severity Index] level 4 - Patients in this category have conditions that, related to patient age, distress or potential for deterioration/complications would benefit from intervention or reassurance. Patients who are ESI level 4 will be expected to use only one resource. A QMP [Qualified Medical Provider] will perform a Medical Screening Examination to determine the existence of an Emergency Medical Condition ...Waiting room patients are monitored for decline or change in condition and changes communicated to the ED staff ...Leaving the ED Without Being Seen by a Physician ... Waiting room patients are paged by last name as beds become available. If there is no answer when the patient is paged, the triage nurse should make at least 3 attempts to locate the patient ...If there is no answer by the third attempt, the patient is noted to have left without being seen... The patient is classified as "Left Without Being Seen" if the patient left ED prior to Medical Screening Exam..."

2. Review of the facility's "ED (Emergency Department) STANDARDS OF CARE" document (July 2020) revealed, "...The triage system is based on the 5 level Emergency Severity Index (ESI) ...emergency room nurse triages each patient to obtain pertinent and objective data while providing physical, emotional and psychosocial support for the patient ...VITAL SIGNS ...ESI 4: reassessed per acuity and clinical assessment but no less frequently than four (4) hours..."

3. Medical record review revealed Patient #1 presented to the hospital's ED via private vehicle on 1/29/2024 at 8:30 PM with complaint of hearing loss. A triage assessment was performed at 8:40 PM and revealed, "Chief Complaint Description: onset x [times] 1 year with "muffled hearing" and has seen ENT [Ear Nose Throat] and had done round of abx [antibiotics] with no improvement/also reorts [reports] anxiety ..." Triage vital signs revealed Temperature 98.1 degrees Fahrenheit, Respirations 20, Heart Rate 100, Blood Pressure 138/87, Oxygen Saturation 97%. Functional pain scale documented, "No pain". Patient #1 was assigned Tracking acuity (ESI) of 4.

Patient #1's lab work, including a Comprehensive Metabolic Profile (CMP; a blood test that measures the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) and Complete Blood Count (CBC; a blood test that looks at conditions including anemia, infection and leukemia) was collected at 1:00 AM on 1/30/2024, 4.5 hours after arrival to the ED. White Blood Cell count was 11.5 (normal range between 4.8 and 11.0).

Depart Documentation revealed, "Patient left ED: 01/30/24 02:30 [2:30 AM] ...attempt to call pt [patient] x3 with no response ..."
Discharge Disposition documented as "Left Without Being Seen"

There was no documentation Patient #1 was re-assessed or monitored by hospital staff after triage assessment was performed at 8:40 PM. (Patient #1 was determined to be an ESI level 4 during triage, which required reassessment of vital signs at a minimum of every 4 hours).

There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1's total time in the ED from arrival to being determined Left Without Being Seen (LWBS) was 6 hours.

In an interview on 3/5/2024 at 11:37 AM, the Executive Director of the Emergency Department verified any reassessment vital signs, would be found in the flowsheet section of the record. The Director verified the triage assessment vital signs were the only vital signs documented in the record.