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Based on interview, a review of the Emergency Department's registration logbook, and a review of the facility's policies, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled patients (Patient #1) was registered in the facility's central logbook. The facility failed to have a system in place to ensure that the names of all patients who presented to the Emergency Department (ED), but left without being medially screened, were logged into the registration logbook. Patient #1 presented to the ED on 09/21/14 at approximately 5:30 PM. A triage form was completed by the patient's family member; however, Patient #1 left the facility at approximately 6:10 PM without being assessed by facility staff and there was no record of the patient's information in the ED logbook. Refer to 42 CFR 489.24 (A2405).

Based on interview and a review of the facility's Emergency Department registration logbook, the facility's investigation, the facility's policies, video footage of the Emergency Department, and 911 call recordings, it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-two (22) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment. Interview and review of the facility's video footage revealed Patient #1 presented to the facility (Facility #1) with family on 09/21/14 seeking treatment for diarrhea and not responding to his/her family. The patient had been treated five (5) times in the past for C. diff (Clostridium difficile (C. diff) is a condition where the bacterium overgrow and release toxins that attack the lining of the intestines. Symptoms of mild cases include watery diarrhea with abdominal pain or tenderness. Symptoms of more severe C. diff infection include watery diarrhea, up to 15 times each day; severe abdominal pain; loss of appetite; fever; blood or pus in the stool; and/or weight loss). Patient #1's family member (FM #1) attempted to have staff screen/assess the patient; however, staff told FM #1 that they were busy and there were other patients with more severe conditions that would be seen before Patient #1. However, there was no evidence facility staff had assessed/triaged Patient #1 to assign the patient an acuity level per the facility's policy. Patient #1's family left the facility with Patient #1 and went to another facility (Facility #2) where Patient #1 was diagnosed with C. diff and a Urinary Tract Infection. Patient #1 was transferred back to the facility (Facility #1) for admission and treatment of the conditions. Refer to 42 CFR 489.24 (A2406).

Based on interview, a review of the Emergency Department's registration logbook, and a review of the facility's policies, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled patients (Patient #1) was registered in the facility's central logbook. The facility failed to have a system in place to ensure that the names of all patients who presented to the Emergency Department (ED), but left without being medically screened, were logged into the registration logbook. Patient #1 presented to the ED on 09/21/14 at approximately 5:30 PM. A triage form was completed by the patient's family member; however, Patient #1 left the facility at approximately 6:10 PM without being assessed by facility staff and there was no record of the patient's information in the ED logbook.

The findings include:

The facility did not have a policy related to the keeping of the Emergency Department logbook.

An interview with Patient Registration Clerk #1 on 10/14/14 at 2:00 PM revealed when patients entered the Emergency Department lobby, the patient completed a "triage" form, and put that form through a window to the ED triage Registered Nurse (RN). The triage RN then conducted a triage assessment according to "priority." After the triage assessment, staff placed the patient in a room in the ED, and the registration clerk went to the patient room to register the patient in their computer system. When the patient was registered, the patient's name was entered into the ED logbook, and the patient's name would be entered on the tracking board in the ED.

Interview with Triage Nurse (RN) #1 on 10/15/14 at 1:00 PM confirmed the process for obtaining treatment in the ED was for the patient to complete a triage assessment form and slip the form through the window of the triage office. The triage nurse assessed the patient's complaint and decided based on a "priority" scale which patient to triage first. Once the triage assessment was conducted, the patient was then placed in a room and the patient's name was entered into the ED logbook and placed on the ED tracking board. RN #1 stated Patient #1's name was not entered into the ED logbook because the patient never received a triage assessment.

Interview with the ED Manager on 10/14/14 at 12:45 PM revealed the process to obtain treatment in the ED was for the patient to present to the lobby of the ED and complete a "triage" form. The triage nurse then took all forms, looked at the priority level, and triaged based on the complaint and the patient's arrival time. After the RN completed the triage assessment, the patient was placed in a room and a registration clerk completed the registration process. At that time, the patient's name and information was placed in the ED logbook. The ED Manager stated Patient #1's name was not entered into the ED logbook because the patient never received a triage assessment.

Based on interview and a review of the facility's Emergency Department registration logbook, the facility's investigation, the facility's policies, video footage of the Emergency Department, and 911 call recordings, it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-two (22) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment. Interview and review of the facility's video footage revealed Patient #1 presented to the facility (Facility #1) on 09/21/14 with diarrhea and was not responding to his/her family. The patient had been treated five (5) times in the past for C. diff (Clostridium difficile (C. diff) is a condition where the bacterium overgrow and release toxins that attack the lining of the intestines. Symptoms of mild cases include watery diarrhea with abdominal pain or tenderness. Symptoms of more severe C. diff infection include watery diarrhea, up to 15 times each day; severe abdominal pain; loss of appetite; fever; blood or pus in the stool; and/or weight loss). Patient #1's family member (FM #1) attempted to have staff screen/assess the patient; however, staff told FM #1 that they were busy and there were other patients with conditions that were more severe that would be seen before Patient #1, even though no one had screened/assessed Patient #1. Patient #1's family left the facility with Patient #1 and went to another facility (Facility #2) where Patient #1 was diagnosed with tachycardia, C. diff and a Urinary Tract Infection and was transferred back to the facility (Facility #1) for admission.

The findings include:

A review of Facility #1's policy titled "Admission of a Patient to the Emergency Department," dated June 2006, revealed any person who went to the facility requesting assistance for a potential emergency medical condition/emergency services would receive a medical screening and persons with a medical emergency condition would be treated and their condition stabilized. Further review of the policy revealed a patient of the facility had the right to an appropriate medical screening examination, necessary stabilizing treatment, and an appropriate transfer to another facility. The policy revealed the process for obtaining a screening was for an ED Registered Nurse (RN) to perform and document a triage assessment. The RN triage assessment would establish acuity levels from Level 1 (patients requiring lifesaving interventions) through Level 5 (patients requiring no resources). Based on the priority level established, the triage RN would collaborate with other ED RNs to assign the patient to the appropriate treatment area.

Review of the facility's Bylaws/Rules and Regulations revealed the facility had established that a physician was acceptable to perform the medical screening in order to determine if an emergency medical condition existed.

Interview with Patient #1's Family Member (FM) #1 on 10/16/14 at 11:30 AM revealed she took Patient #1 to Facility #1's ED on 09/21/14 for treatment for C. diff. FM #1 stated that she completed the triage form in the ED and wrote "C-Diff" at the top of the form. FM #1 stated that Patient #1 had fever and chills, was in and out of awareness, and could not tell anyone if he/she was okay. FM #1 stated she knocked on the door of the triage room and informed RN #1 that Patient #1 was very sick and needed to be seen. FM #1 stated RN #1 told them to have a seat and she would get them assistance. FM #1 stated Charge Nurse #1 then came and asked FM #1 to go into another room and asked the family member, "Who is [Patient #1's] physician?" FM #1 stated she informed Charge Nurse #1 that she wrote the doctor's name on the triage form and had told Charge Nurse #1 that Patient #1 was very ill. FM #1 stated that Charge Nurse #1 stated, "We won't put up with threatening behavior at this facility. We have heart patients and head injuries that will be seen before we see [Patient #1's] diarrhea." FM #1 stated no one at Facility #1 ever assessed Patient #1. FM #1 stated at that time she got Patient #1, went to the parking lot, and called 911 because he/she understood from Charge Nurse #1 that Facility #1 was refusing to treat Patient #1. FM #1 stated that 911 staff would not respond to her call because Facility #1 had told them Patient #1 "just had diarrhea." FM #1 stated at approximately 6:10 PM Patient #1 was taken to Facility #2 by other family members and evaluated and treated for C. diff, then transferred back to Facility #1, and admitted on 09/21/14 through 09/26/14.

Interview with Patient #1 on 10/16/14 at 11:15 AM revealed his/her family transported the patient to the facility on 09/21/14 for treatment for C. diff. The patient stated that he/she had been diagnosed and hospitalized five (5) times in the recent past for the same illness. The patient's private physician had told the patient when he/she had symptoms of C. diff he/she needed to go to the ED and be evaluated and possibly admitted. Patient #1 stated the patient's daughter and spouse transported the patient to the facility (Facility #1) on 09/21/14. The patient stated that he/she was having fever and chills and could not recall much about the visit to the facility. The patient stated that he/she remembered being at Facility #1, and then recalled being on a bed at Facility #2. The next thing the patient remembered was waking up and being informed that he/she was a patient at Facility #1 on the third floor. Patient #1 stated that his/her daughter obtained a copy of the 911 dispatch recordings and he/she was very upset that Charge Nurse #1 could be heard laughing on the recording about the patient and stating that the patient "just has diarrhea. "

Review of the facility's investigation and a review of video footage of the ED, revealed on 09/21/14 at 5:37 PM Patient #1 presented to the ED lobby with Family Member #1. Family Member #1 completed a "triage" form at 5:38 PM and RN #1 spoke with Family Member #1 at 5:39 PM. Continued review of the investigation revealed that at 6:00 PM Charge Nurse #1 took Family Member #1 into the Triage Room and spoke with him/her, and at 6:08 PM, Patient #1 and Family Member #1 exited the facility. The facility investigation also included copies of 911 calls made by Patient #1's family.

Review of the 911 recorded call revealed on 09/21/14 at approximately 6:05 PM Family Member #1 requested an ambulance to transport Patient #1 to another facility because the facility refused to treat Patient #1. A 911 Dispatcher contacted the facility and spoke with Charge Nurse #1. Charge Nurse #1 was heard on the call laughing while she told the dispatcher that Patient #1 "just has diarrhea" and there was no reason for an ambulance to be dispatched to the parking lot of the facility for Patient #1.

Interview with Registered Nurse (RN) #1 on 10/15/14 at 1:00 PM revealed she was working as the triage nurse in the ED on 09/21/14. She stated she was conducting a triage assessment on a patient at approximately 5:30 PM when she heard knocking on the door to the triage room. She stated she left the patient, went to the door, and found a family member of Patient #1 at the door. She stated the family member stated Patient #1 was very ill and needed to be seen immediately. She stated that she never assessed Patient #1 at any time. She stated she directed the family member to wait and she would get assistance for them from the charge nurse in the ED. She stated that she informed Charge Nurse #1 of the concerns of Patient #1's family and continued her triage assessment of the other patient. She stated Charge Nurse #1 instructed her to take a lunch break and RN #1 left the ED at approximately 5:40 PM.

Interview with Charge Nurse #1 on 10/15/14 at 12:20 PM revealed she was working as the charge nurse in the ED on 09/21/14 when Patient #1 was in the lobby of the ED. She stated RN #1 informed her that Patient #1's family requested the patient be seen immediately because the patient was very ill. Charge Nurse #1 stated that at that time the ED was full and she had patients in the hallway on stretchers. She stated that she had also been informed by RN #2 that another family member of Patient #1 had been calling the ED and demanding the ED treat Patient #1. Charge Nurse #1 stated that she got Patient #1's family member and took her back into an office in the triage area and explained that the ED was currently full and the ED treated according to priority and severity of complaint. She stated that the ED had patients with chest pain and other conditions that required attention before Patient #1. However, there was no evidence that the facility had assessed Patient #1 to determine the severity of the patient's condition. Charge Nurse #1 stated she informed Patient #1's family member that the ED would treat the patient, but it would "be a while." She stated the family member of Patient #1 was very upset and left the triage office. She stated the family member got Patient #1 and left the facility. She stated the next thing she knew, a 911 dispatcher was on the phone and informed her that there was a person in the facility parking lot requesting an ambulance to respond for Patient #1, who was gravely ill, and the facility was refusing to treat the patient. She stated she informed the 911 dispatcher that the facility did not refuse to see Patient #1, but told dispatch she had informed the family they would have to wait because other patients' priority was higher and an ambulance was not needed at that time. However, interview with Charge Nurse #1 confirmed that she never assessed Patient #1 and Patient #1 never received a medical screening. Charge Nurse #1 stated she only saw the patient through the glass of the triage room.

Interview with the ED Manager on 10/14/14 at 12:45 PM revealed she became aware of the incident in the ED on 09/21/14 when the House Supervisor contacted her and informed her that a family member of Patient #1 made a threatening phone call. The ED Manager stated that the hospital was currently investigating the incident and had viewed the video footage from the ED and listened to the 911 recordings. The interview revealed the process for patients to receive a medical screening in the ED was to complete a "triage" form when the patient presented to the lobby of the ED. The triage nurse then took all forms, looked at the complaint, and triaged based on the complaint and the arrival time. Once the patient was triaged, a priority level was assigned. After the RN completed the triage assessment, the patient was placed in a room to be assessed/screened by a physician/nurse practitioner/physician assistant.

An attempt was made to obtain Patient #1's ED medical record from Facility #1 for the visit on 09/21/14; however, Facility #1 did not have a record of Patient #1 being in the ED. Interview with RN #1 on 10/15/14 at 1:00 PM and with the ED Manager on 10/14/14 at 12:45 PM revealed Patient #1 did not have a medical record for the ED visit because the patient was never assessed/triaged. The ED Manager stated that Facility #1 did not keep the "triage" forms if the patient was not seen at the facility.

Review of Patient's #1's medical record from Facility #2 revealed Patient #1 was evaluated and treated in the Emergency Department on 09/21/14 at 7:02 PM and diagnosed with Clostridium difficile colitis (C. diff colitis - recurrent) and transferred back to Facility #1 by Emergency Medical Services for continued hospitalization at 10:16 PM.

Review of Patient #1's medical record from Facility #1 revealed Patient #1 was admitted on 09/21/14 at 10:55 PM and diagnosed and treated for C. diff colitis and a Urinary Tract infection. Patient #1 was discharged from Facility #1 on 09/26/14.