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Based on interview and record review the facility failed to:

1. Initiate a Medical Screening Examination (MSE) for four of 27 sampled patients (Patient 1, Patient 26, Patient 14, Patient 5). This failure had the potential to result in an emergency medical condition (EMC) unrecognized for these eight patients who visited the emergency department (ED).

2. Complete an MSE for two of 27 sampled patients (Patient 27 and Patient 6). This failure had the potential to result in a delay of necessary treatment to provide stabilization treatment for these seven patients who visited the ED.

Findings:

1a. The ED record for Patient 1 was reviewed on 10/6/20. Patient 1 visited the emergency room on 8/9/20 at 11:38 AM accompanied by his son. Patient 1 arrived in the ED alert and oriented and visibly anxious. At 12:10 PM, Patient 1 was triaged and returned back to the waiting room lobby, moaning and in pain. At 12:49 PM (approximately one hour and ten minutes after arrival in the ED) staff was alerted Patient 1 felt faint. Patient 1 was provided 2 L (liters) of oxygen via nasal cannula but was not assessed by the MD or by nursing staff. Patient 1 remained in the waiting room lobby. At 12: 55 PM Patient 1 showed signs and symptoms of increasing discomfort. At 1:20 PM (approximately one hour and 42 minutes after arrival in the ED) Patient 1 was no longer moaning but was unresponsive, slight mottling and purplish discoloration was seen on both lower legs. ED staff took Patient 1 to room 3 in the treatment area and initiated CPR. Patient 1 expired on 1:58 PM.

During a tour in the Emergency Department on 10/6/20, at 12:20 PM with Emergency Department Manager (ED Manager), ED Manager stated, walk-in patients are first seen by the Registration Nurse, after obtaining patient's name, and etc. . . patient is then told to wait in the waiting room. Registration nurse notifies triage nurse of patent's arrival. Triage nurse will then call patient in the triage room to be assessed. Vitals (signs), medical information, home medications, and chief complaint (reason for emergency room visit) were obtained. ED Manager stated, Patient's ESI level is determine by both the Triage Nurse and Charge Nurse on duty, base on patient's triage assessment and chief complaint. ESI level 1 or 2 should be taken to the treatment area and placed in a room. ESI level of 3, 4, 5 would return to the waiting room lobby if there were no beds available and reassessed every 2 hours. If a patient had a change in condition, patient's ESI level could be upgraded to meet their immediate needs. ED Manager stated it was the facility's goal for the MD to perform an MSE within 30 minutes of the patient's arrival to the ED.

During a review of Patient 1's ED Triage Report (assessment of health status to determine acuity level), dated 8/9/20, the Triage Report indicated, Patient 1 arrived at the ED, on 8/9/20, at 11:38 AM. Patient 1 was assessed by a triage registered nurse (Triage RN 1) at 12:10 PM. Patient 1 presented with abdominal pain, numb hands and pus in his indwelling urinary catheter (flexible tube placed through the urinary tract to drain urine). Vital signs included a low temperature of 94.6 Fahrenheit (F normal adult temperatures range from 97 F to 99 F), heart rate of 107 beats per minute (bpm normal heart rate 60 - 100), oxygen level of 97 percent at room air, and a pain level of 10 out of 10 (worst possible imaginable pain). Patient 1 was assigned an ESI level 3.

During a review of Patient 1's ED Triage-Sepsis (a life threatening complication of infection) Screening Tool, completed by Triage RN 1 on 8/9/20 at 12:10 PM, the Sepsis Screening Tool indicated, Patient 1 presented with signs of shortness of breath, hypothermia (temperature lower than 96.8) and tachycardia (heartbeat greater than 100 bpm). Based on the Sepsis Screening Tool, Patient 1 was positive for sepsis.

During a review of the Daily Focus Assessment Report (form used on all patient in the ED to document patient ongoing condition), dated 8/9/20, the Daily Focus Assessment indicated the following:

"12:10 PM Pt [Patient 1] was moaning and in pain, but no rooms are open in the back, pt and son escorted back to lobby. MD [Medical Doctor] and charge nurse [Charge] aware of pt.
12:49 PM front desk alerts me that pt is in distress and still asking to come back, pt is on 2L [liters] NC [nasal cannula] now, as he felt faint.
12:55 PM pt condition discussed with MD, I was told 'there is nothing to make of it'. Again, asked MD charge nurse aware. Asked colleagues to take a look at patient, staff aware. No beds available.
1:20 PM witnessed pt no longer moaning in lobby became unresponsive. . . CPR [Cardiopulmonary Resuscitation (emergency lifesaving procedure performed when the heart stops beating)] started.
1:58 PM Patient 1 expired."

During an interview on 10/6/20, at 12:20 PM, with the Chief Nurse Executive (CNE), the CNE stated, it was the facility's goal for the MD to perform an MSE within 30 minutes of the patient's arrival to the ED. The CNE stated, the MSE could be done in the hallway or the triage room if there were no ED beds available.

During an interview on 10/6/20, at 1:41 PM, with Triage RN 2, Triage RN 2 stated, it was the facility practice for patients to be seen for a MSE by the MD within 30 minutes of arrival in the ED.

During an interview on 10/7/20 at 9:32 AM, with the Chief Executive Officer (CEO), the CNE, and the ED Manager, the CEO stated, only MD's were qualified to provide an appropriate MSE. The CNE stated, an MSE was to be provided within 30 minutes of arrival time in the ED. The CNE stated, the 30 minute goal was not in the hospital policy, "It's not written anywhere, it's always been our goal."

During a concurrent interview and record review on 10/7/20, at 10 AM, with Charge 1, Charge 1 stated, she was the Charge nurse on duty when Patient 1 arrived in the ED. Charge 1 stated, she was made aware by Triage RN 1 of Patient 1's arrival and complained of abdominal pain. Charge 1 stated, Triage RN 1 had requested Patient 1 to be placed in the back treatment area. Charge 1 stated, Patient 1 had to be placed back in the lobby waiting room after triage due to hospital being "very busy" and no patient bed available. Charge 1 stated, she observed and overheard Triage RN 1 talking to MD 1 three or four times requesting MD 1 to physically assess Patient 1. Charge 1 stated, MD 1 did not physically assess Patient 1.

During a concurrent interview and record review, on 10/7/20, at 10:48 AM, with Triage RN 1, Triage RN 1 stated, she was the Triage RN on 8/9/20 when Patient 1 arrived. Triage RN 1 stated, Patient 1 presented with a low temperature, a high heart rate, and complained of abdominal pain. Triage RN 1 stated, she made both MD 1 and Charge 1 aware of Patient 1's arrival and his change of condition several times. Triage RN 1 stated, she wanted to bring Patient 1 from the lobby waiting room to the back treatment area but was told by Charge 1 there were no rooms available. Triage RN 1 stated, MD 1 never evaluated Patient 1 while he was in the waiting room. Triage RN 1 stated, "he [MD 1] was sitting and playing on his cell phone. I knew something was wrong, I just didn't know what and I just wanted him [MD 1] to take a look." Triage RN 1 stated, she had walked back in the treatment area several times, begged someone to help her, wanted someone to look at Patient 1 to get a second opinion but got no help.

During an interview on 10/7/20, at 12:22 PM, with ED Medical Director (Medical Director), the Medical Director stated, only the ED physicians were qualified to provide an appropriate MSE. The Medical Director stated, the hospital's goal was to follow the national standard to provide an appropriate MSE to patients within 30 minutes of their arrival time in the ED. The Medical Director stated, he had spoken to MD 1 regarding Patient 1's 8/9/20 incident, MD 1 stated, "nobody had approached him regarding Patient 1 deteriorating condition and therefore did not set eyes on Patient 1." The Medical Director stated, "Patient should have already been seen. If triage nurse says patient needs to be seen, you don't say no. I expect myself and for all physicians to get up and see the patient unless a physician has his hands deep into something else, there is no reason not to get up and take a look." The Medical Director stated, MD 1 resigned after the incident.

During an earlier interview, with a surveyor, on 9/14/20, at 12:30 PM, with MD 1, MD 1 stated, he was made aware of Patient 1 only when he was brought back from the waiting room for an immediate change of condition. MD 1 stated, he had only seen Patient 1's name "on the board (an electronic tracking board that contains the names of all the ED patients and all that are waiting)."

During a follow up interview on 9/21/20, at 10 AM, with MD 1, MD 1 stated, he did not physically assess Patient 1 before the CPR (cardiopulmonary resuscitation, a life saving intervention). MD 1 stated, "No, I didn't, we were super busy."

During a previous interview and record review conducted by another surveyor on 9/30/20, at 9:40 AM, regarding Patient 1's emergency department visit on 8/9/20. The ED Medical Director (Medical Director), after reviewing Patient 1's triage record, stated, 11:38 AM was the time MD 1 clicked on the electronic tracking board for Patient 1. The Medical Director confirmed at 11:38 AM, MD 1 would have had to go to the waiting room lobby to see Patient 1. The Medical Director stated, when the physician clicked on the patient name, it indicated they had accepted the patient, intended to initiate an MSE, and document the MSE section; including the "Time Seen" and "MSE Signature."

1b. During a review of Patient 26's Triage Report, dated 5/10/20, the Triage Report indicated, Patient 26 arrived at the ED from home by private car, on 5/10/20, at 3:26 PM. He was triaged at 3:36 PM. The Triage Report indicated, Patient 26 complained of worsening high blood pressure and chest tightness. The Triage Report indicated, Patient 26 had a blood pressure of 185/105 (normal blood pressure ranges from 90/60 to under 120/80), Temperature 96.1 Fahrenheit (F normal adult temperatures range from 97 F to 99 F), and a pain assessment of five out of 10 (10 point scale with 0 being no pain, and 10 the worst possible pain). The Triage Report indicated an acuity of 3.

During a review of Patient 26's tracking information, dated 5/10/20, it indicated, Patient 26 was first seen by a provider at 3:28 PM, two minutes after arrival and eight minutes before being triaged. Patient 26 left without being seen at 9:14 PM, almost six hours after arrival.

During a concurrent interview and record review on 10/7/20, at 4:30 PM, with the CNE, Patient 26's medical record was reviewed. The CNE was unable to provide documented evidence an ED physician performed an MSE for Patient 26.

During a phone interview on 10/12/20, at 2:51 PM, with Patient 26, Patient 26 stated, he was not sure how long he was at the ED on 5/10/20. He was told by the staff, "There was no doctor available (to see him)." Patient 26 stated, the RN took his blood pressure about every hour and reported to the MD. Patient 26 stated, the nurse told him it was no use for him to remain at the ED since there was no change in his blood pressure or pain level. Patient 26 stated, "The staff were pretty direct about him leaving."

1c. During a concurrent interview and record review on 10/7/20, at 10:53 AM, with the ED Manager, Patient 14's medical record was reviewed. Patient 14 visited the ED on both 9/28/20 and 9/29/20. The ED Manager was unable to provide documented evidence the ED physician had performed an MSE for Patient 14 on either 9/28/20 or 9/29/20's visit.

1d. During a concurrent interview and record review on 10/7/20, at 3:35 PM, with the CNE, Patient 5's Physician Worksheet, dated 8/8/20, was reviewed. Patient 5 came to the ED at 7:45 PM, triaged at 7:47 PM. An ED physician documented, on the MSE section, indicated, "A: NKA (no known allergy)." The CNE confirmed there was no other documentation under MSE.




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2a. During a review of Patient 27's medical record, Patient 27's Triage Report, dated 5/25/20, indicated, Patient 27 arrived at the ED, on 5/25/20, at 11:31 AM, from home, by private car, with a complaint of on and off chest pain for the past four days and a current pain level of 10 out of 10. Patient 27 was triaged at 11:47 AM. The ED information also indicated, MD 2 first saw Patient 27 three minutes after registration and 13 minutes prior to triage.

During a concurrent interview and record review on 10/7/20, at 4:30 PM, with the CNE, Patient 27's MSE was reviewed. The CNE stated, the MD had neither signed nor timed the MSE section.


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2b. During a concurrent interview and record review on 10/7/20, at 3:35 PM, with the CNE, Patient 6's Physician Worksheet, dated 8/9/20, was reviewed. The Physician Worksheet indicated, Patient 6 had dizziness and nausea. The MSE section was neither signed nor timed. The CNE confirmed the findings.

During an interview on 10/6/20, at 3:28 PM, with the CNE, the CNE stated, the medical records department scanned the ED Physician Worksheet into the patients' medical record. It is considered a permanent patient record.

During an interview on 10/7/20, at 12:22 PM, with the Medical Director, he stated, only the ED physicians were qualified to provide an appropriate MSE. The Medical Director stated, the hospital goal was to follow the national standard to provide an appropriate MSE to patients 30 minutes after arrival time in the ED.

During an interview on 10/7/20, at 3:55 PM with the Medical Director, the Medical Director stated, if he (Medical Director) was unable to complete the patient's medical exam (when patient first seen), he would complete the MSE section of the Physician Worksheet. The Medical Director stated, the MD should time and sign the MSE section of the Physician Worksheet after performing the MSE. The Medical Director stated, the purpose of the MSE was to determine if a patient an emergency medical condition.

During a review of the facility policy and procedure (P&P) titled "Documentation Guidelines," dated 7/26/18, the P&P indicated, "It is the policy of [facility name] to ensure patient records are complete including authentication (date, time and legal signature) of entries by a professional authorized by the hospital...6. Date and time all entries. Include month, day, year and time. 7. Use first initial, last name and legal title for signature."

During a review of the Rules and Regulations of Medical Staff, dated 11/2015, the Rules and Regulations indicated, "IV. Medical Records Members of the Medical Staff shall be held responsible for the preparation and completion of the medical record. . .2. Authentication - All entries are dated, timed and authenticated by the appropriate physician, and if written, are legible."


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