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Based on medical record review and interview, the hospital failed to ensure each patients' medical record contained sufficient information to support the diagnosis and condition of the patient, justify the care, treatment, and services, and documented accurately and correctly the course and results of care, treatment and services for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients who presented to the hospital's emergency department (ED) seeking medical treatment, care and services.

Failure to ensure staff documented accurate information concerning patients' care and treatment in the medical records exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. The hospital failed to ensure staff accurately and correctly documented the care, treatment and services that all patients received in the hospital's ED resulting in the inability to correctly determine the time services were initiated and provided in the ED.

Refer to A 0438

Based on medical record review and interview, the hospital failed to ensure staff documented accurate information concerning patients' care and treatment in the medical records for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients presenting to the hospital's emergency department (ED) seeking care and treatment.

Failure to ensure staff documented accurate information concerning patients' care and treatment in the medical records exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the Emergency Medical Services (EMS) Patient Care Report dated 9/20/18 revealed EMS arrived at Nursing Home #1 on 9/20/18 at 2:42 PM to transfer Patient #1 to the hospital.

EMS documented the patient's vital signs were normal sinus rhythm heart rate (HR), blood pressure (BP) 104/64, Pulse (P) 72, respiration rate (RR) 12 and O2 saturation (O2 Sat - the fraction of oxygen saturated in hemoglobin relative to the total hemoglobin in the blood normal being 95 - 100%). EMS documented the patient was not in cardiac arrest.

EMS left the nursing home with the patient at 3:00 PM.

EMS documented in route to the hospital the patient's O2 sat increased to 93% and had no other change in status during transport.

EMS documented they arrived at the hospital's ED at 3:46 PM with patient's condition upon arrival documented as "improved".

EMS documented while waiting in the ED the patient developed a decrease level of consciousness, went into agonal respirations, and the ED staff began Cardiopulmonary Resuscitation (CPR).

2. Review of the hospital's CPR Record for Patient #1 revealed CPR began on 9/20/18.
The time of the event was documented as "PTA", prior to arrival.
Under the area titled "Resuscitation initiated prior to arrival" the ED staff checked "yes".
Under the area titled "Time chest compressions started" it was written "PTA", prior to arrival.
Under the area titled "Intubation Time" it was written "PTA", prior to arrival.
There was no documentation the patient experienced a cardio-pulmonary arrest in route to the hospital with EMS.

There was no documentation on the hospital's CPR record of the time that CPR was initiated in the ED.

The hospital's CPR record documented Patient #1 was "reintubated" at 4:30 PM. There no documentation the first time the patient was intubated.

At 4:34 PM it was written on the hospital's CPR report, "cardiac ultrasound per [name of physician] - TOD [time of death]".

The hospital's CPR record was signed by the "recorder" on 9/20/18 at 7:50 PM.

There was no documentation of a physician's signature on the CPR report.

3. Medical record review for Patient #2 revealed a Patient Care Record dated 9/21/18 by EMS #2. EMS #2 documented Patient #2 was a 75 year old female who had increased confusion, tremors and decreased appetite. Patient #2 was transported to the hospital by EMS #2 on 9/21/18 and EMS #2 documented arrival at the hospital's ED at 12:12 PM (sic).

The ED record documented Patient #2 arrived at the hospital's ED on 9/21/18 at 12:20 PM (sic) (8 minutes after documented time of arrival by EMS #2).

4. Medical record review for Patient #3 revealed a Patient Care Record dated 9/21/18 by EMS #2. Patient #3 was a 30 year old female involved in a motor vehicle crash who initially did not wish to seek medical treatment but called EMS back to the scene to transport her to the ED. Patient #3 was transported to the hospital by EMS #2 on 9/21/18 and EMS #2 documented they arrived at the hospital's ED at 12:06 PM (sic).

The ED record documented Patient #3 arrived at the hospital's ED on 9/21/18 at 12:23 PM (sic) (17 minutes after documented time of arrival by EMS #2).

5. Medical record review for Patient #4 revealed a Patient Care Record dated 9/23/18 by EMS #2. Patient #4 was a 4 month old male with vomiting and lethargy transported from home to hospital's ED by EMS #2. Patient #4 was transported to the hospital by EMS #2 on 9/23/18, and EMS #2 documented arrival at the hospital's ED at 2:03 PM (sic).

The ED record documented Patient #4 arrived at the hospital's ED on 9/23/18 at 2:27 PM (24 minutes after documented time of arrival by EMS #2).

6. Medical record review for Patient #5 revealed a Patient Care Record dated 9/20/18 by EMS #2. Patient #5 was a 44 year old female with a history of asthma who was transported by EMS #2 from her physician's office for an asthma attack. Patient #5 was transported to the hospital by EMS #2 on 9/20/18, and EMS #2 documented arrival at the hospital's ED at 2:44 PM (sic).

The ED record documented Patient #5 arrived at the hospital's ED on 9/20/18 at 3:06 PM (sic) (22 minutes after documented time of arrival by EMS #2).

7. During an interview in the ED hallway with the ED Director and ED Supervisor on 9/26/18 at 10:00 AM, the ED Supervisor stated the patients who arrived to the ED via EMS were registered when they were placed into a room. The ED Supervisor stated the ED time of arrival was documented as the time when the patient was registered. The ED Director and ED Supervisor confirmed the ED time of arrival was not when the patient arrived at the ED via EMS when the patient had to wait in the hallway for a room. The ED Director and ED Supervisor confirmed they did not track the time ED patients had to wait in the hallway for a room.

During an interview in the conference room on 9/26/18 at 10:58 AM, the Chief Quality Officer stated the Quality Department monitored wait times in the ED based on the information put into their computer system by the ED Director. The Chief Quality Officer confirmed the information tracked by the Quality Department did not include the time patients had to wait in the hallway with EMS before they were registered. The Chief Quality Officer confirmed the documented ED time of arrival was when the patient was registered and not necessarily when the patient arrived at the ED.

During an interview in the conference room on 9/26/18 at 11:07 AM, the Chief Nursing Officer stated the ED time of arrival should be the time the patient arrived through the door of the ED. The Chief Nursing Officer confirmed there were times when the documented ED time of arrival was not when the patient arrived through the ED doors.

Based on policy review, medical record review and interview, the hospital failed to provide medical staff oversight and ensure the provision of services, equipment, personnel and resources to emergency department patients was within timeframes that protected the health and safety of all patients presenting to the hospital's Emergency Department seeking medical attention for a medical condition.

The findings included:

The staff failed to follow policies and assess all patients presenting to the ED by EMS in order to determine if an emergency medical condition existed. The appropriateness of treatment could not be determined due to the failure of assessment by ED personnel to determine if an emergency existed.

Failure to ensure staff followed policies and provide assessment to all patients presenting to the ED by EMS placed all patients coming to the hospital seeking emergency care at risk for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

Refer to A 1104.

Based on policy review, medical record review and interview, the hospital's medical staff failed to ensure that policies were followed and the provision of services, equipment, personnel and resources to emergency department patients was within timeframes that protected the health and safety of all patients presenting to the hospital's Emergency Department seeking medical attention for a medical condition for 5 of 5 (Patient #1 ,2, 3, 4 and 5) sampled patients.

In emergency situations, the time needed to provide the patient with appropriate diagnostic and care interventions can have a significant effect on the patient. Delays in diagnosis and the provision of interventions is likely to adversely affect the health and safety of patients who require emergency care.

Failure to ensure policies were followed and the provision of services, equipment, personnel and resources to emergency department patients was within timeframes that protected the health and safety of all patients exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the hospital's "TRIAGE ASSESSMENT OF PATIENTS BY EMERGENCY SEVERITY INDEX (ESI)" policy revealed, "...PURPOSE...Determine patient acuity...Identify severity of illness or injury...Ensure patients with highest acuity are seen first...Determine number of expected resources to reach a disposition decision...Determine placement in appropriate treatment areas...POLICY...When EMS [Emergency Medical Services] arrives with a patient and no beds are available, the patient will receive a documented ESI Triage assessment by a licensed RN [Registered Nurse] to determine assignment of the patient. All EMS patients are to be triaged and assessment discussed with a provider before being placed in the waiting room due to bed availability in the department. Discussion should be documented in the EMR [electronic medical record]..."

Review of the hospital's "Emergency Medical Treatment and Patient Transfer Policy" revealed, "Definitions...Ambulance Parking occurs when hospital staff delays the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS by refusing to release EMS staff or equipment and preventing EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney..."

Review of the hospital's "The EMTALA [Emergency Medical Treatment and Active Labor Act] Medical Screening Stabilization Policy" revealed, "...Once a patient presents to the Dedicated Emergency Department of the hospital, whether by ambulance or otherwise, the hospital has an obligation to see the patient. A hospital's EMTALA obligations begin when the patient presents at the hospital's Dedicated Emergency Department on hospital property, or is picked up a Hospital-owned ambulance, and a request is made for examination or treatment of an emergency medical condition. Patients arriving via ambulance meet this requirement when ambulance staff requests treatment from hospital staff. Ambulance Parking is not appropriate and could result in an EMTALA violation..."

Review of Nursing Home (NH) #1's medical record for Patient #1 revealed she was a 72 year old resident of a nursing home. Patient #1 had diagnoses that included Alzheimer's Disease, Schizoaffective Disorder, Anxiety Disorder, Gastro-Esophageal Reflux Disease, and Hypertension.

Patient #1 sustained a fall from her bed on 9/20/18 at the nursing home. The NH Certified Nurse Aide reported the fall to the charge nurse who assessed the patient and asked the facility treatment nurse to complete a full assessment.

The NH treatment nurse documented the following injuries for Patient #1:
Bruise to right eye.
Hematoma above right eye measuring 1.5 X 4 centimeters (cm).
Small cuts on both the upper and lower lip.
A 0.3 X 0.3 abrasion to the right knee.
Small laceration to the 5th digit measuring 0.2 X 0.1 cm.
An abrasion to the right side of the nose measuring 0.5 X 1.5 X 0.1 cm.
A 1 X 1 cm skin tear to the right little finger.
A small red mark on the left ear.
Bruising to the right elbow measuring 1 X 0.5 cm.
The nose swollen and bruised.

The nursing home called for EMS to transport the resident to an emergency department (ED) for assessment of her injuries.

Review of EMS #1's Patient Care Report revealed EMS #1 arrived at the nursing home at 2:40 PM and left with Patient #1 at 3:00 PM.

EMS #1 documented the Neuro/Mental status as "alert, altered mental status, normal for this patient, confused..."

Vitals documented by EMS at 2:55 PM were: Normal Sinus Rhythm, BP 104/64, Pulse 72, Respiration rate - 12, O2 Sat - 89 (O2 saturation is defined as blood oxygen levels with the normal being 95 - 100 %), Glucose- 123, Glasgow Coma Scale - 15 (The Glasgow Coma Scale is a common scoring system used to describe a person's level of consciousness. A score of 8 or less indicates severe head injury; 9-12 indicates moderate head injury and 13-15 indicates mild head injury.).

Vitals documented by EMS at 3:10 PM were: Normal Sinus Rhythm, BP- 129/95, Pulse- 80, Respirations-12, Glucose- 92, Glasgow Coma Scale- 15. EMS arrived at the Hospital's Emergency Department at 3:46 PM.

The EMS #1 narrative report revealed, "Responded Emergent to [name of nursing home] for Pt [patient] fell. Upon arrival found Pt supine in bed c/o [complaints of] generalized pain. Staff stated Pt fell off bed at roughly 1355 (1:55 PM) and was placed back in it...decided to send Pt to ER [Emergency Room]. Pt was chronically confused so was unable to tell us where she hurt. Pt did have some swelling to her upper lip and had a small cut to nose. Assessed Pt vitals, Pt AAO [alert and oriented] X [times] 3, Pearl (sic) [pupils equal and reactive to light]...Resp [respirations] non labored, pulse strong and regular...O2 [oxygen] sat [saturation] increased to 93%, no other change in Pt status..." EMS documented they arrived at the hospital ED at 3:46 PM.

There was no documentation on the hospital's ED record that the hospital staff assessed and triaged Patient #1 upon arrival to the ED with EMS.

The EMS staff documented, "While waiting for bed at [named Hospital] ER noted Pt had a sudden decrease in LOC [level of consciousness]. Pt went into agnal [agonal] respirations. Staff started Cardiopulmonary Resuscitation (CPR) in hallway. Moved to bed 8 with [named Hospital] staff running code. Gave report to nurse [Nurse #1], Returned to service."

Review of the hospital's ED record for Patient #1 revealed the ED staff documented Patient #1 presented to the hospital's ED at 4:13 PM (27 minutes after the actual arrival time documented by EMS #1) and was triaged by Nurse #2 at 4:15 PM (29 minutes after the actual arrival time documented by EMS #1).

The chief complaint documented by Hospital Nurse #2 was "Pt. sent from nsg [nursing] home, EMS said she slid out of bed and moved back into bed with wincing movements at nsg home. During transport baseline mentation confused with slight grimacing. While in ER hallway pt coded."

Physican #1 documented he performed a medical screening examination (MSE) at 5:22 PM (1 hour and 26 minutes after the patient had arrived in the ED and 52 minutes after the patient had expired in the ED) The MSE revealed "...The patient presents in cardiac arrest. The onset was 5 minutes ago Witnessed arrest yes by nurse...Initial cardiac rhythm Asystole [total cessation of the electrical activity of the heart]. Pre-arrival Treatment none. Preceding symptoms fall at nursing facility...Patient brought in from nursing facility due to fall and altered level of consciousness. Patient was near baseline upon arrival to ED but didn't have significant head injury. Pt was being wheeled to the room when she was found to have sudden cardiac arrest and was transported to room 8. The [there] was a full code and CPR initiated...Patient was initially given 1 mg [milligram] of epinephrine...with no return of spontaneous circulation. Concern for intracranial hemorrhage or possible head injury".

The hospital's CPR record for Patient #1 revealed the following:
At 4:10 PM (3 minutes prior to documented Hospital arrival time) 1 milligram of Epinephrine was administered and CPR was resumed at 4:13 PM.

At 4:32 PM the patient was in asystole.

At 4:34(sic) PM a cardiac ultrasound was performed per Physican #1.

At 4:34(sic) PM Patient #1 expired.

During an interview in the conference room on 9/25/18 at 1:30 PM, the ED Supervisor confirmed there was no triage or assessment of Patient #1 by a nurse documented in the medical record while the patient waited in the hallway with EMS.

During a telephone interview on 9/25/18 at 3:04 PM, Emergency Medical Technician/Paramedic (EMT/P) #1 was asked about the condition of Patient #1 when he picked her at the nursing home on 9/20/18. EMT/P #1 revealed that Patient #1 had a bruise above her right eye and a "fat lip...she had slipped out of bed...pretty stable when we picked her up ..."

When asked what happened once the patient arrived at the hospital, EMT/P #1 stated the ED was full and "they had to stand in line." EMT/P #1 stated there were other patient's waiting as well.

When asked if anyone examined Patient #1 while they were waiting in line, EMT/P #1 stated, "No."

When asked if he has had to wait in line with patients before, EMT/P #1 stated, "Yes."

EMT/P #1 stated that Patient #1 was "doing fine and looking around" while waiting for a room. He further stated they were told to go to room 21 and were then told that room needed to be cleaned due to MRSA (Methicillin-resistant Staphylococcus aureus). EMT/P states they were moving to room when 29 when Patient #1 became unresponsive.

EMT/P #1 stated that he told his partner to run out and get the equipment and then a nurse came by and said the patient was having agonal respirations. The ED staff then hooked her to the monitor and took over the code.

During an interview at Nursing Home #1 on 9/25/18 at 4:30 PM, the NH Treatment Nurse verified her nursing assessment accurately documented the condition of Patient #1 after her fall and before she was transported to the Hospital ED. She further stated Patient #1 was unable to communicate how she fell but was able to answer simple questions about how she felt and was alert and talking before transport. The NH Treatment Nurse stated Patient #1 had cognitive impairments but when she left the facility she was at baseline for her condition.

During an interview in the conference room on 9/26/18 at 10:38 AM, Hospital Nurse #2 stated the time documented as the admission (9/20/18 at 4:13 PM) was not necessarily the time of arrival for Patient #1. Hospital Nurse #2 stated she got on the computer to do the triage for Patient #1 after she entered the room while Patient #1 was being coded. Hospital Nurse #2 confirmed there was no triage or assessment documented for Patient #1 by hospital staff prior to her documentation.

During an interview in the conference room on 9/26/18 at 8:54 AM, Hospital Nurse #1 was asked to review the ED record of Patient #1. Hospital Nurse #1 stated Patient #1 was triaged at 4:15.
When asked why there was a delay from arrival time of 3:46 PM until triage assessment, Hospital Nurse #1 stated, " ...very busy ER ...as fast as we can move patient out [of ED rooms] we move patients into a bed ..."
When asked how she was involved in caring for Patient #1 she stated she was on the way to get a blanket for another patient when she saw EMS and another nurse (could not recall her name) bagging (providing rescue breathing) Patient #1. Hospital Nurse #1 stated she checked for a pulse and began chest compressions on Patient #1 in the ED hallway.
Hospital Nurse #1 stated Patient #1 was in the ED hallway near Room 29 lying on an EMS stretcher when she began compressions.
Hospital Nurse #1 was asked who monitored patients arriving via EMS before they were assigned a room and triaged. Nurse #1 stated, " ...EMS stays with patient until they are handed off [to ED staff] ...EMS monitors patient until they are handed off."
When asked how long delays were for patients arriving via EMS for emergency care, Nurse #1 stated, " ... [some] days it's been hours, some days no wait ...EMS stays with the [patients] the entire time ...they stay in a central location [hallway near EMS entrance] we expect EMS to tell us of any changes ...They [EMS] have continuous monitoring ..."
When asked if EMS patients in the hallway awaiting a room assignment were assigned a nurse she stated, " ...better answered by [named ED Director] or [named ED Supervisor]."

During an interview in the conference room on 9/26/18 at 11:12 AM, the hospital's Chief Nursing Officer (CNO) was asked about the ED process when a patient arrives by EMS. The CNO stated that if a room is not immediately available the patient waits with EMS in the hallway. The CNO stated that the Charge Nurse was "sitting right there" and was expected to know what was going on and which patient needs to be seen first.
When asked where that information would be documented, the CNO stated it would be in nurses notes that "predate the triage note."
The CNO looked at the ED record for Patient #1 and verified there was no documentation prior to when the patient coded. When asked if that was acceptable, the CNO stated, "No, it isn't acceptable ...If it wasn't charted it wasn't done ..."

The CNO further stated the Charge Nurse was responsible to get up, greet the patient, decide who is most critically ill, move the patients in and out of the rooms, and initiate treatment if needed. The Charge Nurse was responsible to provide care and EMS does stay with the patient until they get into a room. The Charge Nurse does not have a patient assignment; they are the "air-traffic control system for EMS."

During an interview in the conference room on 9/26/18 at 12:26 PM, Hospital Nurse #4 confirmed there was no assessment documented by a nurse for Patient #1 before the triage note during the code.

2. Medical record review for Patient #2 revealed a Patient Care Record dated 9/21/18 by EMS #2. EMS #2 documented Patient #2 was a 75 year old female who had increased confusion, tremors and decreased appetite. Patient #2 was transported to the hospital by EMS #2 on 9/21/18 and EMS #2 documented they arrived at the hospital's ED at 12:12 PM.

There was no documentation the ED staff triaged or assessed the patient upon arrival by EMS per hospital policy.

The ED record documented Patient #2 was triaged with an ESI rating of 3 at 12:21 PM (9 minutes after documented time of arrival by EMS #2).

3. Medical record review for Patient #3 revealed a Patient Care Record dated 9/21/18 by EMS #2. Patient #3 was a 30 year old female involved in a motor vehicle crash who initially did not wish to seek medical treatment but called EMS back to the scene to transport her to the ED. Patient #3 was transported to the hospital by EMS #2 on 9/21/18 and EMS #2 documented they arrived at the hospital's ED at 12:06 PM.

There was no documentation the patient was assessed or triaged by the ED staff upon arrival tot he ED by EMS per hospital policy.

The ED record documented Patient #3 was triaged with an ESI rating of 3 at 12:23 PM (17 minutes after documented time of arrival by EMS #2).

4. Medical record review for Patient #4 revealed a Patient Care Record dated 9/23/18 by EMS #2. Patient #4 was a 4 month old male with vomiting and lethargy picked up by EMS #2 at his home. Patient #4 was transported to the hospital by EMS #2 on 9/23/18, and EMS #2 documented they arrived at the hospital's ED at 2:03 PM. The EMS record further revealed, "...delay at [named hospital] secondary to no bed available..."

There was no documentation the patient was assessed or triaged by the ED staff upon arrival to the ED with EMS.

The ED record documented Patient #4 was triaged with an ESI rating of 4 at 2:27 PM (24 minutes after documented time of arrival by EMS #2).

5. Medical record review for Patient #5 revealed a Patient Care Record dated 9/20/18 by EMS #2. Patient #5 was a 44 year old female with a history of asthma picked up by EMS #2 at her physician's office for an asthma attack. Patient #5 was transported to the hospital by EMS #2 on 9/20/18, and EMS #2 documented they arrived at the hospital's ED at 2:44 PM.

There was no documentation the ED staff assessed or triaged the patient upon arrival to the ED with EMS per hospital policy.

The ED record documented Patient #5 was triaged with an ESI rating of 3 at 3:07 PM (23 minutes after documented time of arrival by EMS #2).

6. During an interview in the conference room on 9/25/18 at 1:30 PM, the ED Supervisor stated the hospital staff kept patients who arrived by ambulance in the hallway with EMS if there were no beds available. The ED Supervisor stated a nurse should go to the hallway when a patient arrives, assess the patient and document the assessment in the triage note. During the same interview, the ED Director stated patients became the responsibility of the hospital when they arrived to the ED.

During an interview in the ED hallway on 9/26/18 at 10:00 AM, the ED Supervisor stated EMS waited in the hallway with the patient when there were no beds available. The ED Supervisor stated the ED nursing staff depended on EMS to notify them of any changes in the patient's condition.

During an interview in the conference room on 9/26/18 at 11:30 AM, The ED Medical Director stated EMS medics were trained professionals and were with patients at all times until they could be handed off to ED staff. He verified at times several ambulances came in at one time, and due to a high volume of patients, there was a wait time. He stated ED staff initiated care as soon as possible. He stated the time in the computer [EMR] was the time staff initiated care to a patient, not the time EMS arrived with a patient. He verified the Hospital was responsible for all patients presenting to the ED seeking treatment. He stated, "...we are responsible on a functional level...before ED staff gets to them [patients] the medic [EMS] is trained and best to...before the hand off [to ED staff]." He verified the electronic medical record did not capture the time a patient arrived via EMS, only when ED staff or a physician picked up the care. He stated the Charge Nurse in the ED greeted EMS when a patient arrived and obtained information from EMS and the patient. When the survey team explained identified concerns with delay in care from EMS arrival time to triage time, he stated the records were not reflecting what was actually being done, because he saw the charge nurses carrying out the practice. The survey team explained the initial assessment by charge nurses were not documented on the five records reviewed.

During an interview in the conference room on 9/26/18 at 12:26 PM, ED Nurse #4 stated the nursing staff did not triage or assess patients who arrive to the ED via EMS until the patient was put in a room. Nurse #4 stated she had witnessed patients who had arrived to the ED via EMS lined up in the hallway waiting for a room in the last couple of weeks. Nurse #4 stated the hospital staff was ultimately responsible for a patient when the patient came through the door.

7. During an interview in the ED hallway with the ED Director and ED Supervisor on 9/26/18 at 10:00 AM, the ED Supervisor stated the patients who arrived to the ED via EMS were registered when they were placed into a room. The ED Supervisor stated the ED time of arrival was documented as the time when the patient was registered. The ED Director and ED Supervisor confirmed the ED time of arrival was not when the patient arrived at the ED via EMS when the patient had to wait in the hallway for a room. The ED Director and ED Supervisor confirmed they did not track the time ED patients had to wait in the hallway for a room.

During an interview in the conference room on 9/26/18 at 10:58 AM, the Chief Quality Officer stated the Quality Department monitored wait times in the ED based on the information put into their computer system by the ED Director. The Chief Quality Officer confirmed the information tracked by the Quality Department did not include the time patients had to wait in the hallway with EMS before they were registered. The Chief Quality Officer confirmed the documented ED time of arrival was when the patient was registered and not necessarily when the patient arrived at the ED.

During an interview in the conference room on 9/26/18 at 11:07 AM, the Chief Nursing Officer stated the ED time of arrival should be the time the patient arrived through the door of the ED. The Chief Nursing Officer confirmed there were times when the documented ED time of arrival was not when the patient arrived through the ED doors.