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Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure: 1.) patient transfer documentation is completed in accordance with facility policy (A1104); 2.) patients in the emergency department waiting room receive continued monitoring in accordance with facility policy, in one out of two medical records reviewed of patients with an acuity level of "2" (Patient (P)5) (A1104); 3.) a pain assessment is completed during triage in accordance with facility policy, in four out of six medical records reviewed (P7, P8, P11, and P19) (A1104); 4.) a pain reassessment is completed after pain medication administration per facility policy (A1104).

Cross Reference:
482.55 (a)(3) Emergency Services: Emergency Services Policies

Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure: 1.) patient transfer documentation is completed in accordance with facility policy; 2.) patients in the emergency department waiting room receive continued monitoring in accordance with facility policy, in one out of two medical records reviewed of patients with an acuity level of "2" (Patient (P)5); 3.) a pain assessment is completed during triage in accordance with facility policy, in four out of six medical records reviewed (P7, P8, P11, and P19); 4.) a pain reassessment is completed after pain medication administration per facility policy.

Findings include:

1. Facility policy titled, "Patient Transfer Process From [Facility Name] to Other Hospitals" last reviewed 06/10/22, stated, " ...Transfer Process. 2.) ...For patients [error - stable] for transfer, either the patient's request for and consent to the transfer, or the physician's certification outlining the risk and benefits of the transfer. ..."

On 06/10/25 at 10:46 AM, Patient (P) 5's medical record was reviewed and revealed the following:

On 02/08/25 at 5:20 PM, P5 arrived at the Emergency Department (ED) via ambulance, with a chief complaint of drug overdose.

At 5:25 PM, P5 was triaged, vital signs were obtained, and a Columbia Suicide Severity Rating Scale was conducted.

At 5:36 PM, P5 had a medical screening examination (MSE) by Staff (S)49. S49 documented in the "ED Provider Note" that P5's plan was for labwork, a psychiatric consultation, and a two to one observation of P5. S49 documented, "... MRI brain negative for acute stroke. Pt is now medically cleared pending psych eval ..."

Review of P5's medical record "Consult Notes" dated 02/08/25 at 10:28 PM, S50 documented " ...Plan is for voluntary admission ..."

Review of P5's medical record "ED Note" dated 02/09/25 at 7:17 PM, S50 documented, "...[P5] believes [he/she] could benefit from psychiatric admission and has signed for voluntary admission ..."

Review of P5's medical record "ED Turnover Note," dated 02/10/25 at 03:30 AM, S51 documented, "... Previously medically cleared incl [including] med [medical] tox [toxicology] consult, neuro consult. Pending vol [voluntary] admission ..."

Review of P5's medical record "ED Note," dated 02/10/25 at 9:01 AM, S52 documented, "... Plan is for psychiatric voluntary admission ..."

Review of P5's medical record "ED Note," dated 02/10/25 at 3:04 PM, S53 documented, "... "Pt taken to [facility name] via [name of transport company] with all belongings and paperwork."

The facility was unable to provide documentation of a transfer order or certification from the physician with the risk and benefits of the transfer.

On 06/10/25 at 1:18 PM, S24 confirmed the above findings.

On 06/11/25 at 10:40 AM, an interview with S10 was conducted. S10 explained the process of transferring a psychiatric patient to a facility. S10 stated that the ED physician medically clears the patient, a psychiatric evaluation and Crisis evaluation is completed, and the disposition of the patient is decided. The screeners will work on finding a bed for the patient. The ED physician will re-evaluate the patient, discuss the risks and benefits with the patient, sign the Transfer Form, and write a transfer order. S10 stated, "you have to put in a transfer order that contains why the patient is being transferred and where the patient is going." S10 explained that by signing the Transfer form, the physician is attesting that he/she has discussed the risks and benefits with the patient.

On 06/11/25 at 11:30 PM, S24 stated that the facility reached out to the accepting facility for clarification on P5's disposition.

On 06/11/25 at 12:35 PM, S55 was interviewed to provide clarification on P5's discharge disposition. S55 explained that the Crisis screeners use two systems: the facility Electronic Medical Record (EMR) and a Crisis EMR. S55 had documented in the Crisis EMR on 02/10/25 at 09:45 AM - "Screener saw and spoke to patient, the process was explained and explained the process of a bed search. The patient reported that if [he/she] is accepted at an outside hospital patient will sign [himself/herself] out because all [his/her] services are at [facility]. 9:50 am: Spoke to [psychiatrist] patient to be converted to involuntary...."

The facility was unable to provide documentation of the patient's involuntary status in the facility EMR. The facility was also unable to provide documentation of an update to the primary medical team from psychiatry on the conversion of P5 to involuntary status. These findings were confirmed with S4 (Director of Regulatory) and S24.

2. Facility policy titled, "Vital Signs," last reviewed 04/22/2025, stated, "... Procedure ... B. Patients who are in a waiting area of the ED shall have vital signs reassessed a minimum of every 4 hours. C. Vital signs shall be reassessed during the ED visit as indicated by the clinical acuity outlined below. Clinical acuity is determined by the Emergency Severity Index (ESI) during the triage process...ii. ESI 2: Every hour until stabilized and then a minimum of every 4 hours..."

On 06/10/25 at 10:03 AM, P6's medical record was reviewed and revealed the following:

On 02/01/25 at 2:43 PM, P6 arrived at the facility via ambulance with complaints of drug overdose.

At 2:44 PM, P6 was triaged, had vital signs taken, and was assigned an acuity level of "2."

At 2:51 PM, P6 had his/her blood sugar taken and returned to the waiting room.

At 9:14 PM, 6 and a half hours after triage, P6 had a second set of vital signs taken.

At 9:41 PM, the triage nurse wrote a note stating, "pt [patient] now aao [awake, alert, and oriented], ambulated to the bathroom, given sandwich to eat, left ed, gait steady."

At 9:42 PM, P6's Emergency Department (ED) Disposition was set to "Left without being seen."

The facility was unable to provide documentation of additional vital sign reassessments or a medical screening examination for P6.

On 06/10/25 at 1:10 PM, S24 reviewed P'6s chart and confirmed the above findings. S24 explained that per policy, a patient with an acuity level of "2" would have his/her vital signs taken every hour until stable and then every four hours after.


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3. Facility policy titled, "Triage," last reviewed on 04/14/2023, stated, " ... IV Procedure ... 3. A complete set of vital signs, pain assessment, and height and weight should be taken and documented in the EHR [Electronic Health Record] of all patients during triage."

Facility policy titled, "Nursing documentation: Assessment and Reassessment in the Emergency Department/ Emergency Department Observation Unit," last reviewed on 06/06/2023, stated, " ... IV. Procedure: Triage Assessment ... 2. Documentation in the EHR should include: ... f. Pain assessment ..."

A review of P7's Medical Record (MR) was conducted and revealed the following:

On 05/01/2025 at 11:27 AM, P7 arrived at the ED with complaints of arm pain.

At 11:44 AM, a set of vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) were completed by an ED staff member.

Review of P7's "Chief Complaints Updated" note at 11:48 AM, S36 documented, "Arm pain (c/o R [right] forearm pain, back pain s/p MVA [motor vehicle accident] last Saturday)."

At 11:50 AM, S36 documented, "Triage completed" and an acuity of 4 was assigned.

There was no evidence of a pain assessment during triage in P7's MR.

The above findings were confirmed with S24 on 06/10/2025 at 1:04 PM.

A review of P8's MR was conducted and revealed the following:

On 05/01/2025 at 6:49 PM, P8 arrived at the ED with complaints of blurred vision, chest pain, headache, and shortness of breath.

At 6:54 PM, S36 documented triage vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) and a triage acuity level of 3 was assigned.

At 6:58 PM, S36 documented, "Triage Completed."

There was no evidence of a triage pain assessment in P8's MR.

The above findings were confirmed with S24 on 06/10/2025 at 1:05 PM.

A review of P11's MR was conducted and revealed the following:

On 05/05/2025 at 9:49 AM, P11 arrived at the ED with complaints of seizures. P11's child reported that the patient had two episodes of seizure like activity at home. P11 has a history of cerebral aneurysms.

At 10:00 AM, S19 documented a set of vital signs (blood pressure, pulse, respirations, temperature, and pulse ox), S19 documented, "Triage Completed" and an acuity level of 3 was assigned.

There was no evidence of a triage pain assessment in P11's MR.

The above findings were confirmed with S24 on 06/10/2025 at 12:56 PM.

A review of P19's MR was conducted and revealed the following:

On 03/14/2025 at 6:58 AM, P19 arrived at the ED with complaints of CVA (cerebral vascular accident - stroke) symptoms.

At 7:13 AM, S47 documented triage vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) and a triage acuity level of 2 was assigned.

At 7:14 AM, S47 documented, "Triage Completed."

There was no evidence of a triage pain assessment in P19's MR.

The above findings were confirmed with S24 on 06/10/2025 at 1:38 PM.

4. Facility policy titled, "Nursing documentation: Assessment and Reassessment in the Emergency Department/ Emergency Department Observation Unit," last reviewed on 06/06/2023, stated, " ... 2. Pain assessment and reassessments must be completed as per the Pain Assessment and Management policy."

Facility policy titled, "Pain Assessment and Management," last reviewed on 02/2023, stated, "...V. Procedure:... 6. Pain reassessment should occur within two (2) hours from the time a patient is treated with a pharmacological or non-pharmacological intervention based on the actions of the medication and route of administration."

A review of P13's MR was completed and revealed the following:

On 05/17/2025 at 5:30 AM, P13 arrived at the ED with complaints of mid-sternal chest pain for six days.

At 6:30 AM, S45 administered ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID] used to relieve pain, reduce inflammation, and lower fever) 600 mg (milligrams) orally.

At 8:54 AM, S56 documented a pain assessment that states, "Pain Assessment: No/denies pain." The pain reassessment was not completed within two hours after medication administration as per facility policy.

This finding was confirmed by S24 on 6/10/2025 at 12:53 PM.

A review of P12's MR was conducted and revealed the following:

On 05/29/2025 at 8:42 AM, P12 arrived at the ED with complaints of seizures.

At 2:12 PM, a pain assessment documented by S36 stated, "Pain Assessment: Pain Score 10."

At 2:12 PM, S36 administered acetaminophen (a pain reliever/fever reducer medication) 650 mg orally and ketorolac (an NSAID used to treat moderate to severe pain) injection 15 mg IV (intravenous).

At 5:47 PM, a pain assessment documented by S44 stated, "Pain Assessment:... Pain Score: 4." The pain reassessment was not completed within two hours after medication administration as per facility policy.

On 06/10/2025 at 12:55 PM, an interview was conducted with S24. When asked what the process is for pain reassessment after medication administration, S24 stated, "pain should be reassessed one hour after meds are given."

The above findings were confirmed with S24 on 06/10/2025 at 12:55 PM.


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A review of P14's MR was conducted and revealed the following:

On 01/22/25 at 2:09 PM, P14 arrived at the ED with a complaint of back pain.

At 2:19 PM, P14's pain was documented as 10/10 on a pain scale.

At 4:51 PM, P14 received 975 mg of acetaminophen orally, 15 mg of ketorolac intravenously, and 15 mg of morphine orally for pain relief.

P14's medical record does not display another pain assessment until 01/23/25 at 6:31 AM, 4/10 on a pain scale. The pain reassessment was not completed within two hours after medication administration as per facility policy.

This finding was reviewed upon exit conference on 06/11/25 at 2:04 PM.