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WINTER HAVEN HOSPITAL 200 AVE F NE WINTER HAVEN, FL 33881 Feb. 12, 2015
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure staff followed their policy for Triage and Chest Pain Protocol for four (#1, #3, #4, #5) of ten patients reviewed and leaving without being seen. The facility failed to ensure staff followed their policy for leaving against medical advice for two (#7, #8) of ten patients reviewed.

Findings include:

1. Patient #1 presented to the ED (Emergency Department) on 01/03/2015 at 9:19 p.m. for complaints of left sided chest pain. Documentation revealed the patient was triaged by the nurse at 9:27 p.m. A medical screening exam was initiated by the physician at 10:00 p.m. The documentation revealed the patient's vital signs were initially taken in triage with the patient's blood pressure recorded but did not state from which arm the blood pressure was taken. Documentation revealed the patient waited in the main ED until 10:01 pm.

Review of the facility policies titled: "Triage", #NA, Issued 07/1985, Revised 01/2014 and "Triage Responsibility", #NA, Issued 08/1993, Revised 01/2014 stated: Patients will be evaluated and categorized, according to the "Triage Procedure, within fifteen minutes and appropriate information will be collected". A review of the facility protocol titled: "Chest Pain Emergency Services Protocol", #NA, Issued 12/2002, Revised 01/2014 stated: assessment of patient's vital signs including B/P (Blood Pressure)in both arms and if the patient is currently experiencing chest pain the patient will be transported to a treatment room and heart monitor applied and oxygen will be administered at two (2) liters per minute by nasal cannula. An EKG will be ordered and repeated in 30 minutes and the emergency room physician will be notified.

Review of the documentation with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 3:00 p.m. confirmed the findings.

2. Patient #3 (MDS) dated [DATE] at 4:44 p.m. for complaints of shortness of breath and chest pain. Documentation revealed the patient was triaged by the nurse at 5:21 p.m. A medical screening exam was initiated by the physician at 9:08 p.m. The documentation revealed the patient's vital signs were initially taken in triage with the patient's blood pressure recorded but did not state from which arm the blood pressure was taken. Documentation revealed the patient waited in the main ED until 8:38 p.m.

Review of the facility policies titled "Triage", #NA, Issued 07/1985, Revised 01/2014 and "Triage Responsibility", #NA, Issued 08/1993, Revised 01/2014 stated: Patients will be evaluated and categorized, according to the "Triage Procedure, within fifteen minutes and appropriate information will be collected". A review of the facility protocol titled "Chest Pain Emergency Services Protocol", #NA, Issued 12/2002, Revised 01/2014 stated: assessment of patient's vital signs including B/P in both arms and if the patient is currently experiencing chest pain the patient will be transported to a treatment room and heart monitor applied and oxygen will be administered at two (2) liters per minute by nasal cannula. An EKG will be ordered and repeated in 30 minutes and the emergency room physician will be notified.

Review of the documentation with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 3:00 p.m. confirmed the findings.

3. Patient #4 (MDS) dated [DATE] at 9:39 p.m. for complaints of chest pain. Documentation revealed the patient was triaged by the nurse at 9:39 p.m. A medical screening exam was initiated by the physician at 10:20 p.m. The documentation revealed the patient's vital signs were initially taken in triage with the patient's blood pressure recorded but did not state from which arm the blood pressure was taken. Documentation revealed the patient waited in the main ED until 10:04 p.m.

Review of the facility policies titled "Triage", #NA, Issued 07/1985, Revised 01/2014 and "Triage Responsibility", #NA, Issued 08/1993, Revised 01/2014 stated: Patients will be evaluated and categorized, according to the "Triage Procedure", within fifteen minutes and appropriate information will be collected". A review of the facility protocol titled: "Chest Pain Emergency Services Protocol", #NA, Issued 12/2002, Revised 01/2014 stated assessment of patient's vital signs including B/P in both arms and if the patient is currently experiencing chest pain the patient will be transported to a treatment room and heart monitor applied and oxygen will be administered at two (2) liters per minute by nasal cannula. An EKG will be ordered and repeated in 30 minutes and the emergency room physician will be notified.

Review of the documentation with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 3:00 p.m. confirmed the findings.

4. Patient #5 (MDS) dated [DATE] at 9:51 a.m. for complaints of chest pain. Documentation revealed the patient was triaged by the nurse at 9:56 a.m. A medical screening exam was initiated by the physician at 10:39 a.m. The documentation revealed the patient's vital signs were initially taken in triage with the patient's blood pressure recorded but did not state from which arm the blood pressure was taken. Documentation revealed the patient waited in the main ED until 10:04 p.m.

Review of the facility policies titled: "Triage", #NA, Issued 07/1985, Revised 01/2014 and "Triage Responsibility", #NA, Issued 08/1993, Revised 01/2014 stated: Patients will be evaluated and categorized, according to the "Triage Procedure, within fifteen minutes and appropriate information will be collected". A review of the facility protocol titled "Chest Pain Emergency Services Protocol", #NA, Issued 12/2002, Revised 01/2014 stated assessment of patient's vital signs including B/P in both arms and if the patient is currently experiencing chest pain the patient will be transported to a treatment room and heart monitor applied and oxygen will be administered at two (2) liters per minute by nasal cannula. An EKG will be ordered and repeat in 30 minutes and the emergency room physician will be notified.

Review of the documentation with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 3:00 p.m. confirmed the findings.

5. Patient #8 (MDS) dated [DATE] at 5:57 p.m. for complaints of chest pain. Documentation revealed the patient was triaged by the nurse. A medical screening exam completed by the physician. The physician recommended the patient be admitted for monitoring. Documentation by the physician revealed the patient refused to be admitted and choose to leave AMA (Against Medical Advice). Review of the record revealed the nurse documented the patient left without being seen prior to triage although documentation revealed documentation of the triage assessment. Review of the physician documentation timed at 10:32 p.m. revealed the patient's disposition was "AMA-Eloped". Review of the record revealed the patient signed discharge instructions. There was no evidence the patient was explained the risk factors to his health status if medical treatment was not continued. There was no evidence the patient signed an AMA form as required by facility policy.

Review of the facility policy, "Consent Section: Discharge Against Medical Advice", last reviewed 12/2013, stated (6) obtain patient's signature on "Discharge Against Medical Advice (AMA) form. If the patient refuses to sign place check in the box to document.

Interview with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 4:00 p.m. confirmed the above findings.

6. Patient #7 (MDS) dated [DATE] at 8:56 p.m. for complaint of difficulty breathing. The nurse completed the triage assessment. At 9:01 p.m. a respiratory treatment was provided. Nursing documentation revealed the patient left without being seen by the physician. Review of the record revealed the patient signed a form providing the patient with information stating the importance of being seen by the provider. Review of the form revealed no evidence of a date, time, or witness signature.

Review of the form with the Regulatory Compliance Coordinator on 2/12/2015 at approximately 4:00 p.m. confirmed the form should have been dated, timed and witnessed by a staff member.