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HOLY CROSS HOSPITAL 4725 N FEDERAL HWY FORT LAUDERDALE, FL 33308 Sept. 25, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on clinical record review, staff interview and policy review, the hospital failed to comply with Requirements at 489.24. The hospital emergency service personnel failed to provide triage evaluation and medical screening examination to determine if a patient emergency medical condition existed. This affected 1 of 20 sampled patients, Patient #7, who presented to the hospital emergency department for treatment of a psychiatric emergency. See findings at A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on clinical record review, staff interview and policy review, the hospital emergency service personnel failed to provide triage evaluation and medical screening examination to determine if a patient emergency medical condition existed. This affected 1 of 20 sampled patients, Patient #7, who presented to the hospital emergency department with a psychiatric emergency.

The findings include:

Review of the facility policy titled Emergency Department (ED) Patient Registration Walk-In Policy, effective 01/01/2008 (no policy number documented on form) revealed: policy is to register all patients who present to the ED in a timely manner without causing any delay in patient care regardless of their ability to pay or insurance status ... 'When a patient presents to the ED the PAR (patient access representative) will place them on the tracker and immediately alert the triage nurse if any individuals present with the below complaints: ...psychiatric disturbances or substance abuse..."
Review of the Triage policy NS-50-844, titled Triage in the Emergency Department (ED) revealed: Purpose: ED ensures care is provided to patients with emergency medical conditions, including female patients with contractions, when requested by the patient, an EMS provider on behalf of the patient and another hospital seeking a medical necessary transfer for a stabilized patient. Medical Screening is initiated ASAP and the patient's ability to pay is not questioned before this occurs. Triage is a process by which patients are evaluated and classified according to the type and acuity of their condition, for the purpose of determining treatment priorities. Patients are identified promptly using rapid assessment and comprehensive triage assessment to maintain patient flow through the emergency department. Policy: The registered emergency nurse triages each patient & determines the priority of care based on physical, development, and psychosocial needs, as well as factors influencing access to health care and patient flow through the emergency care system...Utilizes the Emergency Severity Index Five-Level triage system to determine priority of care. The five levels are: Level I (Resuscitations, Immediate Care, Life Threatening Conditions); Level II (Major Illness or Injury-emergency), Level II (Urgent), Level IV (SemiUrgent) and Level V (Non Urgent). Procedure: Under 1 - The chief complaint is received and recorded at the time of presentation; Under 2 - The Triage nurse then performs an assessment to determine severity of illness and priority of care using the Emergency Severity Index-five Level System; A combination of rapid triage & comprehensive triage is used; Immediate bedding following triage is the preferred process when open beds are available ...Under 5 - The triage nurse is responsible for patients who have been triaged and awaiting an assigned emergency treatment bed ...Critical thinking, prioritization and communication between the triage nurse, charge nurse and emergency physician ensures emergency care is initiated as soon as possible ..."

Review of the ED Clinical file for Patient #7 revealed: Patient # 7 presented to the Emergency Department (ED) on 9/4/2014 at 2237 hours (10:37 PM) with the Triage nurse note of Stated Complaint: 'Suicidal Thoughts, Panic Attack'; Chief Complaint: Triage and Chief Complaint History: 09/04/2014 2237 (10:37 PM) Triage.' The triage registered nurse's note of 11:08 PM (2308 hours) documented: no known allergies and 'Parent with patient states patient wants to kill self, went to' another local acute care hospital. There was no further documentation or triage completed or a Priority documented. There was no evidence the Emergency Department physician was notified. There was no evidence of a medical screening examination completed to determine if a medical emergency existed. There were no additional notes or documentation provided related to this patient's visit to the ED on 9/4/2014.

Interview with the Chief Nursing Officer (CNO) on 9/25/14 at approximately 9:40 AM revealed Psychiatric services are offered in the Emergency Department (ED), but they do not have an inpatient psychiatric unit in the hospital. If needed the patient will be transferred to a psychiatric receiving facility.

An interview with the Registered Nurse Manager of the Emergency Department on 09/25/2014 at 10:02 AM with the CNO present, revealed the manager said: If a patient presents at registration, we will do a quick registration (ID, chief complaint and if any allergies); at this point, ID bands are printed and placed on the patient's wrist and labels are given to the Triage nurse. At triage, depending on the chief complaint, if emergent, the patient will be put in the emergency triage area to go to treatment area. If the patient is more stable, they can be triaged by this nurse at the quick registration desk area. In the case of Patient #7, he says he spoke with the nurse and was told the parent said the child was suicidal and asked what the hospital process was. The parent was told the process is to go to back to see the physician who will provide transfer if needed. The parent said this is ridiculous and didn't want to wait. The parent asked where the closet psychiatric facility was, and was given the name of another acute care hospital. The parent didn't want to wait, and left; no vital signs were done, and no other nursing or medical screening was done. He said the documentation was faulty here. The CNO agreed. The ED Manager said the parent did not want to waste time and wanted to leave the ED and no AMA (against medical advice) form was signed as the patient had not seen a medical person. The patient was not triaged and the ED physician did not evaluate the patient prior to leaving the ED. The nurse manager said the triage nurse did not document this information in the patient medical record, and the ED physician was not notified.

A telephone interview was conducted on 9/26/14 at approximately 5:10 PM with the triage registered nurse (RN) who was on duty on 9/4/14. She stated the child with parents arrived in the ED. The child had a history of depression and that day wanted to kill herself. She was told the child had attempted to take pills, but the father was able to take the pills before the child took them. The parent asked whether the hospital was a psychiatric hospital, " I told them no, but we see psychiatric patients." The parent asked if this is not a psychiatric hospital, what is the process? She told them, the ED doctor would evaluate and decide if a transfer was needed. The parent asked, if they could go to the psychiatric hospital (the RN said, she thought they meant to visit if the child was there) so she said yes. They said, if this is not a psychiatric hospital, we will go. She told them again that they are here already, and it is best to see the doctor. She asked them to wait and she would talk with charge nurse. The RN went to speak with charge nurse who was involved in a transfer related to patient with cardiac arrest. The charge nurse said if the patient was not triaged, it was okay to go to the psychiatric hospital. The RN said, she asked the parents if the child would be under their care at all times, and they told her, yes, but she said they should stay here and see the ED doctor. The Parent /Mom said, no, and they left the ED.
The RN said, she gets mandatory Emergency Medical Treatment and Labor Act (EMTALA) training each year and had it in 2013 & was aware of the process for triage and medical screening, but the parents wanted to leave even before triage was done. She said they have had additional training since this time (9/4/14).

Review of the service capabilities listed on the facility license revealed that Psychiatry is a provided service. Observation of the posted Emergency Department services in the main lobby on 9/25/14 at approximately 12:50 PM revealed that Psychiatric services were a provided service.

Review of the On-call specialty list for the month of September 2014 and on 09/04/2014, when Patient #7 presented to the ED, revealed there was a psychiatric physician on call.

Further interview with the CNO and the ED Manager on 9/25/14 at approximately 10:00 AM revealed, they agreed there was a lack of documentation on the nurse's part for Patient #7. They agreed, the triage nurse should not have provided additional information to the parent, but should have followed the process and at least have contacted the ED physician.

Interview with the ED Medical Director on 9/25/2014 at approximately 10:19 AM revealed: If a patient refuses any care, the nurse should contact the physician and speak with the physician saying something like, 'the patient wants to leave and could you speak with them to maybe ensure they are seen and have a medical screen exam done'. The Medical Director said it would be his expectation that the triage nurse would speak with the physician prior to the patient leaving the ED if at all possible. The Medical Director said, he and the ED physicians would see any patient who comes or presents to the ED.