The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


1. Based on review of policies, interview, and observations it was evident that the emergency department (ED) failed to formulate and implement a policy and prodedure to ensure a timely and accurate triage process.

Findings include:

During the ED tour on 2/11/13 at 1230 it was observed that the security guard in the waiting room greeted the patients and instructed them to fill out a slip of paper that included information regarding " reason for coming to the ED". This information is inserted into a time stamp machine. The guard was observed giving the slip of paper to the ED registration clerk who interviewed the patient and provided a " mini-registration " that included the chief complaint. This process created an entry into the ED log as " arrival time. "

Patients are then called into triage by the triage nurse once the mini-registration process is complete.

At interview with the security guard on 2/11/13 at 1300 and 2/13/13 at 1430, it was stated that he will inform the triage nurse if the patient looks ill, is asthmatic, or has chest pain.

At interview with the ED clerk on 2/11/13 at 1315, it was stated that the triage nurse will be informed immediately if the patient appeared to be ill.

Review of the ED triage policy and procedure on 2/12/13 found no reference to this process.

Review of the job description of security guards and ED reigistration clerks found no reference to this practice.


2. Based on interviews, tours of the Emergency Department, the review of medical records and policies, it was determined that the facility did not have an effective process to ensure timely triage and assessment of patients upon arrival to the Emergency Department. Specific reference is made to the lack of timely triage and the failure to implement appropriate Emergency Department protocol for 13 of 45 records reviewed.

Findings include:

1. Review of MR #1 revealed that there was no timely assessment of this patient upon arrival at the ED. The patient is a 1year [AGE] years old male brought in by ambulance on 12/17/12 accompanied by his mother. Although the ED record indicated that the patient arrived at 1951 with complaint of seizures, the Ambulance Call Report (ACR) revealed the patient was signed off by the Ambulance Technician at 1926. The Receiving RN signature was noted at 1945. The Receiving RN documented that the patient received Motrin 100mg as per physician verbal order at 1945.

The ED nurse at 01:40 on 12/18/12 documented that the patient left the ED before triage. There was conflicting documentation in the ED record regarding the patient time of departure. The nurse noted that the patient did not respond when called for triage on 12/17/12 at 2000 and at 2015. Another note indicated that the patient departed at 0228 on 12/18/12, more than six hours after his arrival in the ED.

The information provided in the medical record is contrary to the account provided by the patient's mother on 12/20/12 who stated that upon arrival on 12/17/12 at 1930, she was directed to wait at the pediatric section of the ED. She stated that she left the ED with her baby at 2030 after waiting 60minutes without an assessment.

(a)The patient's record failed to show a timely triage assessment upon arrival to the ED.

(b)There was no vital signs documented in the record, hence the indication for administering Motrin to the patient was not established.

(c) The facility's policy on verbal orders was not implemented. The nurse did not write the verbal order for Motrin on the Physician's Order Sheet.
There is no evidencee that the Attending Physician reviewed the order and signed the Physician's Order Sheet within twenty-four hours as per the policy.

2. MR #2 is a 3year [AGE] years old female who was brought to the ED on 01/13/13 at 0030 by her parent with complaints of fever of 102 degree Fahrenheit, coughing, running nose, and chills. There was no evidence of a timely triage upon arrival of the patient. The triage nurse noted that the patient did not respond when called for triage at 0227, which was two hours after arrival to the ED.

3. MR #3, a 3 year-old female presented to the ED with a chief complaint of asthma on 01/04/13 at 0914. There was no documentation of a triage assessment in the medical record. The patient was registered at 0948, and departed the ED at 1738. The record lacked evidence of a medical screening examination and treatment of the patient's medical condition.

4. MR #4, an [AGE] year-old female (MDS) dated [DATE] at 2217 with complaint of eye problems. The patient was noted to have departed the ED at 0311 without a triage assessment and medical screening examination.

5. MR #5 is a [AGE] year-old female who arrived in the ED on 1/30/13 at 1335 with a chief complaint of chest pains. The triage assessment was initiated at 1445. The Emergency Department policy and procedure manual titled "Acute Coronary Syndrome" revised on July, 2012 was not implemented. This policy and procedure indicates that an EKG should be obtained within 10 minutes of arrival to the Emergency Department for the purpose ensuring prompt evaluation and appropriate treatment of all patients presenting with chest pain. The EKG was obtained at 1447, about 70 minutes after the arrival of the patient.

6. MR #6, a [AGE] year-old male arrived in the ED on 01/04/13 at 2256. The triage assessment was initiated at 0304 on 01/05/13, more than 4 hour hours after arrival in the ED . The patient's chief complaint was chest pain with a pain intensity of 8/10. An ESI Level 3 was assigned.
The patient did not have a timely electrocardiogram within 10 minutes of arrival of the ED as indicated in the Emergency Department policy and procedure manual titled Acute Coronary Syndrome. The EKG was ordered at 0342 on 01/05/13 and completed at 0458, about 6 hours after the patient's arrival.

7. MR #7 is a [AGE]-year-old female who was triaged at 1033 on 01/10/13 with a chief complaint of chest pain. Although the EKG was completed immediately after triage at 1039, the Acute Coronary Syndrome protocol that requires the EKG to be obtained within 10 minutes of arrival was not implemented. The patient's EKG was obtained 77 minutes of the patient's arrival to the ED.

8. Similar findings regarding delay of EKGs for patients presenting with chief complaint of chest pains were noted in MR #8 and #9.

MR #8, a [AGE] year-old female arrived at 1112 on 01/03/13 and triaged at 1221. The EKG was obtained at 1348, 2 hours 36 minutes after the patient arrived in the ED. The EKG revealed normal sinus rhythm with non specific T wave abnormality. The patient departed the ED at 1500 without medical evaluation.

MR #9, a [AGE] year old male with chief complaint of chest pain, arrived at 0930 on 01/03/13. The patient was triaged at 1000 and EKG obtained at 1012, about 42 minutes after arrival in the ED.

9. MR #10 is a [AGE] year-old male with a medical history of asthma who (MDS) dated [DATE] at 0149 with a chief complaint of difficulty breathing. The patient was triaged 22 minutes later and was classified ESI 3. The patient was not reassessed by the assigned nurse until 1034, more than eight hours after triage. The Emergency Department Policy and Procedure titled "Assessment of patients in the ED" notes that patients triage as ESI level 3 will be assessed and vital signs obtained no less frequently than every four hours after the initial triage assessment.

The physician initial assessment of the patient at 0747 indicated that the patient already had 4 doses of albuterol via nebulizer with some improvement in symptoms. The ED record however did not reflect these treatments. The time of administration and the patient response to treatment were not documented. Physician orders were only noted for Prednisone and Guaifenesin at 0900 on 1/5/13. The patient was noted to have been discharged and departed the ED at 1056 on 1/5/13.

10. MR #11 is a [AGE] year-old female who presented with complaint of fever on 1/03/13. The triage assessment was not timely. It was initiated at 1855, about 1 hour and 30 minutes after the patient's time of arrival in the ED. The patient was assigned ESI Level 4 with stable vital signs documented. The nurse noted that the patient departed the ED at 2130 prior to having a physician assessment.

11. Similarly, MR #12, a [AGE] year-old female with complaint of wheezing and asthma arrived at 1715 on 01/03/13 and triaged 2 hours later at 1917. The triage assessment did not include a focus evaluation based on the patient's chief complaint. There was no documentation of the presence or absence of wheezing at the time of triage. The patient was noted to have departed the ED at 2110 without physician assessment and an appropriate treatment for her respiratory condition.

12. MR #13 is an [AGE] year-old female who arrived in the ED at 2311 on 01/20/13. The triage assessment initiated 86 minutes later at 0036 on 01/21/36 noted complaints of poor appetite, nausea, vomiting with streaks of blood. The triage assessment did not include a pain assessment and a triage level to determine the urgency of the patient's symptoms and the priority for medical evaluation. The patient was noted to have departed the ED at 1550, more than 16 hours after arrival in the ED. The ED log revealed that the patient walked out after triage.

During the tour of the Emergency Department on 02/11/13 and 02/13/13, it was observed that the facility's triage process changed from the plan stated in a previous EMTALA survey conducted on 05/22/12. The approved plan indicates that walk in patients upon arrival are required to complete a form which indicates date and time of arrival, their name and reason for visit.
The form is given to a prescreening nurse/greeter who completes a prescreening of the patient. The patient then proceeds to the Triage Nurse for a complete assessment. It was observed during the tour that the prescreening nurse/greeter role was eliminated. Currently, a security guard hands the form completed by the patient to the Business Associate for a mini registration. The form then goes to the triage nurse who prioritizes care based on the symptoms stated on the forms. This new triage process eliminates the face to face assessment of the patient by qualified personnel upon arrival to the ED. Based on observation on 02/11/13 and 02/13/13 at 1200 to 1330, patients are seen by the triage nurse in close view only when they are called for a triage assessment.

At interview with the Assistant Nursing Director of the ED/ICU on 02/11/13 at 1230, she stated that triage assessment takes an average of 4-5 minutes. One nurse is assigned to triage from 2300 to 1100 and two nurses during the peak period from 1100 to 2300. In addition, the triage nurses have been directed to call for assistance when there are up to five patients waiting for triage assessment. However, the review of the facility's triage data from 02/01/13 through 02/14/13 regarding comparing the time lapse between patient arrival and triage revealed that some patients waited extensively for triage.