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Based on review of policies and procedures, hospital documents clinical records and staff interviews, it was determined the hospital failed to enforce polices and procedures that comply with the requirements of 42CFR §489.20 and 42 CFR §489.24, responsibilities of Medicare participating hospitals in emergency cases.


SUMMARY OF FINDINGS:

Hospital policy titled, "Triage, Registration, and Treatment", revealed: " ...I Procedure: A. Triage 1. As soon as practical after arrival, individuals who came to the Dedicated Emergency Department of Facility will be triaged by clinical staff to determine the order in which they will receive a MSE ...."

Patient #1 ED Patient Depart Summary dated [03/28/2023] revealed Patient #1's arrival time as [1959]. ED Discharge Time: [2041 on 03/28/2023].

The hospital failed to provide vitals or ESI to Patient #1.

Employee #3 confirmed on 06/19/2023 during a medical review that Patient #1 arrived to the ED on [03/28/2023 at 1959]. Employee #3 further confirmed that Patient #1 did not receive vitals. Employee #3 confirmed that Patient #1's discharge time was [2041]. Employee #3 further confirmed that Patient #1 was marked as an LWOT.

Based on review of polices and procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the medical record was complete with all required documentation for one (1) patient (Patient #1).

FINDINGS INCLUDE:

Hospital policy titled, "Care Expectations and Documentation", revealed: " ...II PURPOSE: To provide guidelines for nursing care and nursing documentation in the Emergency Department, to ensure thorough, pertinent patient care and to ensure that treatment is accurately documented ...
A review of Patient #1 ED Patient Depart Summary medical record revealed: " ...Arrival [03/28/2023 1959] ED Discharge Time [03/28/2023 2041] ...."

A review of Patient #1 ED Disposition medical record revealed: " ...ED Disposition Entered On: [03/29/2023 18:32] by Employee #11 ... Preformed on: [03/28/2023 1959] ...Discharged: [Abrazo Arrowhead Campus] entered on [03/29/2023 1828] by Employee #11 ...ADH Disposition ED Disposition: LWOT ...ED Condition: Other: lwot entered on [03/29/2023 1828] by Employee #11 ...."

Employee #3 confirmed during a medical record review on 06/19/2023 that Patient #1's ED Disposition was entered as LWOT on [03/29/2032 at 1828] by Employee #11. Employee #3 further confirmed that Patient #1's discharge time and date was entered as [03/28/2023 1959] on [03/29/2023 1828] by Employee #11. Employee #3 confirmed that according Patient #1 medical record that Patient #1 registered at [1859] and was entered as a LWOT at [1859].

Employee #3 confirmed during a medical review on 06/19/2023 that they were unable to explain the discrepancy on the Patient #1's medical record entry.

Based on review of policies and procedures, hospital documents, clinical records, and staff interviews it was determined the hospital failed to provide a Medical Screening Examination to Patient #1 who presented to the ED on 03/28/2023 for complaints of an arm injury.

SUMMARY OF FINDINGS:

Hospital policy titled, "Emergency Medical Treatment and Labor Act of 1986 (EMTALA)", revealed: " ...IV Policy ...An individual is deemed to have come to the Dedicated Emergency Department if the individual: 1. Presents at a Dedicated Emergency Department and requests examination or treatment on a medical condition ...2. Presents on the Facility Property, other than a Dedicated Emergency Department, and requests examination or treatment for what may be an emergency medical condition ...V. Procedure: A. Abrazo Market will provide an appropriate MSE within the capability of Abrazo Market to any individual coming to the Dedicated Emergency Department ...."

Hospital policy titled, "Triage, Registration, and Treatment", revealed: " ...I Procedure: A. Triage 1. As soon as practical after arrival, individuals who came to the Dedicated Emergency Department of Facility will be triaged by clinical staff to determine the order in which they will receive a MSE ...."

Hospital policy titled, "Rapid Intake", revealed: " ...I PURPOSE: To provide rapid assessment and priority placement of patients who present to the Emergency Department for care. All patients presenting to the Emergency Department will be evaluated and categorized to determine the urgency of each patient's needs ...II. Procedure: 1. Patients who present to the Emergency Department will be evaluated upon arrival. The information recorded on the medical record by the RI/Triage nurse will include: A. presenting chief complaint B. vital signs C. Allergies ...."

Hospital policy titled, "AMA (Against Medical Advise)", revealed: " ...I. PURPOSE: Patients at Abrazo Arrowhead Campus will have the right to accept medical care or refuse medical treatment to the extent permitted by law and to be informed of the material medical risks of such refusal ...III. RESPONSIBILITIES: Registered Nurse-Advises physician caring for patient that patient is refusing procedure(s). Physician-Establishes competency of patient and documents this information on chart ...Documentation must use the e-Demand form #EDEMF2008 - Leaving or Refusal of Treatment Against Medical Advice ...."

A review of Patient #1 ED Patient Depart Summary medical record revealed: " ...Arrival [03/28/2023 1959] ED Discharge Time [03/28/2023 2041] ...."

A review of Hospital #1 ED Log from [March 2023] revealed Patient #1: " ...arrived at [1959] on [03/28/2023] ... Assigned a room at [2029] ...Disposition LWOT ...Discharge time [2038] ...."

Further review of Patient #1 medical record for Hospital #1 revealed no documentation of attempts to located Patient #1. Review of Patient #1 medical record from Hospital #1 revealed no evidence of the Leaving or Refusal of Treatment Against Medical Advice form.

A review of Patient #1 medical record from hospital #2 revealed: " .... Registered at [Phoenix Children Urgent Care at 2035] ...Triaged at [2044] ....Consent to transfer for higher level of care [2105] ...registered at [Phoenix Children's Hospital ED at 2141] ...Triaged at [2145] ...ESI 3 ...MSE [2227] ...Discharged at [0016 on 03/29/2023] ..."

A total of 22 ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Three (3) of the twenty-two (22) patients left after triage and no Leaving or Refusal of Treatment Against Medical Advice form or nursing note was on file. One (1) of the twenty-two (22) patients left before triage and no Leaving or Refusal of Treatment Against Medical Advice form or nursing note was on file. One (1) patient of the twenty-two (22) patients that left after triage had documentation on file.


Observation while on tour of the Emergency Department on 06/19/2023 revealed one (1) Patient Access Technician who registers the patients, one (1) Emergency Department Technician who can assess heart rate and oxygen saturation, and one (1) Nurse who triages the patients at the registration desk.

Employee #3 confirmed on 06/19/2023 during the medical record review that Patient #1 registered on [03/28/2023 at 1959]. Employee #3 further confirmed that vitals were not obtained on Patient #1. Employee #3 confirmed that Patient #1's final disposition was LWOT and no documentation was on file.

Employee #3 confirmed on 06/19/2023 that a nursing notes or documentation of patients LWOT is currently not documented in the patients' medical record. Employee #3 further confirmed that no further documentation is required except changing the patient status to LWOT in the EMR system.

Employee #3 confirmed during an interview on 06/14/2023 that the facility does not document the time that the patient is initially called back for triage. Employee #3 further confirmed that they do not documents how many times they call out for the patient before marking the patient LWOT.

Employee #8 confirmed on 06/19/2023 that a patient will walk into the facility and register at the registration desk. Employee #8 further confirmed that the patient is asked for name, symptoms and insurance, if available. Employee #8 states that they have a clear view of when a patient is leaving the facility. Employee #8 confirmed that they will notify the charge nurse if a patient would like to leave and if the patient does leave will document that the patient left the facility in the EMR system.