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Review of 10 closed ED records revealed 7 of 10 patients did have an assigned triage level, yet the hospital could provide no policy by which to guide those triage level assignments, nor to standardize the assignment of triage levels to all presenting patients.

Additionally, no MSE policy was found to delineate the appropriate parameters of a MSE, or the qualifications of clinicians who could conduct a MSE. Further, review of the hospital Bylaws, Rules and Regulations revealed no information related to the qualifications of clinicians who were authorized to conduct a MSE. The hospital failed to identify qualified medical personnel either in policy or in credential files.

In addition, the ED had no initial or periodic competency evaluation or training of nursing personnel in the ED. RNs who floated from other areas were found to lack specific competencies related to their EMTALA obligations. The hospital did provide a video used for training RNs and MDs but the individual personnel or credentialing files of two ED physicians and two ED RNs did not contain indications that training had been completed.

The absence of these ED policies, along with inadequate personnel practices, meant the hospital failed to standardize and meet regulatory foundations of care for patients presenting to the ED.