HospitalInspections.org

A. Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that pain assessments and reassessments are conducted according to facility policy.

Findings include:

Reference #1: Facility policy, Pain Management states, "... C. Patients... can expect... 2. To participate in the decision making process regarding pain management options to insure effective treatment, including the right to... treatment... III. PROCEDURE A. Screening for pain is completed as part of the patient's initial evaluation... It is documented in the electronic medical record. B. If pain is identified, a comprehensive pain assessment consistent with the patient's condition is performed and documented... The assessment may include, as appropriate, pain intensity (using standardized pain rating scale), location, quality... C. All inpatients are screened for new onset/site of pain and are assessed/reassessed regarding their pain intensity and pain relief... E. Intervention... 1. Effective pain management will include the use of both pharmacologic and non-pharmacologic methods of control. ... All interventions will be documented. ... ."

Reference #2: Facility policy, Vital Signs states, "... A. All patients presenting to the Emergency Department/S.E.D. will have vital signs taken upon triage/first assessment. Additional vital signs will be taken for re-assessment at a minimum of four (4) hours and at time of discharge. ... G. Complete vital signs will include temperature, pulse, respiration, blood pressure, pulse ox and pain assessment. ... ."

1. Review of Medical Record #2 on 3/14/19 revealed the following:

a. The patient arrived to the ED on 3/13/19 at 8:11 AM with complaints of nausea, anxiety and hypertension.

b. The patient was triaged at 8:17 AM and initial vital signs were taken. There was no pain assessment documented at this time.

c. Review of the nurse's notes indicated that at 12:39 PM, the patient complained of moderate back pain rated 7 out of 10 on the numeric pain scale.

d. There was no evidence that pain interventions were performed.

2. Review of Medical Record #6 on 3/14/19 revealed the following:

a. The patient arrived to the ED on 10/19/18 at 10:48 PM with complaints of suicidal ideation.

b. The patient was triaged at 10:58 PM and initial vital signs were taken. There was no pain assessment documented at this time.

c. Review of the nurse's notes indicated that on 10/20/18 at 12:03 AM, the patient complained of abdominal pain rated five (5) out of ten (10) on the numeric pain scale.

d. There was no evidence that pain interventions were performed.

3. Review of Medical Record #7 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 10/19/18 at 12:00 PM with complaints of suprapubic pain for four (4) days.

b. The patient was triaged at 12:09 PM. The patient's pain assessment upon triage indicated that the patient rated his/her pain eight (8) out of ten (10) on the numeric pain scale.

c. Review of the MAR on 10/19/18 indicated that the patient was medicated for pain at 5:01 PM, four (4) hours and fifty-two (52) minutes after his/her initial complaints of pain.

d. The nurse's notes indicated that the patient's pain was reassessed at 6:05 PM, five (5) hours and fifty-six (56) minutes after the patient's initial pain assessment.

4. Review of Medical Record #10 on 3/14/19 revealed the following:

a. The patient arrived to the ED on 10/19/18 at 1:11 PM with complaints of abdominal pain, nausea, and vomiting.

b. The patient was triaged at 1:20 PM and initial vital signs were taken. There was no pain assessment documented at this time.

5. Review of Medical Record #13 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 10/20/18 at 7:04 PM with complaints of lightheadedness, dizziness, and hypotension.

b. The patient was triaged at 7:06 PM and initial vital signs were taken. The ED triage note states, "Pain Present: Yes."

i. The pain assessment did not include a pain intensity score, pain location, or the quality of the pain.

ii. There was no evidence that pain interventions were performed.

6. Review of Medical Record #14 on 3/15/19, revealed the following:

a. The patient arrived to the ED on 9/22/18 at 11:00 PM with complaints of a fall, resulting in the patient hitting his/her head and left knee.

b. The patient was triaged at 11:12 PM. The patient's pain assessment upon triage indicated that the patient rated his/her pain seven (7) out of ten (10) on the numeric pain scale.

c. There was no evidence that pain interventions were performed.

d. There was no evidence in the medical record that the patient's pain was reassessed.

7. Review of Medical Record #19 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 11/17/18 at 5:30 AM with complaints of a laceration to the foot and thigh.

b. The patient was triaged at 6:25 AM and initial vital signs were taken. The ED triage note states, "Pain Present: Yes."

i. The pain assessment did not include a pain intensity score, pain location, or the quality of the pain.

ii. There was no evidence that pain interventions were performed.

8. Review of Medical Record #22 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 12/31/18 at 10:29 AM with complaints of a severe headache and blurred vision.

b. The patient was triaged at 10:31 AM and initial vital signs were taken. The ED triage note states, "Pain Present: Yes."

i. The pain assessment did not include a pain intensity score, pain location, or the quality of the pain.

c. Review of the medication administration record (MAR) indicated that the patient received Dilaudid 1 MG intravenously for pain at 12:41 PM.

i. At 1:12 PM, the effectiveness of the pain medication was assessed. The MAR indicated "Medication Effective: No."

d. There was no evidence that additional pain interventions were performed.

9. Review of Medical Record #24 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 12/31/18 at 4:30 PM with complaints of a headache and hypertension.

b. The patient was triaged at 4:37 PM and initial vital signs were taken. The pain assessment during triage indicated that the patient complained of a headache that was rated ten (10) out of (10) on the numeric pain scale.

c. There was no evidence that pain interventions were performed.

d. There was no evidence that the patient's pain was reassessed.

10. Review of Medical Record #25 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 11/17/18 at 5:52 PM with complaints of back pain and left and right knee and thigh pain. The patient was hit by a car two (2) hours prior to arrival to the ED.

b. The patient was triaged at 5:54 PM and initial vital signs were taken. The ED triage note states, "Pain Present: Yes."

i. The pain assessment did not include a pain intensity score, pain location, or the quality of the pain.

ii. There was no evidence that pain interventions were performed.

c. The patient's pain was reassessed at 7:13 PM and indicated that the patient reported pain to his/her back, knee, and leg and rated his/her pain ten (10) out of (10) on the numeric pain scale.

i. There was no evidence that pain interventions were performed.

d. The patient's pain was reassessed at 8:17 PM and indicated that the patient reported pain to his/her back and knee that was rated six (6) out of ten (10) on the numeric pain scale.

e. Review of the MAR indicated that the patient received Dilaudid 1 MG intravenously at 8:58 PM, three (3) hours and four (4) minutes after the patient first reported pain during triage.

11. Staff #1, Staff #3, and Staff #4, Staff #23, and Staff #33 confirmed the above findings.

B. Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that its policy regarding leaving against medical advice (AMA) and leaving without treatment (LWT) is adhered to.

Findings include:

Reference: Facility policy, Leaving Without Treatment/Against Medical Advice/Elopement states, "... LEAVING AGAINST MEDICAL ADVICE ("AMA") - patient has received a medical screening examination, but leaves Against Medical Advice before definitive treatment, admission or discharge. ... c. Physician, PA, NP or Nurse Midwife informs the patient of the risks and benefits specific to the patient's condition associated with leaving. Explain any alternative treatments to patient. d. The patient and a witness sign the AMA form indicating that he/she is aware of the risks and is leaving 'Against Medical Advice'. e. If patient refuses to sign the AMA form, hospital staff should sign the form stating that the patient refused to sign the form. ... g. Document discussions with the patient, the risks explained and the patient's medical decision-making capacity and understanding of the ramifications of leaving AMA in the medical record. ... e. ... 1) LWBS (Left Without Being Seen - Before Triage)... The following procedures will be initiated in the ED: Check the waiting room and call for the patient at least 3 times; document all attempts to find the patient in MedHost. ... . "

1. Review of Medical Record #8 on 3/14/19 revealed the following:

a. The patient arrived to the ED from his/her physician office, on 10/19/18 at 12:53 PM, for evaluation of a right side ovarian cyst. The patient was triaged at 12:57 PM.

b. The ED Central Log disposition indicated that the patient "Left Without Being Seen" (LWBS) on 10/19/18 at 4:12 PM.

c. There was no documentation in the medical record that the ED staff checked the waiting room and called for the patient at least three (3) times.

2. Review of Medical Record #12 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 9/22/18 at 6:08 AM with complaints of nausea, vomiting and abdominal pain. The patient was triaged at 6:14 AM.

b. The ED Central Log disposition indicated that the patient "Left Without Treatment" (LWT) on 9/22/18 at 6:57 AM.

c. There was no documentation in the medical record that the ED staff checked the waiting room and called for the patient at least three (3) times.

3. Review of Medical Record #24 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 12/31/18 at 4:30 PM with complaints of a headache and hypertension. The patient was triaged at 4:37 PM and received an MSE at 5:06 PM.

b. An ED physician note dated 12/31/18 at 5:35 PM states, "Patient reports he/she saw a good blood pressure and wanted to leave. Patient given risks of disability, change lifestyle and death and patient wants to leave against medical advice."

c. The medical record lacks evidence of an AMA form signed by the patient and a witness indicating that the patient is aware of the risks associated with leaving. There is no evidence in the medical record that the patient refused to sign the AMA form.

4. Review of Medical Record #26 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 12/31/18 at 7:28 PM with complaints of suicidal ideation. The patient left the ED prior to triage and never received treatment.

b. There was no documentation in the medical record that the ED staff checked the waiting room and called for the patient at least three (3) times.

5. Staff #1, Staff #31 and Staff #33, and Staff #34 confirmed the above findings.

C. Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that the facility's triage policy is implemented.

Findings include:

Reference: Facility policy, Patient Triage states, "... C. The Triage Nurse/RN shall assign a Triage Level to each patient according to the nationally recognized Emergency Severity Index (ESI) Guidelines and will be monitored consistent with the level assigned. ... 2. Level 2... When the patient is an ESI Level 2, the triage nurse has determined that it would be unsafe for the patient to wait in the waiting room for any length of time. ... 3. Level 3... Level 3 requires two or more resources... Resources can be hospital services, tests, procedures, consults or interventions that are above and beyond the physician history and physical, or very simple emergency department interventions such as applying a bandage. ... 4. Level 4... ESI level 4 patients are predicted to require one resource. ... ."

1. Review of Medical Record #25 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 11/17/18 at 5:52 PM. The patient reported that he/she was hit by a car two hours before arrival, and was now complaining of increasing left-sided back pain, left thigh, right knee, and right ankle pain.

b. The patient was triaged at 5:54 PM and was assigned an ESI Level four (4). Initial vital signs were taken.

i. The triage pain assessment indicated that the patient reported pain, however, there was no numeric value identified to rate the pain.

c. Based on the information presented during triage, the patient would have required more than one resource to address the patient's chief complaint.

d. Review of the physician orders indicated that the patient received bloodwork, urine cultures, IV and IV fluids, pain medication, X-Rays of the left femur and the right knee, a CT scan of the thorax, a CT scan of the abdomen and pelvis, a CT scan of the spine, a CT of the head, and a cervical neck collar.

e. The patient was transferred to a trauma center for a fractured lumbar vertebrae and a retroperitoneal hemorrhage.

2. Staff #1, Staff #4, and Staff #31 confirmed the above findings.

D. Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that its policy regarding one to one (1:1) observation for suicidal patients is implemented.

Findings include:

Reference: Facility policy, One to One (1:1) Criteria states, "A. To provide guidelines for the assessment and use of one to one (1:1) intervention for patients on suicide precautions. ... D. A physician's order is required. ... ."

1. Review of Medical Record #6 on 3/14/19 revealed the following:

a. The patient arrived to the ED on 10/19/18 at 10:48 PM with complaints of suicidal ideation.

b. The nurse's note dated 10/19/18 at 10:48 PM states, "Pt (patient) placed on 1:1 observation."

i. There was no evidence of a physician's order to place the patient on 1:1 observation.

c. The nurse's note dated 10/20/18 at 1:35 AM states, "Per PA (name of physician's assistant), 1:1 my [sic] be d/c'ed (discontinued) and close observation may be initiated."

i. There was no evidence of a physician's order to discontinue the 1:1 observation.

2. Staff #1, Staff #3, and Staff #4 confirmed the above findings.


37433

E. Based on observation, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that the policy regarding telemetry monitoring is implemented.

Findings include:

Reference #1: Facility policy, Cardiovascular Monitor With Central Nursing Console (Woodbury ER) states, "... PROCEDURE... G. Alarms will be set in the 'on' position at all times. ... ."

Reference #2: Facility document, Silencing Alarms states, "Temporarily silencing alarms from the CIC Pro Center- WARNING Do not continuously try to silence audible alarms. You may inadvertently silence new patient alarms. ...you can silence audible alarms from the CIC Pro center for one minute by clicking the Silence Alarms button located on the display screen. "

1. During a tour of the Emergency Department (ED) on 3/13/19 at 9:50 AM, the following was observed:

a. Continuous audible telemetry alarms were heard during a tour of the ED. At 10:40 AM, further review of the telemetry central console at the nursing station indicated that Patient #1 was on telemetry, and the screen indicated "ALARM PAUSE."

b. Patient #1 was observed at 10:45 AM lying on a stretcher with the telemetry monitor on and the alarm paused. No staff member was at the patient's bedside at the time of observation.

i. When asked, Staff #5 was unable to determine the length of time the telemetry alarm was paused.

ii. Upon interview on 3/13/19 at 11:00 AM, Staff #19 was asked if the telemetry was paused at the patient's bedside. Staff #19 stated, "probably." When asked why the telemetry alarm was paused, Staff #19 stated, "I was drawing the patient's labs so I silenced the alarm." When asked how long the alarms were silenced, Staff #19 stated, "You can silence the alarm for a short period of time if you hit the alarm once, but if you hit it twice it will silence the alarm for five (5) minutes. I paused it for five (5) minutes."

2. Upon interview on 3/15/19 at 9:52 AM, Staff #32 confirmed that the telemetry alarms in the ED can only be silenced for sixty (60) seconds. After sixty (60) seconds, the system will reset the alarm.

3. Staff #3 and Staff #5 confirmed the above findings.

F. Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that a physician order is obtained for patient discharge.

Findings include:

Reference #1: Facility policy, Emergency Room states, "... PROCEDURE C. The physician/Resident/APC is responsible for completing documentation in the appropriate aspect of the chart. ... K... All documentation should be complete and legible. ...Times & initials should be recorded for all treatment junctures & narrative entries... ."

Reference #2: Facility policy, Discharge Referral Procedure states, "... Physician... Completes chart and signs electronically in accordance with Medical Staff Bylaws. ... RN/LPN reviews chart for completeness. ... ."

Reference #3: Facility document, Medical Staff Rules and Regulations states, "... 3 C. CONTENT OF RECORD... (5) Emergency Care... This documentation will be the joint responsibility of the responsible practitioners... (e) conclusions at termination of treatment, including final disposition, condition... A... Patients will be discharged only upon the order of a responsible practitioner. ... ."

1. Review of Medical Record #14 on 3/15/19, revealed the following:

a. The patient arrived to the ED on 9/22/18 at 11:00 PM. The patient was triaged at 11:12 PM and received an MSE at 11:22 PM.

d. The discharge information dated 9/23/18 at 12:24 AM indicated that the patient was "Discharged to Home with Self Care/Family."

2. There was no evidence of physician discharge orders in the medical record.

3. Staff #31 and Staff #33 confirmed the above findings.

4. Review of Medical Record #29 on 3/15/19, revealed the following:

a. The patient arrived to the ED on 3/11/19 at 3:07 PM. The patient received an MSE at 3:26 PM.

i. The chief complaint indicated that the patient had complaints of "increasing SOB [shortness of breath] and cough."

ii. The Physician's Assessment/Plan stated, "Cough, SOB."

5. There was no evidence of an Assessment/Plan to indicate the patient's condition and disposition.

6. Staff #31 confirmed the above findings.

Based on observation and staff interviews, it was determined that the facility failed to ensure that EMTALA signage is conspicuously posted in areas of the facility where patients may come to seek emergency treatment.

Findings include:

1. A tour of the Emergency Department (ED) on 3/13/19 at 9:50 AM revealed the following:

a. In the Main Hospital Entrance, there was no EMTALA signage at either of the two (2) entry points of the lobby.

b. Adjacent to the ED waiting area, there were hallway chairs for patient overflow with no evidence of EMTALA signage posted.

c. In the ED, there were hallway chairs for patient overflow, adjacent to a patient bathroom, Bay #2 and Bay #3, with no evidence of EMTALA signage posted.

d. In the Pediatrics hallway, there were stretchers located at P-Hall #07A and P-Hall #08A that were used for patient overflow. There was no evidence of EMTALA signage posted.

e. There was a hallway stretcher located at D-01A that was used for patient overflow. There was no evidence of EMTALA signage posted.

f. In the ED Behavioral Pod, Exam Room #B2, Room #B3, Room #B4, Room #B5 and Room #B6, there was no evidence of EMTALA signage in the Pod or patient rooms.

2. Staff #3 confirmed the above findings.

3. Upon interview on 3/13/19, Staff #3 stated there is no designated unit for observation patients. Observation patients can be assigned to beds throughout the facility.

4. During a tour of 6 East on 3/14/19, there was no evidence of EMTALA signage.

a. Patient #30 was an ED patient placed in observation status on 6 East. There was no evidence of EMTALA signage in the room of Patient #30.

5. Staff #26 confirmed that EMTALA signage is not posted on the various units that house ED patients in observation status.

6. Staff #3 and Staff #26 confirmed the above findings.

Based on document review and staff interviews, it was determined that the facility failed to ensure that individual physician names are identified for each service on the hospital's on-call list.

Findings include:

1. Review of the facility's Emergency Department (ED) on-call schedule on 3/13/19 revealed the following:

a. For September 2018, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 9/1/18, 9/2/18, 9/3/18, 9/4/18, 9/6/18, 9/7/18, 9/8/18, 9/9/18, 9/11/18, 9/13/18, 9/17/18, 9/19/18, 9/21/18, 9/22/18, 9/23/18, 9/25/18, 9/27/18, 9/28/18, 9/29/18, and 9/30/18.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

b. For October 2018, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 10/2/18, 10/4/18, 10/5/18, 10/6/18, 10/7/18, 10/8/18, 10/10/18, 10/12/18, 10/13/18, 10/14/18, 10/16/18, 10/18/18, 10/22/18, 10/24/18, 10/25/18, 10/26/18, 10/27/18, 10/28/18, 10/29/18, 10/30/18, and 10/31/18.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

c. For November 2018, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 11/1/18, 11/5/18, 11/7/18, 11/9/18, 11/10/18, 11/11/18, 11/13/18, 11/14/18, 11/16/18, 11/17/18, 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/27/18, 11/29/18, and 11/30/18.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

d. For December 2018, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 12/1/18, 12/2/18, 12/3/18, 12/5/18, 12/7/18, 12/8/18, 12/9/18, 12/12/18, 12/13/18, 12/17/18, 12/19/18, 12/21/18, 12/22/18, 12/23/18, 12/24/18, 12/25/18, 12/28/18, 12/29/18, 12/30/18, and 12/31/18.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

e. For January 2019, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 1/1/19, 1/3/19, 1/4/19, 1/5/19, 1/6/19, 1/7/19, 1/8/19, 1/9/19, 1/10/19, 1/11/19, 1/12/19, 1/13/19, 1/15/19, 1/18/19/ 1/19/19, 1/20/19, 1/22/19, 1/24/19, 1/28/19, 1/29/19, and 1/31/19.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

f. For February 2019, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 2/1/19, 2/2/19, 2/3/19, 2/4/19, 2/6/19, 2/7/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19, 2/16/19, 2/17/19, 2/19/19, 2/20/19, 2/22/19, 2/23/19, 2/24/19, 2/26/19, and 2/27/19.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

g. For March 2019, under the Neurosurgery specialty, there was no individual identified as the on-call physician for the following dates: 3/1/9, 3/2/19, 3/3/19, 3/4/19, 3/7/19, 3/11/19, 3/12/19, 3/14/19, 3/15/19, 3/16/19, 3/17/19, 3/18/19, 3/21/19, 3/22/19, 3/23/19, 3/24/19, 3/28/19, 3/29/18, 3/30/19, and 3/31/19.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

h. For March 2019, under the Plastic Surgery specialty, there was no individual identified as the on-call physician for the following dates: 3/1/19, 3/2/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/9/19, 3/10/19, 3/11/19, 3/12/19, 3/13/19, 3/14/19, 3/15/19, 3/16/19, 3/17/19, 3/23/19, 3/24/19, 3/30/19, and 3/31/19.

i. On the above referenced dates, the space used to identify the on-call physician states "NONE."

2. Staff #1 and Staff #3 confirmed the above findings.

Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that an accurate and complete ED central log is maintained.

Findings include:

Reference: Facility policy, Leaving Without Treatment/Against Medical Advice/Elopement states, "... LEAVING AGAINST MEDICAL ADVICE ("AMA") - patient has received a medical screening examination, but leaves Against Medical Advice before definitive treatment, admission or discharge. ... 2. ELOPEMENT - patient who at any time leaves the department without the knowledge of the staff or leaves prior to receiving medical advice about risks and benefits by a physician, PA, NP or Nurse Midwife. ... ."

1. Review of Medical Record #3 on 3/14/19 indicated that the patient arrived to the ED on 9/27/19 at 1:40 AM with complaints of abdominal pain.

a. Staff #4 confirmed that the patient was a minor who arrived to the ED with an adult that was not the child's parent. The adult was told that the child could not be seen because he/she was not with his/her parent. The adult and the child left the ED.

b. Review of the ED central log for 9/27/19 revealed that the patient's disposition was listed as "LWT" (left without treatment).

c. Staff #4 confirmed that the patient did not leave without treatment but was turned away because his/her parent was not present.

2. Review of Medical Record #13 on 3/15/19 indicated that the patient arrived to the ED on 10/20/18 at 7:04 PM with complaints of a hypotension, lightheadedness, and dizziness.

a. The patient was triaged at 7:44 PM. The physician's ED documentation indicated that the patient was seen by the ED physician on 11/1/18 at 4:56 PM, twelve (12) days after the patient arrived to the ED.

i. There was no evidence that the patient received an MSE on the day he/she arrived to the ED.

b. The ED central log and the patient's medical record indicated that the patient left the ED AMA. There was no evidence that the patient received medical advice about his/her condition, which indicated that the patient's disposition was an elopement and not AMA.

3. Review of Medical Record #22 on 3/15/19 indicated that the patient arrived to the ED on 12/31/18 at 10:29 AM with complaints of a severe headache and blurred vision.

a. The patient received a CT Scan which showed he/she had a brain tumor. The patient was subsequently transferred to another hospital for a higher level of care.

b. Review of the ED central log for 12/31/18 revealed that the patient's disposition was listed as "Acute Care Hosp - General IP (inpatient) Hosp."

i. There was no indication on the central log that the patient was transferred to another facility.

4. Staff #1, Staff #3, and Staff #4 confirmed the above findings.


37433

5. Review of Medical Record #12 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 9/22/18 at 6:08 AM with complaints of nausea, vomiting and abdominal pain. The patient was triaged at 6:14 AM.

b. The ED central log indicated that the patient left without treatment. There was no documentation in the medical record that indicated the patient left without treatment.

6. Staff #34 confirmed the above findings.

7. A request was made to Staff #14 for the OB Triage Log. The Maternal-Child Health Observation Log Book was provided.

a. Review of the log entries of the Maternal-Child Health Observation Log Book, indicated the patient's Time In, Time Out, and/or Disposition. It revealed the following:

i. From 9/1/18 to 9/30/18, ninety-nine (99) out of one hundred and one (101) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

ii. From 10/1/18 to 10/31/18, sixty-three (63) out of sixty five (65) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

iii. From 11/1/18 to 11/30/18, seventy-nine (79) out of seventy nine (79) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

iv. From 12/1/18 to 12/31/18, eighty-five (85) out of ninety four (94) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

v. From 1/1/19 to 1/31/19, ninety-six (96) out of ninety-seven (97) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

vi. From 2/1/19 to 2/28/19, sixty-one (61) out of sixty-four (64) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

vii. From 3/1/19 to 3/13/19, thirty-three (33) out of thirty three (33) log entries were incomplete. Documentation regarding the patient's time in, time out, and/or disposition was missing.

8. Staff #24 confirmed the above findings.

Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that all persons presenting to the Emergency Department (ED) and requesting treatment are provided a medical screening examination (MSE).

Findings include:

Reference #1: Facility policy, Medical Screening Exam states, "... 2. Except in the case of scheduled tests and/or procedures or direct admissions, all persons presenting at the Emergency Department/S.E.D. or any other department of the Hospital and requesting treatment or examination shall be provided a Medical Screening Examination in the Emergency Department/S.E.D. ... 5. Initial triage of all presenting patients in the Emergency Department/S.E.D. shall be provided by the Triage Nurse or other Registered Nurse in the absence of the Triage Nurse. ... 7. MINORS - The medical screening examination shall be provided to any minor, regardless of the failure to obtain parental consent prior to the provision of the examination and necessary treatment. ... ."

1. Review of Medical Record #3 on 3/14/19 revealed the following:

a. The patient arrived to the ED on 9/27/18 at 1:40 AM with complaints of abdominal pain. The ED central log indicated the patient left without treatment.

b. Upon interview, Staff #4 confirmed that the patient did not leave without treatment. He/she stated the patient was a minor who arrived to the ED with an adult that was not his/her parent. The adult was told the child could not be treated without his/her parent present. The adult and child left the ED.

2. During a tour of the ED on 9/27/19 at 10:00 AM, an interview was conducted with Staff #7 who was functioning as the triage nurse.

a. Staff #7 was asked what he/she would do if a minor arrived to the ED without his/her parent present. Staff #7 stated he/she would make every attempt to contact the child's parent(s). He/she stated the child would have to wait until the parent gave consent before the child could be treated. Staff #7 stated if he/she was unsuccessful in reaching the child's parent, he/she would let the Nurse Manager know.

b. Upon interview at 10:07 AM, Staff #5 stated, "[Staff #7] should not have said that. All patients who walk in the ED receive an MSE, including minors."

c. Upon interview at 10:45 AM, Staff #11 indicated he/she occasionally works at the front desk in the ED where he/she does the patient's quick registration.

i. Staff #11 was asked what he/she would do if a minor arrived to the ED without his/her parent present. Staff #11 stated, "If the patient is underage, we have to wait until we reach the parent before the patient can be triaged."

d. Upon interview at 11:00 AM, Staff #12 was asked what he/she would do if a minor arrived to the ED without his/her parent present. Staff #12 stated, "I would try to call the parents. The patient would be triaged but they cannot receive an MSE without the parent's consent. We need their consent before we can do anything. We would let them wait until the parent gets here."

3. Review of Medical Record #13 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 10/20/19 at 7:04 PM with complaints of dizziness and lightheadedness. The patient was triaged at 7:44 PM.

b. The ED physician's note indicated that the date and time the physician saw the patient was 11/1/18 at 4:56 PM, twelve (12) days after the patient arrived to the ED.

c. There is no evidence in the medical record that the patient received an MSE on the date he/she arrived to the ED.

4. Staff #1, Staff #3, Staff #4, and Staff #5 confirmed the above findings


37433

Reference #2: Facility policy, Triage, Patient states, " ... POLICY... Every patient presenting to triage is considered and Emergency Department/Satellite Emergency Department (SED) patient by virtue of their request for medical treatment and will receive a medical screening exam by the physician on duty within four (4) hours. ... ."

1. Review of Medical Record #7 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 10/19/18 at 12:00 PM with complaints of suprapubic pain for four (4) days.

b. The patient received an MSE on 10/19/18 at 4:10 PM, which is greater than four (4) hours from the patient's arrival to the ED.

2. Staff #33 confirmed the above finding.

3. Review of Medical Record #11 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 10/20/18 at 12:35 AM with complaints of a migraine, photophobia, and phonophobia.

b. Documentation in the medical record indicated the patient received an MSE on 11/1/18 at 5:02 PM, twelve days (12) days from the patient's arrival to the ED.

i. There is no evidence in the medical record the patient received an MSE on the date he/she arrived to the ED.

4. Staff #34 confirmed the above finding.

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that reasonable registration processes in the ED do not unduly discourage individuals from remaining for further evaluation.

Findings include:

Reference: Facility policy, Emergency Medical Treatment and Transfer states, "... [Name of facility] can request routine information about insurance or medical plans in accordance with its normal registration process, so long as that does not... discourage the patient from receiving the medical screening exam. ... ."

1. Review of Medical Record #19 on 3/15/19 revealed the following:

a. The patient arrived to the ED on 11/17/18 at 5:30 AM with complaints of lacerations to his/her foot and thigh.

b. At 5:34 AM, the patient received a full registration, including a request for insurance information, four (4) minutes after he/she arrived to the ED. The patient was triaged at 6:25 AM.

c. The patient received a full registration prior to triage, potentially discouraging the patient from remaining at the hospital, to receive an MSE.

2. Staff #1, Staff #4, and Staff #31 confirmed the above findings.