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Based on staff interview, Idaho Statutes review, incident reports, medical records, and hospital policies, it was determined the hospital failed to ensure the Governing Body was effective and assumed responsibility for the overall care of patients in the hospital ED. This resulted in the inability of the Governing Body to direct staff in the provision of patient care. It had the potential to impact all patients who received care at the hospital. Findings include:

1. Refer to A0115 as it relates to the hospital's failure to uphold patient rights

2. Refer to A0431 as it relates to the hospital's failure to maintain accurate and complete records

3. Refer to A1100 as it relates to the hospital's failure to ensure the hospital complied with 42 CFR §489.20(r)(3), 489.24(a),and 489.24(e)

The cumulative effect of these systemic practices resulted in the inability of the hospital to meet the needs of patients.

Based on medical record review, incident report review, Idaho Statutes review, hospital policy, hospital documentation and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in care not being provided in a safe setting and had the potential to affect all patients receiving care at the hospital. Findings include:

1. Refer to A144, as it relates to the failure of the hospital to ensure care was provided in a safe setting.

2. Refer to A145, as it relates to the failure of the hospital to ensure all patients were kept free from physical abuse.

The cumulative effects of these systemic practices seriously impeded the ability of the hospital to protect and promote patient rights, and provide care in a safe setting.

Based on policy review, medical record review, incident report review, and staff interview, it was determined the hospital failed to ensure care was provided in a safe setting. This directly impacted the safety of 2 of 3 patients (Patients #17 and #21) who were assessed as a suicidal risk and whose records were reviewed. This resulted in patients not being kept safe from themselves and had the potential to affect all patients receiving care at the hospital. Findings include:

A hospital policy titled, "Suicide Risk", dated, 9/01/05, stated:
"If the patient is determined to be at risk for suicide, an appropriate level of suicide precaution safety plan is implemented. The suicide precaution safety plan may consist of but not limited to:

A safe environment provided by placing the patient in a private room, in hospital[sic] safety scrubs, separated from his / her belongings and potentially harmful objects ... Remove any objects or equipment that could be used for self harm. This includes any cords or tubes not necessary for patient care. (hanging attempts are a high risk) ...

The following are the recommended interventions for use by nursing staff and case management in the Emergency Department and throughout Portneuf Medical Center in response to the score derived from the Columbia Suicide Severity Rating Scale (an assessment tool to help identify Patients at risk of suicide) ...

For a score of 4-6 on the CSSRS initiate the following interventions:
" - Offer emotional support to patient
- Initiate 1:1 staffing
- Maintain a safe environment."

This policy was not followed. Examples include:

1. Patient #21 was a 62 year old male who presented to the ED on 2/13/22 with a chief complaint of suicidal ideation. He was brought into the ED by police after texting his wife and son making threats of suicide.

Patient #21's medical record included an assessment performed by the hospital's Behavioral Health Assessment Team. The assessment documented Patient #21 was at a high risk for suicide and the social worker requested admission to the behavioral health unit for psychiatric treatment. The note included "RN now states pt was found attempting to strangle himself with the strings of his sweat shirt."

Incident reports were reviewed. One incident 2/13/22 included, "Pt was in the Emergency department in room 10 on a Psychiatric hold, pt had a 1:1 [RN name] RN from NICU at bedside. Social work came to evaluate and 1:1 did not inform this RN she was leaving, however reportedly mentioned to my charge RN [RN name] as she walked past that she needed a break. This RN was medicating another pt when [EMT name] EMT noticed pt was attempting to choke/hang himself with his sweatshirt strings."

There was no documentation in Patient #21's record he was put in safety scrubs when assessed at risk for suicide. There was no documentation Patient #21's personal belongings were removed from his possession. Additionally, there was no documentation in his record of a 1:1 staffing with a hospital staff member.

The Director of the ED and ED Supervisor were interviewed on 8/17/22 beginning at 11:45 AM, and Patient #21's record was reviewed in their presence. The ED Supervisor stated Patient #21 should have been placed in scrubs and his possessions removed from him. He confirmed there was no documentation Patient #21's was placed in scrubs and his possessions removed. When asked if the Patient #21 was on 1:1 staffing he could not provide documentation Patient #21 was placed on 1:1 staffing.

The hospital failed to ensure Patient #21's care was provided in a safe setting.

2. Patient #17 was a 44 year old female who presented to the ED on 7/09/22 at 4:06 AM with a chief complaint of suicidal ideation. Patient #17 was placed on a mental health hold. The mental health hold paperwork indicated Patient #17 "poses an imminent danger to self as evidenced by a threat to substantial physical harm."

Patient #17's medical record included the following nursing notes:

- 7/10/22 at 8:54 AM "Pt noted to not be in room, seen leaving, security brought pt back. No sitter available, keeping pt in line of sight frequent rounding, Charge nurse aware"

- 7/10/22 at 11:54 AM "Pt was noted to be found on the bathroom floor, nudge to awaken, gait is unstable, max assist noted at this time. Returned to bed VSS [Vital signs stable]."

- 7/10/22 at 4:26 PM "Patient elusive in ER. Security notified."

- 7/10/22 at 5:36 PM "Patient eloped out of ER. Security notified. Patient has not been found in over 1 hour."

- 7/11/22 at 11:54 AM "ED pt eloped from psych room. Pt was not seen leaving the building. At approx [sic] 1645 security advised the pt had left the building (via camera footage, I called Pocatello dispatch to report pt was walking outside of building in an unknown location. I called back at approx. [sic] 1700 to let dispatch know that security advised that the pt went left on hospital way towards Center st. "

Patient #17's medical record indicated she was placed on 1:1 staffing. It was documented that the 1:1 staffing was ordered at 4:30 AM on 7/09/22. There was no documentation Patient #17 had 1:1 staffing on 7/10/22 from 7:00 AM until 1:45 PM. There was recorded 1:1 staffing from 1:45 PM until 4:00 PM for Patient #17. The 1:1 staffing documentation at 4:15 PM that Patient #17 was missing from the ED.

There was no documentation in Patient #17's medical record how she eloped from the ED while on 1:1 staffing.

There was no documentation of what safety intervention was provided for Patient #17 when there was no sitter available from 7:00 AM to 1:45 PM on 7/10/22.

The ED Supervisor was interviewed 8/16/22 beginning at 11:00 AM, and Patient #17's medical record was reviewed in his presence. When asked if Patient #17 was ordered to be on 1:1 staffing, the ED Supervisor said yes based on the documentation of the 1:1 staffing flowsheet. He stated the hospital did not document 1:1 staffing orders through doctors' orders and stated there would be no other way to determine if a patient was on 1:1 staffing. The ED Supervisor stated based on how Patient #17 presented and the mental health hold, she should have had 1:1 staffing. When asked if Patient #17 was placed in safety scrubs and her possessions were removed, he stated it was not documented. When asked how Patient #17 eloped out of the ED at approximately 4:15 PM on 7/10/22 when she had 1:1 staffing he stated, "I don't know." He confirmed there was no documentation how Patient #17 eloped from the ED.

The ED Director was interviewed 8/16/22 beginning at 11:00 AM and Patient #17's medical record was reviewed in his presence. When asked if Patient #17's elopement was investigated he said "yes". He stated Patient #17 exited through the radiology door and that she tailed someone out of a badge access only door. He stated education was provided to staff, follwoing this incident, through a "read and sign" education of the facility's policy. When asked for the documentation of the education he could not present it.

The hospital provided documentation of the "read and sign" education provided to ED staff 2 buisness days after survey exit. The training was dated 7/21/22. The training roster listed 76 employees. 40 employees had signed that they received the training.

The hospital failed to ensure Patient #17's care was provided in a safe setting.

Based on hospital policy review, Idaho Statutes review, record review, incident report review, and staff interview, it was determined the hospital failed to ensure patients were free from abuse or harassment for 1 of 1 patients (Patient #20) whos records was reviewed and had incidents reports which documented abuse. This had the potential for unsafe conditions for all patients receiving care at the hospital. Findings include:

"IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/18, stated "39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency." This Statute was not followed.

A hospital policy titled, "Abuse-Neglect - Care of Adult Child or Vulnerable Adult," dated 1/10/20, stated:
"2) Portneuf staff report all suspected abuse, neglect, exploitation or abandonment of any persons to the appropriate authorities per legal statute and rights of privacy by contacting the authorities directly or, if unsuccessful by contacting the Case Management department
3) All Licensed staff document in the medical record which authorities have been contacted The[sic] alleged victim has a right to be advised of the Idaho Law and the specific requirements for reporting the alleged abuse/neglect, etc." This policy was not followed.

Patient #20 was a 50 year old male who presented to the ED on 5/27/22 with a chief complaint of agitation, he was developmentally delayed. He presented from a group home after becoming more agitated and banging his head against the ground.

Patient #20's record documented he was aggressive and agitated throughout his stay in the ED. The hospital was working on placement and he remained in the hospital until 6/23/22

Incident reports were reviewed. One incident, dated 6/10/22, stated that a hospital security officer watched a staff member slap Patient #20 in the face. That security officer called an additional officer over and the hospital staff member slapped Patient #20 in the face a second time.

An investigation of the incident was reviewed. It included that the on-duty security officer witnessed a hospital employee strike Patient #20 twice in the face. The investigation included the hospital employee was immediately suspended and terminated from employment.

Patient #20's medical record was reviewed. There was no documentation in the medical record about Patient #20's abuse. Additionally, there was no documentation police and APS were contacted.

The Security Officer was interviewed on 8/18/22 beginning at 9:45 AM. She stated she was in the security office and witnessed the hospital employee strike Patient #20 twice in the face. She stated she immediately contacted the Charge Nurse on duty to report the incident. When asked if she filed a police report or APS notification she stated she did not.

The Charge Nurse who was present for the incident on 6/10/22 was interviewed on 8/18/22 beginning at 9:30 AM. She stated the on-duty security officer reported to her that Patient #20's sitter struck Patient #20 in the face twice. She stated she immediately removed the employee from duty and sent him home pending an investigation. She stated she notified the house supervisor and human resources. When asked if she filed a police report or APS report she stated "No, I did not." She stated she did not realize the requirement was to report all suspected or alleged abuse.

The Director of Regulatory Compliance and VP of Quality were interviewed together on 8/18/22 beginning at 9:30 AM. When asked if the hospital filed a report with APS or the police regarding the abuse of Patient #20 the Director of Regulatory compliance stated she could not find it in the record.

The hospital failed to report Patient #20's physical to APS. Additionally, the hospital failed to ensure all patients were kept free from physical abuse while in the hospital.

Based on staff interview, hospital policy review,and review of medical records,, it was determined the hospital failed to ensure patient medical records were accurate and complete. This resulted in a lack of documentation that patient care was comprehensive, and complete. Findings include:

1. Refer to A0449 as it relates the hospitals failureto ensure medical records contained sufficient information to describe the progress, condition and disposition of patients recieving care in the ED.

The cumulative effect of these negative systemic practices resulted in a lack of comprehensive, accurate patient information being documented.

Based on policy review, medical record review, and staff interview, it was determined the hospital failed to ensure medical records contained sufficient information to describe the progress, condition and disposition for 4 of 21 patients (#1, #2, #4, and #14) whose records were reviewed. This resulted in incomplete medical records. Findings include:

1. The facility failed to document physician notification of out of parameter vital signs and significant change in patient condition. Examples include:

The hospital policy titled, "Vital signs Protocol-ED-PMC," effective date, 1/30/20, stated:

"Measure vital signs at the time of the triage and/or the primary assessment, and thereafter as indicated by the patient's condition, acuity, history and complaint. Frequency of repeat vital signs is determined by clinical judgement based on the patient's condition, and/or as directed by the physician: this should be minimum of every 2 hours. Initial vital signs for adult patients include temperature, pulse, respiration, blood pressure, pulse oximetry, and weight .... Pain assessment and reassessment should be completed with vital signs. Normal values Adult Respiratory Rate 12-20, Heart Rate 60-100." This policy was not followed.

Patient #4 was a 53 year old male who presented to the ED with a chief complaint of chest pain at 3:24 PM on 6/29/2022 and was pronounced dead at 10:30 PM on 6/29/22 in the ED.

Patient #4's ED triage note signed by an RN at 3:30 PM on 6/29/2022 stated: "Pt reports chest pain since Saturday. Reports increasing pain and shortness of breath. States dizzy and nauseous. Reports 1 episode of emesis. Type 1 diabetic. BG 300s."

-6/29/22 at 3:31 PM Patient #4's pulse of 126, resp 32, SP02 85% on room air. No documentation of BP, temperature, level of pain and location, and physician notification for respiratory rate greater than 20 and pulse greater than 100.

-6/29/22 at 4:21 PM Oxygen Therapy "None (Room air) ...SpO2 96%" Pulse 102, Respirations 24. No documentation of BP, temperature, level of pain and location, and physician notification for respiratory rate greater than 20 and pulse greater than 100.

-6/29/22 at 5:30 PM "Dyspnea ...Two to three word sentences." Placed on "supplemental oxygen." No documentation of respiratory rate, BP, temperature, level of pain and location. Additionally, there was no physician notification on Patient #4's change in condition of speaking in 2-3 word sentences and need for supplemental oxygen.

-6/29/22 at 5:43 PM the RN documented respiratory rate was 28. There was no documentation the physician was notified of Patient #4's respiratory rate greater than 20.

-6/29/22 at 5:45 PM the physician placed an order to notify him of a respiratory rate greater than 28.

-6/29/22 at 8:13 PM the nurse documented that Patient #4's respiratory rate was 30 and he was not on supplemental oxygen. There was no documentation why the oxygen was discontinued. There was no documentation the physician was notified of Patient #4's respiratory rate greater than 28.

An ED Provider note dated 6/29/22 at 10:42 PM stated "53 year old male who was admitted patient boarding in the emergency department. Patient was noted by staff to be increasingly weak and collapsed after going to the restroom. They found him to be ashen and without pulse and a CODE BLUE was called ... CPR was provided for 26 minutes until he was found to be in persistent asystole without any spontaneous cardiac activity on ultrasound exam at pulse check. Patient was pronounced dead at 2230." There was no documentation of a physician reassessment or if staff notified the physician Patient #4 was becoming increasingly weak.

The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM, and Patient #4's medical record was reviewed in his presence. When asked if the above vital signs were reported to the physician, he stated he could not tell by the documentation. When asked if it was the expectation for the RN to report abnormal vital signs to the physician he said "yes."

The Hospital failed to ensure Patient #4's change in condition and out of parameter vital signs were reported to the physician.

2. The facility failed to ensure transfer documentation was complete.

a. Patient #14 was a 9 month old female seen in the ED on 5/15/22. She presented to the ED with a chief complaint of a fever after chemotherapy within the past week.

Patient #14's medical record included the following provider notes.

5/15/22 at 11:36 PM, the physician documented. "Patient is a 9 month old female with a history of neuroblastoma who presents to the emergency department today with a fever after chemotherapy within the past week. I received a phone call from [oncologist name] oncology fellow at [receiving hospital]. that I be prepared for the patient arrived[sic] in the emergency department." The child's oncologist recommended lab work and antibiotics for Patient #14 and that Patient #14 may need a hospital admission.

5/16/22 at 12:06 AM, the doctor documented, "Did sign out from [previous physician] pending laboratory workup. The patient was noted to have an absolute neutrophil count of 1.3 down from earlier the patient does look well I did speak with oncology fellow [Patient #14's oncologist] at [receiving hospital]. Plan is to give cefepime[antibiotic] and admit I spoke with pediatrics who will admit the patient. [sic]"

5/16/22 at 12:57 AM, "Patient and family change their mind wanted to go to the [receiving hospital]. I spoke with the transfer center and [Patient #14 oncologist] who accepted the patient in transport. "

There was no documentation in Patient #14's record on how Patient #14 was transported to [receiving hospital]. Additionally, there was no documentation the ED physician discussed risks and benefits of the transfer.

The ED supervisor was interviewed 8/17/22 beginning at 11:28 AM. When asked if Patient #14 was transferred or discharged he stated, "technically it's a transfer." When asked for the transfer form he was unable to provide it, he stated a transfer form should have been filled out. When asked for documentation that the transfer risks and benefits explained to Patient #14 parents, he confirmed there was no documentation that risks and benefits of the transfer were discussed with the parents. When asked how the Patient #14 was transferred to [receiving hospital], he stated there was no documentation on how Patient #14 was transported.

The hospital failed to ensure risks and benefits of transfer were documented. Additionally, the hospital failed to ensure all transfer information was included in the medical record.

b. Patient #1 was a 22 month old female seen in the ED twice on 8/06/22. The first encounter was at 2:36 AM. Patient was brought in by family with reported abdominal pain. Record states: "Mom states pt has been grabbing her belly and saying ow. Reports of diarrhea, nausea, fever." ED midlevel ordered urinalysis and nasal swab culture. Patient was discharged at 4:50 AM with discharge instructions to follow up with pediatrician and return if symptoms worsen.

Patient #1 presented to the ED again on 8/06/22 at 10:21 PM via ambulance. The EMS run sheet reported a seizure and uncontrolled fever for 2 days. Ultrasound of abdomen was ordered by ED physician. Patient was found to have a acute appendicitis and transferred private vehicle to a higher level of care.

The ED physician who cared for Patient #1 was interviewed 8/17/22, beginning at 9:00 AM. When asked why the patient was transferred, he replied: "she was transferred to the highest level of care, they have pediatric surgeons." When asked why Patient #1 could not be treated at this hospital, the ED physician replied: "I talked to our surgeon here, [surgeon name], she was not comfortable with the case." When asked if he documented the conversation with the surgeon he stated he did not.

When the ED physician was asked if he had physician to physician contact at receiving hospital he replied: "I did not speak to an MD, [midlevel at receiving] relayed to MD." When ED physician was asked about the decision to transport via private auto, he stated: "we had ground transport available with a 2 hour delay, I discussed with them the ground versus air versus private auto and they chose private auto." There was no documentation in Patient #1's record to confirm this conversation.

The section on the transfer form titled: "PHYSICIAN ASSESSMENT AND CERTIFICATION" was signed by the physician but the "BENEFITS: RISKS: " was left blank. When the ED physician was asked if this section should have been filled out, he stated: "ya, it should have been."

When the ED physician was asked if he would expect an RN to RN communication note giving report to the transferring hospital, he stated: "yes."

Medical records for Patient #1 were further reviewed in the presence of the ED Supervisor, the ED Director, the VP of Quality, and the Director of Regulatory Compliance 8/16/22, beginning at 11:00 AM. The ED Supervisor was unable to locate any documentation of physician to physician communication or nurse to nurse report documentation. When asked if there was a documented discussion with parents regarding the risks and benefits of the transfer and the transfer options, he replied: "I can't answer cuz I don't know." When the ED Supervisor was asked if Patient #1 was a transfer or a discharge, he stated: "It's what I see." He was looking at the incomplete transfer form. When asked if it is typical to transfer via private auto to a receiving hospital in another state, the ED Supervisor replied: "No." The ED Director was also asked if this is typical to transfer via private auto and he replied: "No."

The current charge RN on duty was interviewed on 8/17/22, beginning at 10:30 AM. He was asked if the charge nurse is involved in transfers and he replied: "somewhat". When asked if a transfer requires a nurse to nurse documented handoff, he replied: "Yes."

The hospital failed to ensure risks and benefits of transfer were documented. Additionally, the hospital failed to ensure all transfer information, physician to physician and nurse to nurse communication was included in the medical record.

4. The facility failed to document reasons for a delay in care for a patient.

Patient #2 was a 59 year old male admitted to the ED on 2/18/22 at 4:23 PM. He was found unresponsive by his son and brought into the ED via ambulance.

Patient #2's medical record included a Emergency Medicine note dated 2/17/22 at 8:32 PM signed by the physician. The note included "On arrival, the patient had agonal respirations, and oral airway device in place, which she[sic] was tolerating well and was being assisted with his respirations with a bag valve mask. Blood sugar was over 200, Narcan had no effect so I felt it was prudent to intubate him ... We ordered CT imaging bu this was delayed due to other acute patients in the department. Ultimately he was found to have a significant head bleed, with concern for a possible aneurysm." The note continues that the patient was ultimately transfered to a higher level of care for neurosurgery.

Patient #2's medical record included an STAT order for a head CT and a CT angiogram head and neck with contrast.

The head CT was ordered on 2/17/22 at 4:34 PM. The results of the CT were discussed with the ED physician 2/17/22 at 7:39 PM, 3 hours and 5 minutes after the STAT order.

The CT angiogram head and neck with contrast was ordered 2/17/22 at 4:41 PM. The results of the CT were resulted to the ED physician 2/17/22 at 7:55 PM, 3 hours and 14 minutes after the stat order.

The Director of Radiology was interviewed on 8/18/22 at 10:30 AM. When asked how the CT technicians prioritize who to take first to CT imaging, the Director stated the CT technicians take whoever is available at the time and based off the communication between staff in the ED. When asked why Patient #2 was not taken to CT scan for close to 3 hours, he stated he would have to look and did not know.

The VP of Quality was interviewed 8/18/22 at 11:45 AM, and he provided hospital documentation for Patient #2. The documentation stated regarding Patient #2: "Patient was intubated. 2 attempts were made to bring patient to CT but respiratory was unavailable to manage ventilator." The VP of Quality confirmed this documentation was not in Patient #2's medical record. When asked how this information was obtained the VP of Quality stated the Director of Radiology had to call the CT tech that was working that day for the information.

The hospital failed to ensure reasons for delay in care were documented in Patient #2's record.

The hospital failed to ensure medical records contained sufficient information to describe the progress, condition and disposition for patients in the hospital.

Based on review of Hospital ED logs, Idaho Statutes review, policy, medical records, incident reports and staff interview, it was determined the hospital failed to ensure all patients who presented to the ED for emergency medical care were treated in accordance with 42 CFR §489.20(r)(3), 489.24(a),and 489.24(e). This directly affected 6 of 21 patients (#1, #6, #7, #8, #14, and Patient #18) whose records were reviewed. Additionally, the hospital failed to provide a safe environment for patients receiving care in the ED. This failure impeded the hospital's ability to provide emergency care, and had the potential to affect all patients who presented to the ED with an emergency medical condition. Findings include:

1. The hospital failed to maintain an accurate log of everyone who presented to the ED seeking emergency medical care. Findings include:

Policy # 61645.1 titled: EMTALA-RM-PMC, effective date: 11/10/2019 was reviewed. It included a section titled: Signs and Records. It reads: "Portneuf Medical Center will maintain the following signs and records:...
iv) Central log. Portneuf Medical Center will maintain a central log on each individual who comes to Portneuf Medical Center seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged..."

An incident report dated 6/06/22, stated: "I had to have 4 ambulances take their patients out to the waiting room...[EMS]...walked their patient to the waiting room and a few minutes later they walked her back to their ambulance and left...called [EMS] to confirm that they took them to [another local hospital ED]. One of the other patients that came in by ambulance that had to go to the waiting room had her family come and get her after about an hour...they made it to...one of the gas stations and called for an ambulance to take her to [another local hospital ED}...."

A phone interview was conducted on 8/18/22 beginning at 11:15 AM with the ED charge nurse on duty 6/06/22. He confirmed he had written this incident report. When asked if he had a record of these patients' names referred to in the incident report of 6/06/22, he stated: " I don't know their names"; he stated that he "had to call [EMS] to find out what happened."

The ED physician on duty 6/06/22 was interviewed 8/17/22, beginning at 9:00 AM. When asked if the ED was on diversion he stated: "the ER [emergency room] doesn't divert." When asked why patients presenting to the ED via EMS would have been taken out to triage in the lobby, he stated: "We were absolutely destroyed that night, we had 30 patients come in in 8 hours and 2 gunshot wounds..." When asked if he felt staffing is adequate in the ED, he replied: "I don't think staffing is adequate anywhere in the country."

Surveyor attempted to obtain the names of these patients brought in by ambulance by referencing run sheets. No ambulance run sheets were provided. Surveyor called [EMS] to obtain ambulance run sheets. The [EMS] is part of tribal services and information access was denied. [Another local hospital ED] was contacted for patient names but information was not provided.

The hospital failed to maintain an accurate log of all patients who presented to the ED requesting a MSE.

2. The hospital failed to document appropriate transfers of ED patients. Findings include:

a. Patient #1 was a 22 month old female seen in the ED twice on 8/06/22. The first encounter was at 2:36 AM. Patient was brought in by family with reported abdominal pain. Record states: "Mom states pt has been grabbing her belly and saying ow. Reports of diarrhea, nausea, fever." ED midlevel ordered urinalysis and nasal swab culture. Patient was discharged at 4:50 AM with discharge instructions to follow up with pediatrician and return if symptoms worsen. Clinical Impressions documented as rhinovirus.

Patient #1 presented to the ED again on 8/06/22 at 10:21 PM via ambulance. The EMS run sheet reported a seizure and uncontrolled fever for 2 days. Ultrasound of abdomen was ordered by ED physician.

Patient #1's record included that she transferred to a higher level of care, via private vehicle.

The ED physician who cared for Patient #1 was interviewed 8/17/22, beginning at 9:00 AM. When asked why the patient was transferred, he replied: "she was transferred to the highest level of care, they have pediatric surgeons." When asked why the patient could not be treated at this hospital, the ED physician replied: "I talked to our surgeon here, [surgeon name], she was not comfortable with the case." When asked if this conversation with the surgeon was documented, he stated that it was not.

When the ED physician was asked if he had physician to physician contact at receiving hospital he replied: "I did not speak to an MD, [midlevel at receiving] relayed to MD." When ED physician was asked about the decision to transport via private auto, he stated: "we had ground transport available with a 2 hour delay, I discussed with them the ground versus air versus private auto and they chose private auto." There was no documentation in patient record to confirm this conversation.

The section on the transfer form titled: "PHYSICIAN ASSESSMENT AND CERTIFICATION" was signed by the physician but the "BENEFITS: RISKS: " was left blank. When the ED physician was asked if this section should have been filled out, he stated: "ya, it should have been."

Patient #1 was taken by private auto across state lines to the receiving hospital which was a distance of 166 miles. Per MapQuest inquiry 8/23/22, this was a 2 hour and 39 minute drive. Patient #1 was a 22 month old female with an IV intact, documented as stable by the sending physician. When asked how patient was stabilized, the ED physician stated: "she was given fluids, antipyretics and antibiotics." When ED physician was asked if he would expect an RN to RN communication note giving report to the receiving hospital, he stated: "yes." Surveyor was unable to find any nurse to nurse communication note.

Medical records for patient #1 were further reviewed in the presence of the ED Supervisor, the ED Director, the VP of Quality, and the Director of Regulatory Compliance 8/16/22, beginning at 11:00 AM. The ED Supervisor was unable to locate any documentation of physician to physician communication or nurse to nurse report documentation. When asked if there was a documented discussion with parents regarding the risks and benefits of the transfer and the transfer options, he replied: "I can't answer cuz I don't know." When the ED Supervisor was asked if Patient #1 was a transfer or a discharge, he confirmed it was a transfer. The ED Supervisor also confirmed the transfer form was incomplete. When asked if it is typical to transfer via private auto to a receiving hospital in another state, the ED Supervisor replied: "No." The ED Director was also asked if this is typical to transfer via private auto and he replied: "No."

The current charge RN on duty was interviewed on 8/17/22, beginning at 10:30 AM. He was asked if the charge nurse is involved in transfers and he replied: "somewhat". When asked if a transfer requires a nurse to nurse documented handoff, he replied: "Yes." When asked if he recalled the case of Patient #1, he replied: "I vaguely remember the conversation of the transfer." When asked if this transfer via private auto is common, he replied: "no, it is an outlier. We had a form once for private vehicle transport but it was so uncommon we did away with it."

Patient #1 was transferred via private auto with acute appendicitis, requiring a 2 hour and 39 minute drive across state lines. This had the potential for an adverse outcome.

B. Patient #14 was a 9 month old female seen in the ED on 5/15/22. She presented to the ED with a chief complaint of a fever after chemotherapy within the past week.

Patient #14's medical record included the following provider notes.

5/15/22 at 11:36 PM, the physician documented: "Patient is a 9 month old female with a history of neuroblastoma who presents to the emergency department today with a fever after chemotherapy within the past week. I received a phone call from [oncologist name] oncology fellow at [receiving hospital]. that I be prepared for the patient arrived[sic] in the emergency department." The child's oncologist recommended lab work and antibiotics for Patient #14 and that Patient #14 may need a hospital admission.

5/16/22 at 12:06 AM, the physician documented: "Did sign out from [previous physician] pending laboratory workup. The patient was noted to have an absolute neutrophil count of 1.3 down from earlier the patient does look well I did speak with oncology fellow [Patient #14's oncologist] at [receiving hospital]. Plan is to give cefepime[antibiotic] and admit I spoke with pediatrics who will admit the patient. [sic]"

5/16/22 at 12:57 AM, "Patient and family change their mind wanted to go to the [receiving hospital]. I spoke with the transfer center and [Patient #14 oncologist] who accepted the patient in transport."

There was no documentation in Patient #14's record on how Patient #14 was transported to [receiving hospital]. Additionally, there was no documentation the ED physician discussed risks and benefits of the transfer.

The ED supervisor was interviewed 8/17/22 beginning at 11:28 AM. When asked if Patient #14 was transferred or discharged he stated, "technically it's a transfer." When asked for the transfer form he was unable to provide it, he stated a transfer form should have been filled out. When asked for documentation of the transfer risks and benefits explained to Patient #14's parents, he confirmed there was no documentation that risks and benefits of the transfer were discussed with the parents. When asked how the patient was transferred to [receiving hospital], he stated there was no documentation on how Patient #14 was transported.

The hospital failed to ensure risks and benefits of transfer were documented. Additionally, the hospital failed to ensure all transfer information was included in the medical record.

3. The hospital failed to ensure all patients seeking emergency treatment were provided an MSE

A. Policy #60359.1, Title: EMTALA Medical Assessment Screening OB Patient-NS-PMC, effective date: 11/03/19, was reviewed. The Procedure states: "All patients presenting for obstetrical conditions 18 weeks or greater, other than scheduled procedures, or trauma patients go directly in the Labor and Delivery unit." This policy was not followed.

Patient #18 presented to the ED at 2:54 PM and was not assessed in L&D until 5:34 PM, 2 hours and 40 minutes after being triaged in the ED. Patient #18 was a 23 year old female triaged and registered in the ED on 6/06/22. ED triage note written at 2:54 PM states: "Pt presents to ED with R [right] sided lower back pain that started this morning. Pt is 22 weeks pregnant..." Patient #18 was triaged as "urgent" and pain score was documented as "7-severe pain." No further ED documentation was found in the patient record.

Reviewed Patient #18's record with ED Supervisor and ED Director on 6/17/22, beginning at 11:00 AM. When asked to find the MSE, the ED Supervisor stated: "I don't see one. It looks like she was admitted to ED, triaged, and never had a MSE in the ED." The ED Director concurred that there was no MSE documented in the patient record.

Patient #18's medical record indicated on 6/06/22 at 5:34 PM, she was admitted to 2nd floor Labor and Delivery. Assessment was completed by Labor and Delivery physician with a note stating: "the patient....presents with new onset right lower back pain, dysuria/urgency." A urine analysis was negative and a pelvic ultrasound was negative. A renal ultrasound was completed as well as lab work.

Patient #18 was discharged with instructions from Labor and Delivery on 6/06/22 at 9:47 PM. No documentation was found to indicate how or when the patient was transported to Labor and Delivery 2nd floor. No documentation was found to indicate there was communication between the ED and Labor and Delivery.

The ED Charge nurse was interviewed by phone on 8/18/22 beginning at 11:15 AM. When asked about the protocol for a pregnant patient presenting in the ED, he stated: "if they are greater than 20 weeks pregnant and if they are pregnancy related, we would take to Labor and Delivery and not register them, we would call up to L&D. If it is not pregnancy related we would do an MSE here."

Patient #18 presented to the ED at 2:54 PM and was not assessed in L&D until 5:34 PM, 2 hours and 40 minutes after being triaged in the ED.

B. Patient #6 was a 54 year old female who presented to the ED via private vehicle on 6/6/22 at 10:44 AM. Her chief complaint was left ankle pain.

Patient #6's medical record included a triage note documented by an RN. It stated: "Pt reports left ankle pain. Pt reports that she was walking apprx[approximately] 3 days ago and has noticed swelling since then. Pt reports pain in left ankle. "

Patient #6's medical record included that she rated her pain at an 8 on a 0-10 score with 10 being the worst pain. The medical record included Patient #6's vital signs.

Patient #6's medical record did not include an MSE. At 12:08 PM it is documented that Patient #6 was not in the waiting room.

The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #6's medical record was reviewed in his presence. He confirmed Patient #6's record did not include an MSE.

C. Patient #7 was a 66 year old female who presented to the ED via ambulance on 6/5/22 at 11:21 PM. ED clerk documented: "Ambulance Report: [EMS] transporting female patient that fell out of her chair Wednesday and is still experiencing left foot pain with bruising. Patient also reports a bump in the middle of her chest she would like checked out. No recent trauma. Patient a/o [alert and oriented]."

Patient #7's next ED note documented on 6/6/22 at 12:22 AM by RN is "Pt left ED prior to triage assessment."

The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #7's medical record was reviewed in his presence. He confirmed Patient #7's record did not include an MSE.

D. Patient #8 was 51 year old male who presented to the ED via private vehicle on 6/01/22 at 12:04 PM. His chief complaint was bilateral eye burning.

Patient #8's medical record included a triage note documented by an RN at 12:12 PM. It stated "Patient presents to the ED with bilateral eye burning that started around 10am this morning. Patient denies environmental exposer[sic]. No erythema noted to sclera. Patient denies vision changes."

Patient #8's medical record included a pain rating of 8 on a 0-10 score with 10 being the worst pain. The medical record included Patient #8's vital signs.

Patient #8's medical record did not include an MSE. At 12:48 PM the physician documented patient was discharged, and that Patient #8 left without being seen after triage.

The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #8's medical record was reviewed in his presence. He confirmed Patient #8's record did not include an MSE.

The facility failed to ensure all patients seeking care in the ED were provided an MSE..

4. Refer to A0115 as it relates to the hospitals failure to keep patients safe in the ED.