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

Findings Include:

Hospital policy titled "Quick Look Process and Assessment with Reassessment of Patients (Adult and Pediatric) in the Emergency Department Guideline," revealed: "...Acuity: using the Emergency Severity Index (ESI) patients are assigned an acuity...All patients presenting to the ED will receive quick look documentation by a registered nurse (RN)...Assessments and vital signs should occur as described depending on patient acuity...Acuity 1, 2, and 3 should receive a head to toe assessment within thirty (30) minutes of primary RN assignment. Focused assessments along with neurologic/cardiac/respiratory/perfusion status should occur at a minimum of every 2 hours, with change in condition, with new primary RN handoff and within 30 minutes of leaving the ED for disposition...Vital signs should be obtained at a minimum of every 2 hours and with a change of condition while in a room. If in a waiting que, vital signs will be obtained every 3 hours...Levels of Acuity: 1. ESI 1: Resuscitative 2. ESI 2: Emergent 3. ESI 3: Urgent 4. ESI 4: Semi-Urgent...Emergent Criteria: 1. High risk: a patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment or whose condition could easily deteriorate...."

Hospital policy titled "Critical Values, Reporting and Escalation Policy," revealed: "...Critical results are expected to be communicated to a responsible party within 60 minutes for inpatients...from the time the result is first identified as a critical result. D. All critical results require completion of the Communication Log in the LIS...RN's may initiate action based on a defined protocol or physician order...If a protocol or physician order is not available, the RN will contact the physician or RC with the result...Department Specific Critical Values...Blood Hemoglobin <7 g/dl...Adult Potassium 6.2mmol/L...."

Hospital policy titled "Documentation Requirements for Patients That LWBS or AMA," revealed: "...Against Medical Advice (AMA): Before a patient leaves the facility against the advice of the provider, the provider should: 1. Discuss with the patient why they want to leave and encourage the patient to stay explaining that leaving would be against medical advice. 2. Inform the patient of potential consequences of leaving AMA. 3. If patient is leaving AMA, ask patient to sign Refusal of Care AMA form and witness patient's signature. 4. Include the time and date of refusal on the form. If patient leaves without signing Refusal of Care AMA form, YRMC staff should document the efforts to obtain signature and patient's refusal in the medical record. 5. All workforce members who were present when the form was offered and refused should sign as witness. 6. The physician/LIP should fully chart circumstances of the refusal with a summary of the facts leading up to the incident. 7. Discharge the patient as AMA...."

A review of 26 ED records randomly selected for review included nine (9) patients (Patients #2, 5, 6, 7, 13, 15, 17, 22, and 23), who were not reassessed or had vital signs performed while in the waiting queue or according to ESI score.

A review of 26 ED records randomly selected for review included two (2) patients (Patients #2 and 21), who had critical lab values and there was no required notification made to the provider.

A review of 26 ED records randomly selected for review included two (2) patients (Patients #15 and 24), who left AMA, and the required documentation was not completed in the medical record.

Employee #6 confirmed in an interview on 0/08/2023, that the nine patients did not have vital signs and reassessments performed per policy. It was also confirmed that there was no documentation of provider notification when two patients had critical lab values. Employee #6 confirmed that there were no Refusal of Care forms signed by staff or patients, nor any documentation by providers or nurses as to why the patients left or efforts made to prevent them from leaving.

Employee #1 confirmed in an interview on 08/08/2023, that there was no provider notification when Patients #2 and 21 had critical lab values resulted.

Based on review of hospital records and interviews, it was determined the hospital failed to ensure a patient (Patient #1) who came to the Emergency Department by private vehicle was entered into the dedicated ED log.

Findings Include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act ("EMTALA") Compliance Policy," revealed: "...A central log on each individual who comes to the emergency department and/or obstetrics departments seeking emergency medical treatment and whether he or she refused treatment of voluntarily left without receiving a medical screening examination or treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged...."

Hospital document titled "Risk Management Worksheet," dated 12/27/2021, revealed: "...On 12/27/2021 at approximately 1600 hrs. a visitor which refused to identify [himself] appropriately cam {sic} in thru the ED entrance of the hospital. Upon entering thru the main doors, Officer (Employee #26) asked the unknown individual, about the hospital's covid screening question and they proceed {sic} to ask if [he] had any weapons on [him]. The individual then proceeded to laugh and said "Are you playing with me?" According to (Employee #26), the individual then proceeded to request a supervisor...I, shift supervisor (employee #27) arrived on scene...Due to the high volume of patients at the ED and incoming patient {sic} thru the main doors, I (Employee #27), asked if we could move from the entrance to the ED vestibule...After talking to this individual for a period of 15 minutes I then told the individual that if there was nothing else that we could do to help [he] would have to leave...This individual was not causing harm or being physicaly {sic} disorderly to any of the staff present. I told dispatch...to call Yuma Police Department...At approximately 1620 hrs. Yuma Police Department arrived on site...[He] then proceeded to talk to the unidentified individual. After a long conversation, [he] then proceeded to ask the individual to leave the premises at approximately 1623 hrs...."

Review of the Hospital ED log for December, 2021, failed to reveal Patient #1 listed on the log.

Employee #6 confirmed in an interview on 08/08/2023, that Patient #1 was not on the ED log.

Employee #4 also confirmed in an interview on 08/09/2023, that Patient #1 was not on the ED log.

Based on review of hospital records and interviews, it was determined that the hospital failed to provide an appropriate Medical Screening Examination to twenty-one (21) out of twenty-six (26) patients who presented to the ED for examination and treatment. (Patients #1, 3, 4, 13, 14, 24, 2, 5, 6, 7, 8, 10, 11, 12, 16, 17, 21, 22, 23, 25, and 26)

Findings Include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act ("EMTALA") Compliance Policy", revealed: "...An appropriate MSE will be offered to individual's {sic} on the Hospital's Campus who request emergency medical services, on whose behalf such services are requested...Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. An MSE will be conducted to determine whether the Patient has an EMC...If the individual must wait to receive a medical screening examination for an extended period of time, the nurse, of LIP will periodically reassess the individual, to determine whether the individual, should have a higher medical screening priority...The hospital will keep the following records related to EMTALA...A central log on each individual who comes to the emergency department and/or obstetrics department seeking emergency medical treatment and whether he or she refused treatment or voluntarily left without receiving a medical screening examination or treatment...Re-question when there is a prolonged wait for an EMC...Medical Screening Exam: i. Physician/QMP assessment and orders ii. Intervention/treatments iii. Patient/fetus response to treatment...."

Hospital policy titled "Quick Look Process and Assessment with Reassessment of Patients (Adults and Pediatric) in the Emergency Department Guideline," revealed: "...Acuity: using the Emergency Severity Index (ESI) patients are assigned an acuity...All patients presenting to the ED will receive quick look documentation by a registered nurse (RN)...Assessments and vital signs should occur as described depending on patient acuity... Acuity 1, 2, and 3 should receive a head to toe assessment within thirty (30) minutes of primary RN assignment. Focused assessments along with neurologic/cardiac/respiratory/perfusion status should occur at a minimum of every 2 hours, with change in condition, with new primary RN handoff and within 30 minutes of leaving the ED for disposition...Vital signs should be obtained at a minimum of every 2 hours and with a change of condition while in a room. If in a waiting que, vital signs will be obtained every 3 hours...Levels of Acuity: 1. ESI 1: Resuscitative 2. ESI 2: Emergent 3. ESI 3: Urgent 4. ESI 4: Semi-Urgent ...Emergent Criteria: 1. High risk: a patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment or whose condition could easily deteriorate...."

Hospital document titled "Department of Emergency Medicine Rules and Regulations," revealed: "...All patients who present to the Emergency Department will receive a medical screening examination...."

Review of the Hospital ED log for December 27, 2021, failed to reveal Patient #1 listed on the log.

Hospital document titled "Risk Management Worksheet," dated 12/27/2021, revealed: "...On 12/27/2021 at approximately 1600 hrs. a visitor which refused to identify [himself] appropriately cam {sic} in thru the ED entrance of the hospital. Upon entering thru the main doors, Officer (Employee #26) asked the unknown individual, about the hospital's covid screening question and they proceed {sic} to ask if [he] had any weapons on [him]. The individual then proceeded to laugh and said "Are you playing with me?" According to (Employee #26), the individual then proceeded to request a supervisor...I, shift supervisor (Employee #27) arrived on scene...Due to the high volume of patients at the ED and incoming patient {sic} thru the main doors, I (Employee #27), asked if we could move from the entrance to the ED vestibule...After talking to this individual for a period of 15 minutes I then told the individual that if there was nothing else that we could do to help [he] would have to leave...This individual was not causing harm or being physicaly {sic} disorderly to any of the staff present. I told dispatch...to call Yuma Police Department...At approximately 1620 hrs. Yuma Police Department arrived on site...[He] then proceeded to talk to the unidentified individual. After a long conversation, [he] then proceeded to ask the individual to leave the premises at approximately 1623 hrs...."

A total of 26 ED medical records were randomly selected for review including patients who were transferred, admitted, or left before Medical Screening Examinations (MSE).

Six (6) out of twenty-six (26) records revealed patients who did not receive an MSE:
1. Patient #1, 12/27/2021, arrived at approximately 16:00 and left at 1623 without being triaged or receiving an MSE.
2. Patient #3, 01/15/2022, arrived 0014; ED Timeline reveals: "...called for triage, no response...." documented at 01:55, 02:02, and 02:20.
3. Patient #4, 01/31/2022, arrived 00:50, triaged 00:58, ESI 3, LWBS 03:06. Time elapsed: 2 hours, 16 minutes
4. Patient #13, 12/07/2021, arrived 20:27, triaged 20:55, ESI 2, LWBS 03:23. Time elapsed 6 hours, 56 minutes
5. Patient #14, 12/08/2021, arrived 14:03, triaged 14:19, ESI 3, LWBS 18:58. Time elapsed 4 hours, 39 minutes
6. Patient #24, 01/17/20223, arrived 16:44, triaged 16:53, ESI 3, LWBS 22:53. Time elapsed 6 hours, 9 minutes

Fifteen (15) out of twenty-six (26) records reviewed revealed patients who had a delay in receiving an MSE:
1. Patient #2, 01/01/2022, arrived 00:48, triaged 00:59, ESI 2, MSE 05:39. Time elapsed 4 hours, 51 minutes
2. Patient #5, 01/23/2022, arrived 23:27, triaged 23:30, ESI 3, MSE 03:24. Time elapsed 3 hours, 57 minutes
3. Patient #6, 01/18/2022, arrived 09:37, triaged 09:37, ESI 2, MSE 14:50. Time elapsed 5 hours, 13 minutes
4. Patient #7, 01/18/2022, arrived 10:20, triaged 10:40, ESI 2, MSE 14:56. Time elapsed 4 hours, 36 minutes
5. Patient #8, 01/01/2022, arrived 00:34, triaged 00:42, ESI 2, MSE 02:48. Time elapsed 2 hours, 14 minutes
6. Patient #10, 12/22/2021, arrived 08:49, triaged 08:57, ESI 3, MSE 11:05. Time elapsed 2 hours, 16 minutes
7. Patient #11, 12/21/2021, arrived 20:04, triaged 20:04, ESI 2, MSE 01:37. Time elapsed 5 hours, 33 minutes
8. Patient #12, 12/17/2021, arrived 11:11, triaged 11:26, ESI 2, MSE 16:02. Time elapsed 4 hours, 36 minutes
9. Patient #16, 11/27/2021, arrived 04:33, triaged 04:40, ESI 3, MSE 08:21. Time elapsed 3 hours, 48 minutes
10. Patient #17, 11/30/2021, arrived 00:26, triaged 00:50, ESI 3, MSE 04:26. Time elapsed 4 hours, 0 minutes
11. Patient #21, 11/23/2021, arrived 16:34, triaged 16:39, ESI 2, MSE 05:00. Time elapsed 12 hours, 26 minutes
12. Patient #22, 09/30/2022, arrived 20:11, triaged 20:40, ESI 3, MSE 00:38. Time elapsed 4 hours, 27 minutes
13. Patient #23, 04/16/2022, arrived 07:00, triaged 07:16, ESI 4, MSE 09:05. Time elapsed 2 hours, 5 minutes
14. Patient #25, 04/13/2022, arrived 12:58, triaged 13:03, ESI 2, MSE 17:54. Time elapsed 4 hours, 56 minutes
15. Patient #26, 07/29/2022, arrived 21:27, triaged 21:33, ESI 3, MSE 01:39. Time elapsed 4 hours, 12 minutes

Four (4) out of twenty-six (26) records reviewed revealed discharge orders written before an MSE was performed.
1. Patient #11, 12/21/2021, arrived 20:04, triaged 20:04, ESI 2. Discharge orders were written at 01:32. ED Provider Note revealed: "...Time seen: 01:37...." Patient #11 discharged at 01:43, six minutes after the MSE.
2. Patient #12, 12/17/2021, arrived 11:11, triaged 11:26, ESI 2. Discharge orders were written at 16:00. ED Provider Note revealed: "...Time seen: 16:02...." Patient #12 discharged at 16:06, four minutes after the MSE.
3. Patient #21, 11/23/2021, arrived 16:34, triaged 16:39, ESI 2. Discharge orders were written at 04:59. ED Provider Note revealed: "...Time seen: 05:00...." Patient #21 discharged at 05:46, forty six minutes after the MSE.
4. Patient #22, 09/30/2022, arrived 20:11, triaged 20:40, ESI 3. Discharge orders were written at 00:36. ED Provider Note revealed: "...Time seen: 00:38...." Patient #22 discharged at 00:46, eight minutes after the MSE.

A tour of the ED was conducted on 08/09/2023. There were three (3) patients observed in the ED lobby. There were two (2) unoccupied triage rooms and six (6) treatment rooms, staffed by a PCA, where EKG's and labs were done. There was a patient in one of these treatment rooms.

Employee #3 confirmed in an interview on 08/08/2023, that on 12/27/2021, COVID screening was in place for all people entering the hospital. A COVID screener and a security officer were both present at the ED entrance when COVID screening was in effect. It was then confirmed that Employee #26, a security officer, was doing the COVID screening and there was no other officer performing security duties on that day. Employee #3 confirmed that everyone was questioned about weapons before they could enter the ED. Employee #3 also confirmed that Patient #1 was not allowed entrance to the ED, nor received an MSE.

Employee #4 confirmed in an interview on 08/09/2023, that patients entering the ED were not questioned about weapons before the metal detectors were installed. Employee #4 also confirmed that Patient #1 was unable to register at the ED, nor received an MSE.

Employee #7 confirmed in an interview on 08/08/2023, that there were six (6) patients (Patients #1, 3, 13, 4, 14, and 24), who did not receive an MSE before leaving and fifteen (15) patients (Patients #2, 5, 6, 7, 8, 10, 11, 12, 16, 17, 21, 22, 23, 25, and 26) had a delay in receiving an MSE.

Employee #6 confirmed in an interview on 08/08/2023, that Patients #11, 12, 21, and 22, had discharge orders written before the time the patient was documented as being seen by the provider. Employee #6 confirmed that Patient #1 was not on the ED log and did not receive emergency services at the hospital. Employee #6 confirmed that six (6) patients (Patients #1, 3, 13, 4, 14, and 24), left before they had an MSE. It was also confirmed that fifteen (15) patients (Patients #2, 5, 6, 7, 8, 10, 11, 12, 16, 17, 21, 22, 23, 25, and 26) had wait times ranging from 2 hours and 5 minutes, to over 12 hours, from the time they arrived, to the time an MSE was documented.

Employee #6 confirmed during the tour, on 08/09/2023, that the providers attempted to perform MSEs in the triage room during the Quicklook. On some shifts, there was a virtual MSE performed by an assigned provider, or if a provider was busy in the back of the ED, they would provide a virtual MSE.

Based on review of hospital records, and interviews, it was determined that the Hospital delayed examination and treatment for fourteen (14) out of twenty-six (26) patients (Patients #2, 7, 11, 5, 6, 21, 25, 13, 14, 16, 17, 24, 26, and 22), that presented to the Emergency Department for treatment.

Findings Include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act ("EMTALA") Compliance Policy," revealed: "...An appropriate MSE will be offered to individual's on the Hospital's Campus who request emergency medical services, on whose behalf such services are requested...Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. An MSE will be conducted to determine whether the Patient has an EMC...If the individual must wait to receive a medical screening examination for an extended period of time, the nurse, or LIP will periodically reassess the individual, to determine whether the individual, should have a higher medical screening priority...The hospital will keep the following records related to EMTALA...A central log on each individual who comes to the emergency department and/or obstetrics department seeking emergency medical treatment and whether he or she refused treatment or voluntarily left without receiving a medical screening examination or treatment...Re-question when there is a prolonged wait for an EMC...Medical Screening Exam: i. Physician/QMP assessment and orders ii. Intervention/treatments iii. Patient/fetus response to treatment...."

Hospital policy titled "Quick Look Process and Assessment with Reassessment of Patients (Adult and Pediatric) in the Emergency Department Guideline," revealed: "...Acuity: using the Emergency Severity Index (ESI) patients are assigned an acuity...All patients presenting to the ED will receive quick look documentation by a registered nurse(RN)...Assessments and vital signs should occur as described depending on patient acuity...Acuity 1, 2, and 3 should receive a head to toe assessment within thirty (30) minutes of primary RN assignment. Focused assessments along with neurologic/cardiac/respiratory/perfusion status should occur at a minimum of every 2 hours, with change in condition, with new primary RN handoff and within 30 minutes of leaving the ED for disposition...Vital signs should be obtained at a minimum of every 2 hours and with a change of condition while in a room. If in a waiting que, vital signs will be obtained every 3 hours...Levels of Acuity: 1. ESI 1: Resuscitative 2. ESI 2: Emergent 3. ESI 3: Urgent 4. ESI Semi-Urgent...Emergent Criteria: 1. High risk: a patient who presents with symptoms suggestive of
a condition requiring time-sensitive treatment or whose condition could easily deteriorate...."

Hospital policy titled "Critical Values, Reporting and Escalation Policy," revealed: "...Critical results are expected to be communicated to a responsible party within 60 minutes for inpatients...from the time the result is first identified as a critical result. D. All critical results require completion of the Communication Log in the LIS ...RN's may initiate action based on a defined protocol or physician order...If a protocol or physician order is not available, the RN will contact the physician or RC with the result...Department Specific Critical Values...Blood Hemoglobin <7 g/dl...Adult Potassium 6.2mmol/L...."

Twenty six randomly selected ED medical records revealed there were fourteen (14) patients who had a delay in treatment:
1. Patient #25, on 04/13/2022, arrived at 12:58, and was triaged at 13:03 as an ESI 2, with the documentation "...Pt reports that [he] has had abdominal pain and emesis starting this AM. Reports hx of pancreatitis. EMS states sugar was reading HI at home...." An RN was notified by the CNA of a critical point of care (POC) glucose result of 404, at 1334. A lab glucose of 425 resulted at 13:48, and a repeat POC glucose at 13:58 was 404. An ED Note at 15:00 reveals: "...Patient [sister] upset about wait time, states patient is very sick...patient continuously vomiting ...Patient's [sister] asking writer to recheck VS and finger stick...Patient's [sister] informed that quick look nurse and RC are aware about patients status...[Sister] informed that per quick look nurse there is no reason to repeat FS since no treatment for it has been initiated...15:30...Patient's [sister] continues to be mad about patient still waiting to get an ER room...15:45...Patient advocate talking to [sister]...." Patient #25 was moved to an assigned room at 16:18. Patient #25 received fluids and Zofran at 17:17, and insulin at 17:28. Patient #25 received an MSE at 1754. Time between registration and MSE: 4 hours and 56 minutes. There was a 4 hour and 19 minute delay between arrival, with a known high glucose value, and treatment.
2. Patient #2, 01/01/2022, arrived 00:48, with an ED Triage Note "...patient c/o left sided chest pain with radiation into left arm and shoulder intermittently x 3 days but tonite {sic} it is worse and not going away..." Patient #2 received vital signs 00:52, and was triaged at 00:59, with an ESI 2. A critical lab value, 5.5 hemoglobin, was called to an RN at 01:22. There was no provider notification documented, nor further assessment. Patient #2 was placed in a room at 04:44. Vital signs were performed at 04:57 A type and screen was drawn at 04:59. Patient #2 received an MSE at 05:39. A note titled "ED Provider Note," revealed "...Time seen: 05:39...Patient hemoglobin 5.5, [she] is currently pending receiving 2 units of PRBC's. Patient has been taking alot of ibuprofen recently and I have concern for bleeding ulcer in the stomach. For these reasons patient has been started on 80 of Protonix, GI will be consulted and currently pending CT angio of the chest abdomen pelvis...." A blood transfusion was started at 07:05. Time between registration and MSE: 4 hours and 51 minutes. Time elapsed between critical value and treatment start: 5 hours and 43 minutes
3. Patient #21, 11/23/2021, arrived at 16:34 and was triaged at 16:39 with an ESI of 2, and a chief complaint of midsternal chest pain. Initial vital signs were at 17:09, including a blood pressure (BP) of 129/84 and pain score of 8. A critical lab value, Potassium 6.6, resulted at 17:39. There was no documentation of notification to the care team. Patient #21 was placed in a room at 19:26. The next vital signs documented were at 19:30, with a BP of 180/109. The following BPs were documented: 1935, 180/109; 1945, 167/119; 2000, 192/101, with no documentation of provider notification. Patient #21 had an attending assigned at 21:23, and was received an order for Vistaril at 21:27. A repeat potassium of 6.6 resulted at 21:57, and the RN was notified. Patient #21 received insulin, Lasix, sodium bicarbonate and 50% Dextrose at 23:06. A note titled "ED Provider Note'" revealed: "...Time seen: 05:00...Positive for chest pain and palpitations...Patient's potassium was initially elevated at 6.6 we were able to bring [her] down to 4.8 with management therapies here in the ER...." Time between registration and MSE: 12 hours and 26 minutes. Time between first critical value and treatment start: 5 hours, 27 minutes
4. Patient #5, 01/23/2022, arrived at 23:27, was triaged at 23:30 as an ESI 3, with a chief complaint of chest pain, and received vital signs at 23:35. A troponin of 0.34 resulted at 00:08. Patient #5 was placed in a room at 03:04. The next vital signs were documented at 03:05. An MSE was performed at 03:24, and another troponin was ordered. A CT was performed for "high prob of PE" at 0359, which was negative. A troponin of 1.29 resulted at 0412. Patient #5 was admitted to observation at 0611, where cardiology was consulted. A troponin of 3.3 resulted at 10:19, and Patient #5 was taken to the cath lab. Time between registration and MSE: 3 hours and 57 minutes. Patient #5 waited 3 hours and 51 minutes between first troponin results and CT scan to begin diagnosis process.
5. Patient #26, a 4 year old child's, medical record contained an ED Timeline, dated 07/29/2022, which revealed: " ...2127 Patient Arrived in ED ...2133 ...[Mom] states was running and fell landing on right arm. Pt cried immediately and won ' t move arm. Obvious deformity at right elbow ...0019 Imaging Exam Started ...0139 Screening Complete ...0150 Medication Given Acetaminophen ...0227 ...Transfer to another facility ...0232 ...Splint Application ...0353 Patient discharged .... " Patient #26 ' s medical record contained a note titled " ED Provider Note, " dated 07/30/2022, which revealed: " ...Time seen 0229 ...X-rays positive for fracture of the lateral condylar fracture of the right distal humerus...." Time between registration and MSE: 4 hours and 12 minutes. Patient #26 waited for 2 hours and 46 minutes for diagnostic imaging, and 4 hours and 17 minutes before receiving any medication to treat pain resulting from the fracture.
6. Patient #7, 01/18/2022, arrived at 10:20, had vital signs at 10:39, and was triaged at 10:40 with an ESI 2. The next vital signs documented were at 14:25. An MSE was performed at 14:56. Patient #7 was admitted to observation at 15:37. Time between registration and MSE: 4 hours and 36 minutes
7. Patient #11, 12/21/2021. ED Timeline revealed: "...20:04 Arrived in ED...PTA medications: Aspirin, Nitroglycerine (324mg ASA, nitro x 2)...20:09...Pt arrived via ems c/o chest pain, pt reports hx of stents...Patient Acuity: 2...20:11...BP 167/119...21:06...BP 146/101...21:35...BP: 137/99...01:25...Urinalysis...Abnormal Result...Blood, UA: Large !...." Discharge orders were written at 01:32. ED Provider Note revealed: "...Time seen: 0137...History obtained from: Patient and Border patrol...presents to the ED for medical clearance...." The patient was discharged at 01:46. Time between registration and MSE: 5 hours and 33 minutes. Time between MSE and discharge: 9 minutes
8. Patient #6, 01/18/2022, arrived and was triaged at 09:37, with an ESI 2. The next vital signs were documented at 13:40, and the patient received an MSE at 14:50. Patient #6 was admitted to observation at 15:27. Time between registration and MSE: 5 hours and 13 minutes
9. Patient #13, 12/07/2021, arrived at 20:27, and was triaged at 20:55, with an ESI of 2, and had vital signs at 18:05. Vital signs were again documented at 0230. At 03:23 it was documented "...pt decided to leave...." There was no further documentation. Time between registration and LWBS: 6 hours and 56 minutes
10. Patient #15, on 01/15/2021, arrived at 17:50. At 18:05, Patient #15 had vital signs, was triaged as an ESI 3, and had an MSE. It was documented at 21:32 that "...pt stated [he] was to leave the hospital..." and at 21:33 "...pt left the hospital...." There was no additional documentation or vital signs performed. Time between registration and LWOT: 3 hours and 43 minutes
11. Patient #16, on 11/27/2021, arrived at 04:33 with a chief complaint of unresponsiveness and tracheal stenosis. Patient #16, a pediatric patient, was triaged at 04:40, with an ESI of 3. An MSE was performed at 08:21, and the decision was made to transfer to a pediatric hospital. Time between registration and MSE: 3 hours and 48 minutes
12. Patient #17, on 11/30/2021, arrived at 00:26. Vital signs and triage was performed at 00:50, with an ESI of 3. An MSE was performed at 04:26 and the decision was made to transfer the patient. Vital signs were performed again at 04:37. Time between registration and MSE: 4 hours and 0 minutes
13. Patient #24, on 01/17/2023, arrived at 16:44 with a chief complaint of chest pain and shortness of breath. Patient #24 was triaged at 16:53, and assigned an ESI of 3. It was documented by the physician at 22:53 that the patient left against medical advice. There was no other physician documentation or MSE performed. Time between registration and LWBS: 6 hours and 9 minutes
14. Patient #22, on 09/30/2022, arrived at 20:11 with a chief complaint of abdominal pain. The patient was triaged, with an ESI of 3, and had vital signs performed at 20:40, including a BP of 138/105. A CT was performed at 22:38. Discharge orders were written at 00:36. ED Provider Note revealed: "...Time seen 12:38 AM...on exam [she] had more pelvic pain than abdominal pain...CT shows no acute pathology...." There were no further vital signs documented. The patient was discharged at 00:46. Time between registration and MSE: 4 hours and 27 minutes. Time between MSE and discharge: 9 minutes

Four (4) out of twenty-six (26) records reviewed revealed discharge orders written before an MSE was performed.
1. Patient #11, 12/21/2021, arrived 20:04, triaged 20:04, ESI 2. Discharge orders were written at 01:32, MSE at 01:37. Patient #11 discharged at 01:43.
2. Patient #12, 12/17/2021, arrived 11:11, triaged 11:26, ESI 2. Discharge orders were written at 16:00, MSE at 16:02. Patient #12 discharged at 16:06.
3. Patient #21, 11/23/2021, arrived 16:34, triaged 16:39, ESI 2. Discharge orders were written at 04:59, MSE at 05:00. Patient #21 discharged at 05:46.
4. Patient #22, 09/30/2022, arrived 20:11, triaged 20:40, ESI 3. Discharge orders were written at 00:36, MSE at 00:38. Patient #22 discharged at 00:46.

Employee #6 confirmed in an interview on 08/08/2023, that there was no documentation of a provider being notified for critical lab values on Patients #2, 21, and 25, and they remained in the waiting room, for four and a half (4.5) to over five (5) hours, without receiving treatment or being seen by a provider, after the critical values resulted. Employee #6 also confirmed that fourteen (14) patients (Patients #2, 7, 11, 5, 6, 21, 25, 13, 14, 16, 17, 24, 26, and 22), did not receive assessment or treatment in a timely manner. Employee #6 confirmed that four (4) patients (Patients #11, 12, 21, and 22), had discharge orders written before the time it was documented they were seen by the provider.

Employee #1 confirmed in an interview on 08/09/2023, that Patients #2 and #21 were in the waiting room for an extended amount of time, with no reassessments performed, treatment started, or examination done, after having critical lab values.

Employee #21 confirmed in an interview on 08/09/2023, that if a patient is in the waiting room in the ED, there is no assigned RN and there is no obvious alert on the tracker board if a critical lab value is reported. To see the lab you have to hover over the box where all resulted labs are displayed. The lab would call to alert an RN about a critical lab, and for patients in the waiting room it would be the charge RN, known as the RC, that was alerted.

Employee #7 confirmed in an interview on 08/08/2023, that four (4) patients (Patients #11, 12, 21, and 22), had discharge orders written before the time it was documented they were seen by the provider.