Based on interview, clinical record, and administrative document review, the hospital failed to ensure policies and procedures for care of emergency department patients were current and fully implemented by nursing staff. 1. Patient 1 presented to the Emergency Department (ED) on 3/28/18 at 5:40 a.m. with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure. The triage Registered Nurse (RN 1) assessed Patient 1, obtained her blood pressure of 186/120 (normal range 120/80-140/90), and determined the Emergency Severity Index (ESI: a five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources [tests, procedures, or treatments likely to be utilized in order to determine the disposition of a patient]) as Level 3. RN 1 initiated, but did not completely implement the Chest Pain standardized procedure (SP), did not prioritize Patient 1 to be seen by a provider (Physician, Physician's Assistant, Nurse Practitioner), did not prioritize obtaining the blood samples for the lab tests ordered, and had Patient 1 wait in the lobby. 2. Patient 24 (MDS) dated [DATE] at 10:44 a.m. with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN 9) assessed Patient 24 and determined the ESI as Level 3, initiated but did not completely implement the Chest Pain SP, did not prioritize Patient 24 to be seen by a provider, and had Patient 24 wait in the lobby. 3. Patient 13 (MDS) dated [DATE] at 10:13 a.m. with the chief complaint of "suicidal ideation [SI] [thinking about or planning suicide], and depression [A mental health disorder causing persistent feelings of sadness that affect a person's daily life]." Patient 13 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The SP for psychiatric complaints was initiated but not fully implemented. These failures resulted in a delay in evaluation and treatment of Patients 1,13, and 24 by a provider. Findings: 1. Review of Patient 1's clinical record indicated: On 3/28/18 at 5:40 a.m., Patient 1, a [AGE] year old female, arrived via private car to the hospital's Emergency Department (ED) and checked in with RN 1. Patient 1 provided RN 1 the chief complaint that she had been experiencing chest pain for three days described as burning, tightness and intermittent. Patient 1 described her current pain level as 8 on a scale of 0 to 10. RN 1 assigned Patient 1 an ESI of 3. 5:43 a.m.: RN 1 initiated orders from the Chest Pain Standardized Procedure (SP: a protocol for RNs which allows for ordering diagnostic studies and providing initial treatment in specific situations prior to a patient being examined by a provider [physician/physician's assistant/nurse practitioner]) as follows: Blood tests for Troponin I (a protein released when the heart muscle is damaged), CBC (complete blood count), Metabolic Panel (Test measuring blood sugar levels, electrolyte and fluid balance, kidney function, and liver function), 12-lead Electrocardiogram (EKG or ECG-looks at electrical activity in the heart), Chest X-ray, and a urine pregnancy test. RN 1 did not initiate orders for cardiac monitoring, or placing an intravenous line (IV-inside the vein). RN 1 did not perform a focused assessment, obtain a history to identify cardiac risk factors, describe characteristics of pain, or identify all medications taken. 5:45 a.m.: RN 1 obtained the following vital signs from Patient 1: temperature of 96.8 degrees Fahrenheit, a pulse of 75 beats per minute (bpm), respiratory rate of 20, oxygen saturation of 98 percent, and a blood pressure (BP) of 186/120. RN 1 documented next to the blood pressure value: "history of hypertension (high blood pressure), took meds prior to arrival". 5:53a.m.- 6:00 a.m.: Chest x-ray completed. 6:02 a.m.:12-lead EKG completed. 6:07 a.m.: An ED Medical Doctor (MD 1) reviewed the EKG, initialed and marked on the EKG form "no STEMI" (ST elevation myocardial infarction [heart attack]). The EKG automated interpretation was "left axis deviation, ventricular hypertrophy with QRS widening and repolarization abnormality, inferior infarct, age undetermined, anterolateral infarct age undetermined, abnormal ECG [EKG]." After the EKG was completed, Patient 1 waited in the lobby. 7:09 a.m.: Patient 1 was in Rapid Medical Evaluation (RME) room 2 with RN 2. 7:42 a.m.: Blood samples sent to the lab by RN 2. 7:45 a.m.: BP 128/93 and pulse of 109 bpm. 8:00 a.m.: BP 128/108. 8:02 a.m.: Patient 1 is at the registration desk. 8:04 a.m.: Physician Assistant (PA) 1's note indicated he reviewed Patient 1's record, obtained a brief history, and performed a limited exam. PA 1 documented "...Patient 1 has a history of hypertension ... presents to the ED for evaluation of intermittent left sided chest pain for three days described as burning and tightness with shortness of breath on inspiration (breathing in). Reports episodes of chest pain this morning that lasted approximately 1.5 hours. Reports being awoken by chest pain...." PA 1 discussed the EKG results with MD 2 and documented: "no STEMI but concerning findings" and a plan to place Patient 1 in a "bed in the back" (bed in the ED core). 8:10 a.m.: Registration completed. The record does not indicate Patient 1 was observed again after registration. 8:11 a.m.: RN's note indicated the plan to put Patient 1 in a bed in the back. 8:38 a.m.: Critical lab result for troponin was reported to PA 1; the troponin level was 3.3 (normal range is 0.00 to 0.05). 8:42 a.m.: RN 2 documented "...attempted to take to room in main ED, patient not found, lobby, bathrooms; multiple attempts to locate patient unsuccessful. Called phone number on chart, no answer at this time ... PA aware; charge nurse aware." 8:45 a.m.: RN 2 documented "...Attempted to find patient in lobby X 2; unable to find patient or boyfriend." 10:15 a.m.: Record indicated Patient 1 as discharged . 12:49 p.m.: Patient 1 arrived in ED. Triage RN (RN 11) assigned Patient 1 an ESI of 2. BP 136/86. 12:53 p.m.: To Room 37 in ED core. 12:59 p.m.: Patient 1 placed on cardiac monitor, non-invasive blood pressure monitor and continuous pulse oximetry. 1:01 p.m.: EKG completed. Automated interpretation noted as "Sinus tachycardia (rapid heart beat), T-wave abnormality, Abnormal ECG [EKG]". Pain assessment was 3 out of 10. Chest X-ray was done. 1:18 p.m.: MD 2 obtained Patient 1's history of methamphetamine use, last use yesterday. Also noted family history of cardiac disease; father had MI at 40 y/o. From 1:19 p.m. until 2:45 p.m. the care of Patient 1 included blood draw for lab tests, placement of intravenous access and administration of medications including Aspirin, Ativan, Clonidine, nitroglycerin, diltiazem, potassium chloride and heparin (medications that are part of the protocol for patients having a heart attack). 2:05 p.m.: Critical lab value of Troponin 8.55 (range 0.00-005) was reported, as well as Pro-Brain Natriuretic Peptide (PROBNP- a protein present in heart failure) of 1,270 pg/ml (Normal range: 0-450 pg/ml) 2:45 p.m.: MD 2 indicated decision to admit. Diagnosis: Non-STEMI (non-ST elevated myocardial infarction). 4:04 p.m.: Patient 1 was admitted to the telemetry (unit where patients hearts are continuously monitored) unit on the second floor. 2. Review of Patient 24's clinical record indicated: On 2/6/18 at 10:44 a.m., Patient 24, a [AGE] year old non-English speaking female, arrived by car to the hospital's ED and checked in with triage nurse (RN 9). Patient 24's chief complaint was documented, "patient came in with chest pain that began last night; patient also states cough with sputum production for the past 2 months." Patient 24's chest pain level documented at 10 on a scale of 0-10. Blood Pressure at triage was 133/63, pulse 66 bpm and Temp 36.4 degrees Celsius. Oxygen saturation 95 %. 10:47 a.m.: Triage completed. Patient 24 assigned an ESI of 3. After triage was completed, Patient 24 waited in the lobby. 10:49 a.m.: Standardized procedure for chest pain initiated and orders placed for laboratory tests, chest x-ray, and EKG. The record did not indicate the use of a cardiac monitor or placement of an IV. 10:56 a.m.: EKG completed. Screening by ED physician indicated no STEMI (ST elevation myocardial infarction). 11:07 a.m.: Blood samples obtained and sent to the lab. 11:40 a.m.: Chest x-ray completed. Results within normal limits for patient. Patient to wait in lobby. 11:41 a.m. to 2:29 p.m. - There is no documentation of observation or location of Patient 24 during this time. No indication vital signs obtained or cardiac monitoring done. 2:29 p.m.: Patient 24 was taken to the RME (Rapid Medical Evaluation) room to have a Medical Screening Exam (MSE: an exam to determine if an emergency medical condition exists) performed. Patient 24's chest pain level was a 6 on a scale of 0-10. Patient was alert and had a frequent cough. Nurses notes indicate "Patient [Patient 24] c/o chest pain on and off over the past couple of months. Patient states she had chest pain all night and continued today that was worse than normal. Patient has had a cough for the last three weeks." 3:02 p.m.: MSE performed by MD 3. 3:12 p.m.: Patient 24 received an albuterol breathing treatment (medication used to prevent and treat breathing difficulties, shortness of breath and coughing). Oxygen saturation 96%, pulse 65, respiratory rate 20/minute. No blood pressure value recorded. Patient moved to internal waiting room. 3:21 p.m.: Results of lab test D Dimer (blood sample that measures whether or not there are blood clots present in the blood) returned elevated at 597 (normal range less than 250). 3:39 p.m.: Chest Computed Tomography (a diagnostic imaging test to examine organs, soft tissue, blood vessels, and bones) with contrast was ordered by MD 3. 4:28 p.m.: Final result of the EKG performed at 10:51 a.m. was entered into the ED record. Diagnosis: "[DIAGNOSES REDACTED][an irregular heart rhythm occurring when the top chambers of the heart beat out of coordination with the lower chambers] with a competing junctional pacemaker, left anterior fascicular block [blockage of one of the electrical branches that delivers electrical signals to a part of the left ventricle, one of two chambers in the heart], abnormal ECG. When compared with ECG of June 2017, [DIAGNOSES REDACTED]has replaced sinus rhythm (normal heart rhythm)." The record does not indicate whether an ED physician was aware of the EKG results or discussed the findings with Patient 24. 4:41 p.m.: RN 6 indicated Patient 24 wanted to go home prior to the Chest CT exam and RN 6 informed MD 3. 5:43 p.m.: RN 6 indicated Patient 24 was upset at wait times, refused CT of the chest and requested to leave Against Medical Advice (AMA). MD 3 was notified via phone; did not speak with Patient 24 or family. Patient 24 signed AMA form using language line interpreter # 0 and Pt 24 left with her son. RN 6 indicated instructions were not provided to Patient 24 prior to her leaving the hospital. The record did not indicate Patient 24's vital signs were obtained after 3:12 p.m., a chest pain level assessed after 2:35 p.m., or use of a cardiac monitor during Patient 24's ED visit. 3. Review of Patient 13's clinical record indicated: On 1/25/18 at 10:13 a.m., Patient 13 a [AGE] year old male brought in by ambulance (BIBA) to the hospital's ED with a chief complaint "suicidal ideation and depression." 10:19 a.m.: Triage completed with Patient 13 assigned an ESI of 2, and placed in hallway bed 7. Triage nurse indicated, "+ Suicidal Ideation [BIBA from home for feeling depressed, voluntary 5150 hold per EMS. No plans of hurting himself at this time per pt.]" 10:20 a.m.: Nursing assessment indicated Patient 13 was alert and oriented with a depressed mood. 10:43 a.m.: Vitals signs obtained were within normal limits. 10:48 a.m.: Orders initiated per the Standardized Procedure for psychiatric complaints, including a metabolic panel, complete blood count (CBC), urinalysis (UA), and blood tests for alcohol, salicylate (aspirin), and acetaminophen (Tylenol). Urine drug screen was not obtained. The record does not indicate an intravenous line (IV) was ordered or a cardiac monitor. 10:54 a.m.: A chart entry indicated a physician was assigned to Patient 13, however the record does not indicate Patient 13 was seen by a provider. 10:55 a.m.: Urine specimen obtained. No further documentation of contact or observation of Patient 13 within the ED. 11:22 a.m.: RN 7 indicated, "...Pt [Patient 13] unable to find in bed. Public safety informed. Pt not in lobby...Charge Nurse informed and aware...." 11:26 a.m.: RN 8 indicated,"...Attempted to call pt's cell phone listed...unable to leave voicemail... [local town] PD contacted to notify them of patient elopement...." No documentation of the provider being notified. PT 13 discharged in computer and given the disposition of elopement. On 5/16/18 at 11 a.m., during a concurrent interview and clinical record review, RN 8 stated she was working on 1/25/18 as charge nurse when Patient 13 was in the ED. RN 8 stated a staff nurse informed her Patient 13 eloped, and RN 8 contacted the police department. RN 8 did not know if a "sitter" (a staff person assigned to be physically present to observe patient at all times) was requested for Patient 13; the record did not indicate that a sitter was present. RN 8 stated if a sitter is needed, an ED tech can assume this role, or the staff call the house supervisor to request help. On 5/16/18 at 11:05 a.m., during a concurrent interview and record review, RN 7 stated she was the triage RN for Patient 13 on 1/25/18. RN 7 recalled that Patient 13 was BIBA after calling 9-1-1 because he (Patient 13) stated he wanted to hurt himself. RN 7 stated when Patient 13 arrived to the ED, her assessment was Patient 13 did not have a "plan" to hurt himself. RN 7 assigned Patient 13 an ESI of 2. RN 7 stated she was told no other beds were available so Patient 13 was put in hallway bed 7. RN 7 stated she was familiar with the standardized procedures and they usually do follow them to help expedite the care. RN 7 stated she did not initiate all of the orders in the standardized procedure though because "they can pick and choose" which ones to implement. RN 7 stated she did not see Patient 13 leave the department; she found out he was gone when staff from the lab asked where Patient 13 was. RN 7 stated as far as she knows no staff in the ED saw Patient 13 leave. When asked what safety measures were implemented for Patient 13, RN 7 stated "He needed a sitter to be with him." RN 7 stated Patient 13 had been in ED "less than an hour" and they "eventually would get him a sitter." RN 7 stated she notified the physician when Patient 13 left; she just did not document that. On 5/14/18 at 10:15 a.m. during an observation in the ED triage area and lobby (external waiting room), approximately 15 patients wearing identification bands on their wrists sat in chairs in the lobby. Some of the patients were observed with disposable blood pressure cuffs wrapped around their upper arms; no saline locks (IV catheter left in vein to provide access for administration of fluids and medications). None of the patients appeared to be in any distress. A female patient was observed in a wheelchair at the triage desk accompanied by a friend. The triage RN greeted the patient and obtained the chief complaint of heart palpitations and chest pain/discomfort. The triage RN took the patient's vital signs and informed the patient her heart rate was elevated. The patient stated she has [DIAGNOSES REDACTED]The triage RN called the charge nurse immediately to inform her about this patient's condition and symptoms. Approximately two minutes later, the charge nurse arrived at the triage desk and transferred the patient back to the RME (Rapid Medical Evaluation) area to be seen by a provider. On 5/14/18 at 10:25 a.m., during a concurrent observation and interview in the ED triage area and lobby, the ED Manager (EDM) stated they had been working hard to make changes in the ED in response to the issues previously identified concerning Patient 1's care. The EDM explained the recent changes made: The hospital's policies and procedures related to ED care had "just been revised this past week." The EDM stated the D-Pod (an area in the ED core containing eight monitored beds) has been re-opened which means more patients can be put in ED beds, and fewer patients will have to wait out in the lobby in various stages of the evaluation process.The EDM stated D-Pod is now open Mondays, Tuesdays, and Thursdays. The EDM stated these days were chosen based on evaluating the patient volume over time. The EDM stated she obtained approval for additional RN positions with the goal being to keep D-Pod open all of the time. The EDM stated all ED nursing staff have been re-educated on the use of standardized procedures. The expectation is all orders in the appropriate SP will be initiated if the estimated wait time prior to the patient seeing a provider exceeds 30 minutes. The EDM stated all staff have been re-educated that if there is not a phlebotomist assigned to the ED to draw blood for lab tests, they can call the lab for assistance or draw the blood sample themselves; they are not to delay obtaining the blood sample. The EDM stated ED nursing staff were also re-educated to the fact that there is always a provider in the ED 24 hours a day. If the provider is not in Triage or the RME area, they will be in the ED core. The EDM stated another change they have made is patients who have been triaged and assigned an ESI Level 2, will not be put in the lobby except on rare occasions. All patients with an ESI Level 2, and patients with abnormal vital signs will be escalated by the triage nurse in order to be seen by the provider in a timely manner. The EDM stated they have changed the responsibilities of a couple of the RNs who were previously assigned to help out in the ED core and now they are responsible for checking on the patients in the lobby who are waiting to see a provider, or have lab tests or x-rays done, etc. The EDM stated another change they have implemented is putting a registration clerk in the ED so the patients will not have to leave the area to register any longer and there is less chance they will leave altogether. On 5/15/18 at 2:10 p.m. during a concurrent interview and observation of the ED lobby, none of the patients waiting in the lobby were observed to have saline locks. The charge nurse (RN 13) stated patients with "saline locks are not allowed in the lobby...this practice changed when the policy changed...." On 5/15/18 at 2:18 p.m., during a concurrent inerview and observation in the ED, RN 14 stated no high acuity patients are allowed to wait in the lobby, must be in the RME area. RN 14 stated, "A week ago this was changed." RN 14 stated patients with chest pain are not put in the lobby. The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, "...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...." The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, "...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP... 4.Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI)...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for [AGE] years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry...IV access: IV normal saline or saline lock...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ...14. Psychiatric Complaints ...used for the patient presenting with suicidal or homicidal ideations, or other psychiatric complaint where the nurse anticipates a mental health consult ...Obtain nursing history and physical exam: vital signs ...focused assessment and HPI ...Brief History ...current medications ...Screening and Medical Clearance Diagnostic Studies: Urine drugs of abuse screen, alcohol, salicylate level, acetaminophen level, CBC, CMP, 12-lead EKG, urine dip and analysis, urine pregnancy test (females [AGE]-60 years), fingerstick glucose if patient is diabetic...Treatment in treatment area: Obtain IV access ... place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry as indicated ...." The hospital policy and procedure titled "RME (Rapid Medical Evaluation) Guidelines" dated 5/11/16, indicated,"...During periods that RME is staffed, patients that cannot immediately be moved to an ED examination room will be assessed by an ED provider in order to complete the Medical Screening Exam (MSE). Patients will be assessed in order of arrival or as determined by clinical staff or provider...RME is a process in which the patient has a rapid medical examination by a provider. The basic goal of RME is to eliminate barriers and bring patients to providers as quickly as possible upon arrival at the emergency department ...the initial provider evaluation will occur as quickly as possible upon patient arrival and appropriate orders will be initiated ...Patient presents to RN Greeter who will obtain chief complaint ...the greeter RN will determine if a life threatening or time-sensitive condition exists and ...will take appropriate action ...standardized procedures may be initiated during the RME process in order to expedite care ...immediate bedding will be utilized when beds available in the ED ...."

Based on observation, staff interviews, clinical record and administrative document review, the hospital failed to meet emergency needs of patients in accordance with the hospital's policies and procedures when: 1.. Patient 1 presented to the Emergency Department (ED) on 3/28/18 at 5:40 a.m. with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure and the first contact with the qualified medical professional (QMP) was at 8:04 a.m. The triage Registered Nurse (RN 1) assessed Patient 1 and obtained the blood pressure of 186/120, determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 1 to be seen by the QMP and had Patient 1 wait in the lobby. (Refer to A 392) 2. Patient 24 (MDS) dated [DATE] at 10:44 a.m. with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN 9) assessed Patient 24 and determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 24 to be seen by the QMP and had Patient 24 wait in the lobby. The first contact with a QMP for the MSE was on 2/6/18 at 3:02 p.m. (almost 4 ½ hours after walking into the ED). (Refer to A 392) 3. Patient 13 (MDS) dated [DATE] at 10:13 a.m. with the chief complaint of suicidal ideation with depression. Patient 1 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The standardized protocol for psychiatric evaluation was initiated but was not fully implemented. (Refer to A 392) 4. Policies and procedures for the care of patients in the ED were not evaluated and updated on an on-going basis to ensure standardized procedures were current and being fully implemented by nursing staff. (refer to A 1104) The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on observation, interview and record review, the facility failed to provide within the capabilities of the facility and staff at the hospital, further medical examination and treatment as required to stabilize an emergency medical condition when: Patient 5 arrived in Hospital 1 Emergency Department (ED) on 3/16/18 at 4:32 p.m. with complaints of severe abdominal pain and loss of appetite. Patient 5 returned to Hospital 1 ED on 3/19/18 with unrelieved abdominal pain and worsening symptoms. Hospital 1 was aware Patient 5 was seen and treated at hospital 2 for the same symptoms on 3/15/18 on Patient 5's visit of 3/16/18. These failures resulted in delay in stabilizing treatment for Patient 5 and resulted in Patient 5's unnecessary pain and suffering as a result of the delay. Findings: 4/11/18 at 11:20 a.m. a concurrent interview and record review (EHR) was completed with Clinical Informaticist and former ED RN (CI) 2. The clinical record indicated Patient 5 is a [AGE] year old female who arrived in the ED on 3/16/18 at 4:32 pm by private car, accompanied by a family member. The clinical record indicated triage of Patient 5 was completed at 4:35 pm and an ESI of 3 was assigned. The clinical record indicated the chief complaint was abdominal pain for 2 days. The clinical record indicated the initial triage Vital Signs were 36.8 degrees Celsius, Pulse 86, Blood Pressure 116/77. The clinical record indicated the pain level stated by patient 5 as 10 on a scale of 0-10. Patient 5's face sheet indicated her primary language was Spanish and that an interpreter would be needed. Orders were placed by the triage RN using the standardized procedure for abdominal pain, and the clinical record indicated Patient 5 waited in the lobby. At 4:37 p.m. PA 3 entered a note (scribed). The note indicated Patient 5 was in RME (room not specified). The PA's note documented the chief complaint and triage vital signs. In the top section of the note the following is documented "MSE INITIATED at 4:37 p.m.; in the bottom portion of the note under the "Plan" section the PA indicated "Medical Screening Exam (MSE) Initiated at: 5:02 p.m. Patient awaiting further evaluation." The PA signed this note on 3/24/18 at 6:36 p.m. At 5:16 pm, labs were drawn for a complete blood count (CBC), Comprehensive Metabolic Panel (CMP), and Lipase. The results for the lab samples were provided to the ED at 6 pm and were noted to be within normal limits. At 5:50 pm a urine specimen was collected and sent to the lab for a urinalysis. Urinalysis results were abnormal, presence of red and white blood cells noted. The urine sample was sent for culture according to the clinical record. At 6:31 pm the clinical record event log indicated Patient 5 was moved to ED room 19. CI 2 was asked if the record indicated where the patient was between 4:32 pm and 6:31 pm and stated the record does not specifically indicate that information. At 7:51 pm the record indicated PA 3 spoke with Patient 5 and documented the history of present illness. Patient 5 explained to PA 3 she lived in Sonora and was seen at hospital 2 the previous day with the same symptoms. PA 3 noted Patient 5 had a past medical history of chronic back pain and had an ileus 10 years ago. PA 3 documented a physical exam which included findings of diffuse abdominal tenderness and diffuse back tenderness with costovertebral angle tenderness. At 7:51 pm in the same provider note, PA 3 indicated under the heading ED COURSE/Medical DECISION MAKING, that the MSE was initiated at 7:51 p.m. and indicated she will order meds and discuss the case with the ED physician. CI 2 was asked about the documentation in this record of the Medical Screening Exam being initiated at 3 different times: 4:47 p.m., 5:02 p.m., and 7:51 p.m. CI 2 stated there should be only one time documented and that he has no explanation for the 3 different entries in this case. At 8:27 pm Patient 5's pain level is documented as 8 (0-10 scale). An IV was started and Morphine 4 mg was given IV for pain. At 9:17 pm the nurse's notes indicated Patient 5 was taken to have a CT. At 9:36 pm the nurse's notes indicated patient returned from CT and cardiac monitoring was reestablished. Patient 5's pain level was noted to be 8 (0-10), and the note indicated patient 5 was extremely anxious. At 10 pm the ED provider note indicated PA 3 "consulted with [MD 6] who reviewed the CT scan results and said patient can be discharged home." At 10:06 pm the nurse's notes indicated PA 3 was at bedside to reassess patient. At 10:13 pm PA 3 documented her discussion with Patient 5 about the workup: "likely ileus, advised fluids, pain and nausea control and rest. Return precautions discussed. Patient instructed to follow up with PCP in 1-2 days. Patient understands and agrees with plan." Review of PA 3 chart entry summarizing the medical decision making indicated "Patient improved after morphine in the ED. Symptoms consistent with ileus and UTI, although urine sample is contaminated and patient has no urinary symptoms ...patient suitable for outpatient care ...patient discharged with prescription for Keflex, Zofran, and Norco." At 10:20 pm - 4 mg Zofran given IVP for nausea. At 10:34 pm water provided to patient for PO challenge. At 10:51 pm the nurses notes indicated patient able to keep water down but patient stated it makes her feel slightly sick to her stomach. PA 3 aware. At 11:19 pm Patient 5 discharged home. The Clinical Informaticist was asked about documentation regarding use of an interpreter for this patient at any time during her stay from 4:32 pm until 11:19 pm since it is indicated on Patient 5's face sheet that her primary language is Spanish and that an interpreter would be needed. CI reviewed the entire record for evidence that an interpreter was used during any communication with Patient 5 and no documentation was found in any form in this record. CI 2 stated there was no documentation that the provider or any of the nurses spoke Spanish fluently. CI 2 stated that the clinical record indicated there was no documentation that a bilingual family member acted as an interpreter for the patient, or that an interpreter was considered or offered. The clinical record and concurrent interview continued with CI 2. On 3/19/18 at 3:51 pm Patient 5 arrived in the ED (3 days after the first visit). CI 2 stated the clinical record indicated that triage of Patient 5 was completed at 3:56 pm; an ESI of 3 was assigned. CI 2 stated the clinical record documented the Chief complaint as: "Abdominal pain- Patient seen here on Friday (3/16/18) for abdominal pain and diagnosed with an ileus. Patient is now vomiting. Patient states pain medication is not working." CI 2 stated the clinical record indicated the vital signs at triage were stable and the pain level for Patient 5 was listed as 10 out of scale from 0-10. CI 2 stated the clinical record for this visit indicated Patient 5 was provided services and interventions similar to the visit of 3/16/18 with the exception of obtaining a comprehensive history and physical including a history of medication prior to the visit. The hospitalist was called to assess Patient 5 on 3/19/18 and agreed with decision to admit patient. The hospitalist obtained a GI consult who provided a plan for the care of Patient 5. The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at the hospital Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP. 1. Abdominal Pain ...Obtain nursing history and physical exam: Vital signs ...Focused abdominal assessment and HPI ...Brief history including abdominal surgery, ulcers, similar pain, alcohol abuse, use of pain medications or NSAIDs or histamine blockers ...Current medications ...Diagnostic Studies: CBC, CMP (Complete Metabolic Panel), Lipase and liver panel, urine dip and analysis ...urine pregnancy test if potential for pregnancy ...Obtain order from physician for abdominal x-rays if bowel obstruction likely or significant abdominal distention ...12-lead EKG for ACS (Acute Coronary Syndrome)-associated symptoms or atypical signs of ACS ...fingerstick glucose for diabetics ...Treatment in the treatment area: IV access ...Place on cardiac monitor and monitor rhythm and rate, blood pressure, continuous pulse oximetry ...Medications: Oxygen as needed to keep oxygen saturation greater than 95%...obtain order from physician for analgesia ..."

Based on observation, interview and record review, the hospital failed to comply with the provisions of CFR 489.24 when: 1) Patient 1 did not receive a timely MSE and the hospital did not determine whether or not Patient had an emergency medical condition to the best of the facility's capability. This failure resulted in a delay of stabilization and treatment. (refer to A 2406) 2) Patients 9 and 13 did not receive a timely MSE which contributed to both patients leaving without being seen prior to a complete MSE being completed. (refer to A 2406) 3) Patient 5 did not receive appropriate treatment and stabilization which resulted in multiple unnecessary vists to the ED and caused Patient 5 unnecessary pain and suffering. (Refer to A 2407) The cumulative effect of these problems resulted in the hospital failing to provide care in a safe setting in the Emergency Department.

Based on observation, interview and record review, the hospital failed to provide a timely Medical Screen Exam (MSE) and determination of whether or not there existed an Emergency Medical Condition within the hospital's capabilities when: 1. Patient 1 (MDS) dated [DATE] at 5:40 am with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure and the first contact with the qualified medical professional (QMP) was at 8:04 am. The triage Registered Nurse (RN 1) assessed Patient 1 and obtained the blood pressure of 186/120, determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 1 to be seen by the QMP and had Patient 1 wait in the lobby. These failures resulted in delay in the MSE by the QMP, delay in stabilizing measures such as placing Patient 1 on a cardiac monitor, obtaining laboratory results, administration of medications and establishing intravenous access. These failures resulted in the potential harm of not identifying and acting on an emergent cardiac situation in a timely manner. The delay in prioritizing care and permitting Patient 1 to wait in the lobby unmonitored contributed to Patient 1 eloping from the ED and caused ED personnel to call Patient 1 to return to the hospital after receiving the critical value for Troponin of 3.3. Patient 1 returned to the hospital at 12:49 pm on 3/28/18 and was immediately triaged, prioritized and seen by the QMP, stabilizing measures implemented and subsequently hospitalized . 2. Patient 9 (MDS) dated [DATE] at 10:44 am with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN9) assessed Patient 9 and determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 9 to be seen by the QMP and had Patient 9 wait in the lobby. The first contact with a QMP for the MSE was on 2/6/18 at 3:02 pm (almost 4 ½ hours after walking into the ED). These failures resulted in delay in the MSE by the QMP, delay in stabilizing measures such as placing Patient 9 on a cardiac monitor, or establishing intravenous access for the administration of medications. D Dimer (a blood test that measures a substance released when a blood clot breaks up) results returned elevated resulting in the order for a CT Chest (a scan that is more detailed type of chest X ray) with contrast (a liquid used in a CT scan that makes any injury or disease visible to the physician.) The delay in prioritizing care and having Patient 9 wait in the lobby unmonitored contributed to Patient 9 becoming upset with wait times, refusing to have the Chest CT and leaving AMA at 5:43 pm before identifying a potential blood clot. Patient 9 left AMA without having vital signs taken again since triage. 3. Patient 13 (MDS) dated [DATE] at 10:13 am with the chief complaint of suicidal ideation with depression. Patient 1 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The standardized protocol for psychiatric evaluation was initiated but was not fully implemented. The MSE by the QMP was not done by the time the patient left without being seen (LWBS) at 11:22 am. This failure resulted in delay in MSE by the QMP, delay in stabilizing measures such as IV access and environmental safety features and contributed to Patient LWBS and the potential harm of having a patient leave the ED with an emergent medical condition. Findings: 1. On 4/10/18 at 8 am, a review of Patient 1's medical record with RN Clinical Informaticist (CI) 1 indicated: Patient 1 arrived via private car to the ED on 3/28/18 and checked in with RN 1 at 5:40 am. Patient 1 provided RN 1 the chief complaint that she had been experiencing chest pain for three days described as burning, tightness and intermittent. Patient 1 described her current pain level as 8 on a scale of 0 to 10. RN 1 assigned Patient 1 an ESI of 3. RN 1 initiated the following orders from the Chest Pain Standardized Procedures: Blood sample for Troponin I (a protein released when the heart muscle is damaged), CBC (complete blood count), Metabolic panel; 12-lead EKG, Chest X-ray (PA and Lateral views); and a urine test for pregnancy. At 5:45 am, RN 1 obtained the following Vital Signs from Patient 1: temperature of 96.8 degrees Fahrenheit, a pulse of 75 bpm, respiratory rate of 20, oxygen saturation of 98 per cent and a blood pressure of 186/120. RN 1 documented next to the blood pressure value: "history of hypertension, took meds prior to arrival". The clinical record indicated Patient 1 had an EKG and Chest X-ray soon after the vital signs were obtained. The next entry in the electronic clinical record was at 6:07 am when MD 1 reviewed the EKG and marked on the EKG form "no STEMI" (STEMI= ST elevation myocardial infarction). The clinical record indicated the EKG automated interpretation was "left axis deviation, ventricular hypertrophy with QRS widening and repolarization abnormality, inferior infarct, age undetermined, anterolateral infarct age undetermined, abnormal ECG." After the EKG was completed, Patient 1 waited in the lobby. The clinical record indicated that sometime after 7 am Patient 1 was in Rapid Medical Evaluation (RME) area room 2 with RN 2. At 7:38 am, RN 2 documented that she obtained a blood sample and sent it to the lab at 7:42 am. At 7:45 am, RN 2 obtained blood pressure of 128/93 and pulse of 109 for Patient 1. At 7:54 am PA 1 started the clinical record review, obtained a brief history from Patient 1 in the Rapid Medical Evaluation area Room 2 and documented: "Patient 1 has a history of hypertension ... presents to the ED for evaluation of intermittent left sided chest pain for three days described as burning and tightness with shortness of breath on inspiration. Reports episodes of chest pain this morning that lasted approximately 1.5 hours. Reports being awoken by chest pain ..." At 8 am, RN 2 obtained the blood pressure of 128/108. At 8:02 am, the clinical record indicates Patient is in registration and completed this process at 8:10 am. Following registration, Patient 1 was sent to the lobby. At approximately 8:04 am the clinical record indicated PA 1 discussed the EKG results with MD 2 and documented: "no STEMI but concerning findings". The clinical record also indicates PA's plan to place Patient 1 "with a bed in the back" (bed in the ED core) and the clinical record shows a bed was reserved for Patient 1 (at 8:11 am). At 8:38 am, a critical lab result for troponin was reported to PA 1; the troponin level was 3.3 (range is 0.00 to 0.05) 8:42 am, RN 2 documented " ...attempted to take to room in main ED, patient not found, lobby, bathrooms; multiple attempts to locate patient unsuccessful. Called phone number on chart, no answer at this time ... PA aware; charge nurse aware." 8:45 am, RN 2 documented "...attempted to find patient in lobby X 2; unable to find patient or boyfriend. 10:15: Record indicated Patient 1 as discharged . 11:10 am RN 3 documented "[local law enforcement] called to make me aware of patient welfare check unsuccessful; states grandmother answered the door. Patient usually stays there but has not come home." 12:49 pm RN 11 documented "Patient arrived in ED" while in triage area and ESI was documented as 2. BP obtained was 136/86. 12:53 pm Patient placed in Room 37. 12:59 Patient was placed on cardiac monitor, placed on non-invasive blood pressure monitor and continuous pulse oximetry. At 1:01 pm an EKG was done. Automated interpretation noted as "Sinus tachycardia, T-wave abnormality, Abnormal ECG". Pain assessment was 3 out of 10. Chest X-ray was done. At 1:18 pm, MD 2 started the MSE and documented Patient 1's history of methamphetamine use, last use yesterday. Also noted family history of cardiac disease; father had MI at 40 y/o. From 1:19 pm until 2:45 pm the care of Patient 1 included blood draw for lab tests, placement of intravenous access and administration of medications including Aspirin, Ativan, Clonidine, nitroglycerin, diltiazem, potassium chloride and heparin. At 2:05 p.m. a critical lab value of TROPONIN 8.55 (range 0.00-005) was reported, as well as PRO-BRAIN NATRIURETIC PEPTIDE (PROBNP- a protein present in heart failure) of 1,270 pg/ml (Optimized diagnostic cutoff for CHF age < 50 years 0-450 pg/ml) At 2:45 p.m., MD 2 noted decision to admit. Diagnosis: Non-STEMI (non-ST elevated myocardial infarction). MD 2 discussed patient with admitting Hospitalist (MD 4) who will assume care with consulting cardiologist. At 4:04 p.m. Patient 1 was admitted to the telemetry unit on the second floor, attending physician was MD 4. On 4/11/18 at 7:22 am, during an interview held in the Board Conference Room of the hospital and concurrent record review, PA 1 stated on 3/28/18 his shift started at 6 am PA 1 stated his usual pattern is to arrive in the ED to start his shift, to get his phone and check in with the charge nurse for direction. PA 1 stated the decision about which patient to see first depends on many factors. PA 1 stated Patient 1 arrived in ED before his shift started and he was not given any information about her. PA stated he started his Medical Screening Exam (MSE) for Patient 1 at 8:04 a.m. and had no contact with her prior to that. PA 1 stated before he went in to see Patient 1, he looked at her record briefly to familiarize himself but did not have any knowledge of her at all before that time. PA 1 stated he spoke with Patient 1 and briefly examined her. PA 1 stated he then obtained a copy of the EKG and went back to discuss it with MD 2 who said Patient 1 needed a cardiac work up. PA 1 stated he told the RN that Patient 1 needed a bed in the back. PA 1 explained this was the extent of his contact with Patient 1. On 4/11/18 at 8 am, during an interview held in the Board Conference Room of the hospital and concurrent record review, RN 1 stated she was the triage nurse working in the ED on the morning of 3/28/18 when Patient 1 came in. RN 1 stated her shift started at 6:45 pm on 3/27/18 and ended at 7:15 a.m. on 3/28/18. RN 1 stated as Triage RN her role is to obtain the patient's chief complaint, ("describe their story"), take a set of vital signs, assess patient's pain level, assign an ESI level, and enter the patient into the computer (electronic health record). RN 1 stated she followed a checklist for this process. RN 1 stated the triage process determined whether a patient can wait to see the provider; if they can wait, the tracking board will show the patient is in the waiting room, which means the lobby. RN 1 stated orders are placed for lab work and other tests based on the chief complaint per the Standardized Procedure (SP). The SPs are in the computer so they (RNs) know what to order. Asked if standardized procedures are initiated most of the time or only if a provider is not available at that time to see the patient, RN 1 stated at that time (referring to Patient 1's 5:40 am arrival), there is no available provider available in triage area and the SP is not initiated. RN 1 stated she placed orders for an EKG and chest x-ray for Patient 1 per the standardized procedure for chest pain. RN 1 stated the EKG is done by the tech in the ED. After the tech completes the EKG they carry the printed copy to the ED physician in back to review it immediately. RN 1 stated she does not know what the EKG showed for Patient 1. RN 1 stated she placed orders for STAT lab tests per the SP at 5:43 a.m. RN 1 stated there is no phlebotomist in the ED during that time of morning so the lab draw would wait until the phlebotomist is there on day shift. RN 1 stated the RNs can draw labs and sometimes she does draw the labs if she has the time. When asked whose decision it is whether or not the RN draws the labs or waits, RN 1 stated she did not know. RN 1 was asked, when a SP is initiated by an RN, should all of the orders be implemented. RN 1 stated all of the orders are supposed to be activated and followed. Asked about her decision not to implement the order for cardiac monitoring for Patient 1 when she initiated the SP, RN 1 stated the patient was waiting in the lobby and they don't have monitoring in the lobby so she did not implement that order. On 4/12/18 at 9:22 am, during a telephone interview, ED MD (MD 1) stated he was working in the ED core (Pods) on 3/28/18 and had provided the EKG review at 6:07 am for Patient 1. MD 1 stated when an EKG is presented on duty, it is only for the purpose of identifying if there is an ST Elevation Myocardial Infarction (STEMI) in order to facilitate activation of the cath lab team for timely intervention. MD 1 stated this was the extent of his involvement in Patient 1's case. MD 1 stated the ED physician reviewing the EKG has no information about the patient in terms of history or clinical presentation and has no role in the management of the patient. MD 1 stated if there was critical information regarding a patient he would expect the RN or tech to communicate that directly to him when they bring the EKG for review. MD 1 also stated it was his expectation the standardized procedure for chest pain would have been followed for Patient 1. On 4/12/18 at 9:45 am during an interview with the Client Services Supervisor (CSS), Lab Supervisor (LS), and ED Manager, the CSS stated during the hours of 4:30 am to 8 am each day two phlebotomists are assigned to do morning lab draws for the inpatient areas in the hospital. CSS stated no phlebotomists are assigned to the ED during these hours each day. During these hours the phlebotomists can be reached on their cell phone if they are needed in the emergency department. The CSS stated the RNs in ED are responsible for drawing any labs during those hours or contacting the phlebotomist if the lab is needed urgently and/or the ED RN cannot draw the blood. The CSS stated the lab remains open during this time to process specimens per their usual practice. The CSS stated this process has been in place for at least 10 years and is well known to the ED staff. The CSS stated per the lab records on the morning of 3/28/18, no calls for assistance from the ED were received by the lab staff. The LS stated the expectation for STAT orders received by the lab is the lab staff will draw the specimen within 15 minutes of receiving the order, and the lab will process and submit the result within an hour. LS stated the turnaround time for processing and resulting STAT labs drawn by nursing staff is the same. On 4/10/18 at 1:55 pm, during an interview, RN 3 stated when there is no provider up front (meaning the triage area) there is a standardized procedure that RNs should follow. RN 3 stated she had the opportunity to review the presenting symptoms, history and chief complaint for Patient 1. RN 3 stated the ESI should have been a 2 rather than a 3. On 4/10/18 at 3 pm, during an interview, MD 2 (ED Medical Director) stated she had the opportunity to review the clinical record for Patient 1. MD 2 stated that what had occurred to Patient 1 should not have occurred, meaning Patient 1 should have been seen by the QMP more promptly and the standardized procedure should have been fully implemented when Patient 1 first arrived. On 4/12/18 at 4 pm, during an interview, the ED Manager (RN) stated she had the opportunity to review the clinical record for Patient 1. ED Manager stated that the ESI should have been 2 rather than 3, the chest pain standardized procedure should have been fully implemented and the QMP should have been notified in order to start the MSE more promptly. The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, " ...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...." The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP ... 4. Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI) ...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for [AGE] years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view ... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry ...IV access: IV normal saline or saline lock ...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI ...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older ...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ..." The hospital policy and procedure titled "RME (Rapid Medical Evaluation) Guidelines" dated 5/11/16, indicated, " ...During periods that RME is staffed, patients that cannot immediately be moved to an ED examination room will be assessed by an ED provider in order to complete the Medical Screening Exam (MSE). Patients will be assessed in order of arrival or as determined by clinical staff or provider ...RME is a process in which the patient has a rapid medical examination by a provider. The basic goal of RME is to eliminate barriers and bring patients to providers as quickly as possible upon arrival at the emergency department ...the initial provider evaluation will occur as quickly as possible upon patient arrival and appropriate orders will be initiated ...Patient presents to RN Greeter who will obtain chief complaint ...the greeter RN will determine if a life threatening or time-sensitive condition exists and ...will take appropriate action ...standardized procedures may be initiated during the RME process in order to expedite care ...immediate bedding will be utilized when beds available in the ED ...." The hospital policy and procedure titled "Left Without Being Seen" dated 4/18/16, indicated, " ...Patients that are observed leaving or that request to leave without being seen by a provider will be offered medical screening by a provider prior to leaving ...Quality RN will review the LWBS report every 24-72 hours and will conduct a callback in the following situations: patient has left after any diagnostic studies have been conducted (i.e. ED Standardized Procedures), at the request of the ED provider, at the discretion of the Quality RN ...Quality RN will complete the QA ED Follow-up form for all abnormal diagnostic results and will submit to an ED physician for review ...RN shall make an effort to speak to patient and encourage the patient to stay ...identify reason for delay ...attempt alternatives to leaving ...document the condition of the patient and the time last seen ...." 2. On 4/11/18 at 3:00 p.m. a concurrent clinical record review and interview with RN 4 and RN 5 in the Board Conference Room was conducted. Patient 9 arrived to the Emergency Department by way of car on 2/6/18 at 10:44 am and presented to the triage nurse (RN 9) with the chief complaint of chest pain, level of 10 on a scale of 0 - 10. Blood Pressure at triage was 133/63, pulse 66 and Temp 36.4 degrees Celsius. RN 4 stated the clinical record indicated Patient 9 waited in the lobby after triage and prior to the MSE. When asked, RN 4 stated there was no indication that Patient 9 had cardiac monitoring. At 2:27 pm, Patient 9 was taken to the RME (Rapid Medical Exam) room to have a MSE performed. At 3:02 pm, Patient 9 had her MSE by MD 3. RN 4 stated the clinical record indicated that after being seen by MD 3 Patient 9 received an albuterol breathing treatment (medication used to prevent and treat breathing difficulties, shortness of breath and coughing) then returned to the lobby with no indication cardiac monitoring per the CP standardized procedure was started. On 2/6/18 at 3:21 pm, the D Dimer (blood sample that measures whether or not there is blood clots present in the blood) lab results returned elevated (597 with reference range less than 250). At 3:39 pm Chest CT with contrast was ordered by MD 3. At 3:55 pm the Chest CT with contrast order was acknowledged by RN 6. At 4:41 pm, RN 6 indicated Pt 9 wanted to go home prior to the Chest CT exam. RN 4 stated the clinical record indicated that RN 6 informed MD 3 Pt 9 wanted to go home. At 5:43 pm, RN 6 indicated that Pt 9 was upset at wait times, refused CT of the chest and requested to leave AMA. MD 3 was notified via phone. Pt 9 signed AMA form using language line interpreter # 0 and Pt 9 left with her son. When asked if there was any indication that Pt 9 ever had a cardiac monitor in place, or if there is any indication her vital signs were ever checked after triage, RN 4 said there was no indication in the clinical record that Pt 9 ever had a cardiac monitor in place and there is no indication that Patient 9 ever had her vital signs taken after triage. The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, " ...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP ... 4. Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI) ...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for [AGE] years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view ... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry ...IV access: IV normal saline or saline lock ...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI ...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older ...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ..." The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, " ...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...." The hospital policy and procedure titled "Left Without Being Seen" dated 4/18/16, indicated, " ...Patients that are observed leaving or that request to leave without being seen by a provider will be offered medical screening by a provider prior to leaving ...Quality RN will review the LWBS report every 24-72 hours and will conduct a callback in the following situations: patient has left after any diagnostic studies have been conducted (i.e. ED Standardized Procedures), at the request of the ED provider, at the discretion of the Quality RN ...Quality RN will complete the QA ED Follow-up form for all abnormal diagnostic results and will submit to an ED physician for review ...RN shall make an effort to speak to patient and encourage the patient to stay ...identify reason for delay ...attempt alternatives to leaving ...document the condition of the patient and the time last seen ...." 3. On 4/11/18 at 11:20 a.m. a concurrent clinical record review and interview with Clinical Informaticist (CI) 1 in the Board Conference Room was conducted. Patient 13 arrived in the Emergency Department via Emergency Medical Services (EMS - or ambulance) on 1/25/18 at 10:13 a.m. Patient 13 was triaged at 10:19 a.m. and given an ESI of 2, and was placed in hallway bed 7. CI 1 was asked to comment regarding what standardized procedures for Patient 13 were implemented. CI 1 stated that the standardized procedure for Psychiatric complaints should have been fully implemented. CI 1 stated the clinical record for Patient 13 did not have documented evidence that all of the interventions for the standardized procedure were implemented. CI 1 stated the clinical record for Patient 13 did not show that Patient 13 was started with an IV access and the cardiac monitor was not placed. When asked what is the process of obtaining a sitter for a patient exhibiting the type of psychiatric problems similar to Patient 13, CI 1 stated "A CNA would be floated from another department, and be assigned to sit with the patient." When asked if a sitter was assigned to PT 13, CI 1 stated as noted in the chart " ... No plans of hurting himself at this time per pt." and CI 1 stated "a sitter was not assigned during that time" according to the clinical record. CI 1 stated the clinical record indicated that on 1/25/18 at 10:54 am a QMP was assigned to PT 13, but an MSE was not performed. When asked to clarify, CI 1 stated, "That is the time the provider assigned themselves to the patient, not when they saw the patient." CI 1 stated the clinical record for Patient 13 indicated on 1/25/18 at 11:22 am, a clinical notation by charge nurse was documented and states "Pt unable to find in bed, Public safety informed. Pt not in lobby. [first name of RN] Charge Nurse informed and aware." Clinical documentation was requested regarding if a provider was notified of PT 13 missing, CI 1 was not able to locate documentation. CI 1 was asked what actions were implemented to locate PT 13, CI 1 stated as noted in the chart, "Attempted to call pt's cell phone listed ...[local town] PD contacted to notify them of patient elopement." C

Based on staff interview, clinical record and administrative document review, the hospital failed to comply with the provisions of CFR 489.24 when one of twenty patients (Patient 1) was diagnosed with [DIAGNOSES REDACTED]. The dermatology clinic was approximately 70 miles away from Hospital 1. Patient 1 was subsequently admitted to Hospital 2's emergency department on 6/17/15 at 3:57 p.m. (11 hours after discharge from Hospital 1). Patient 1 was admitted to the in-patient medical surgical area of Hospital 2 for symptoms of [DIAGNOSES REDACTED] The failure to provide stabilizing measures within the capabilities of the hospital resulted in the potential for patient harm during the time Patient 1 was not in a hospital setting.

Based on staff interviews, clinical record review, administrative document review, and authoritative Internet medical sources, the hospital (Hospital 1) failed to provide stabilizing treatment within the capabilities of the facility and staff for a known emergency medical condition (EMC) when: Patient 1 arrived at Hospital 1's Emergency Department (ED) via ambulance from a local urgent care with symptoms of [DIAGNOSES REDACTED].m. with instructions to follow-up in the dermatology clinic of a university hospital (Hospital 2) located 71 miles from Hospital 1. On 6/17/15 at 2:45 p.m., a physician's note documented Patient 1 was seen at the Hospital 2's dermatology clinic. He was subsequently admitted to Hospital 2's emergency department on 6/17/15 at 3:57 p.m. (11 hours after discharge from Hospital 1). Patient 1 was admitted to the in-patient medical surgical area of Hospital 2 for symptoms of [DIAGNOSES REDACTED] The failure to provide stabilizing measures within the capabilities of the hospital resulted in the potential for patient harm during the time Patient 1 was not in a hospital setting. Findings: A review of Patient 1's clinical record indicated the following: On 6/16/15 at 7:14 p.m., Patient 1 arrived by ambulance at Hospital 1, presenting with a red raised rash with blisters on his upper body and lower extremities. He was assigned an Emergency Severity Index of 3 (a five-level triage system used to evaluate both patient acuity and facility resources). On 6/16/15 at 7:20 p.m., the Emergency Department physician (EDP) documented in the ED note Patient 1 presented to the ED with a "rash described as intensely itchy and worsening in progression with blister formation.... Patient tried to modify symptoms with benadryl [diphenhydramine-an antihistamine medication used to alleviate itching] and prednisone [a type of steroid medication used to treat inflammation] as prescribed to him 4 days previous." The physical exam of Patient 1 indicated, ".... Intensely red raised large plaque [an elevated skin lesion] covering trunk and extremities with vesicle [a small fluid filled blister] formation on the lower legs...." On 6/16/15 at 7:22 p.m. Patient 1 was roomed in ED room 38. On 6/16/15 at 7:24 p.m. the EDP ordered a saline lock IV (a portal placed and left in a vein, used episodically for fluid or medication infusions, referred to as intravenous, or IV, access), diphenhydramine 25 milligrams (mg) injected IV, and blood sample to be taken for laboratory tests (a Complete Blood Count, or CBC, a Comprehensive Metabolic Panel with GFR (Glomerular Filtration Rate, used to assess kidney function), and an Erythrocyte Sedimentation Rate). On 6/16/15 at 9:17 p.m., the hospitalist (HMD-a physician whose professional activities are performed chiefly within a hospital) consult was ordered by the EDP. On 6/16/15 at 9:48 p.m., as documented in the facility document, "Patient Care Timeline", the EDP indicated he discussed Patient 1 with the HMD who "will admit" Patient 1. On 6/16/15 at 9:50 p.m., as documented in the facility document, "Patient Care Timeline", EDP documented, "ED disposition set to Decision to Admit" and a bed request on a medical surgical unit was made. On 6/16/15 at 9:54 p.m., the Registered Nurse (RN) 1 documented in ED Notes the HMD was at Patient 1's bedside for evaluation. On 6/16/15 at 10:04 p.m., the EDP documented in an ED Note, "Discussed further with [HMD], who states the hospital is not equipped to treat Stevens-Johnson. She recommends referral to burn center at [Hospital 2]." On 6/16/15 at 10:21 p.m., the HMD documented Patient 1's skin was "[DIAGNOSES REDACTED]tous [red] maculopapular [round flat areas as well as firm bumps on the skin] rash with borders and coalescing [areas of the rash that have grown to the point of joining other areas]". The HMD assessment indicated "[DIAGNOSES REDACTED]tous and coalescing rash with blisters and borders suspecting Steven Johnso[DIAGNOSES REDACTED] vs other." She indicated in the plan "Recommend transfer to [Hospital 2] burn center for higher level of care and derm [dermatology is the medical specialty of care and treatment of skin conditions] consult; IVF [IV fluids] for hydration en route; [Patient 1] was [treated] with benadryl and has not had relief, feels rash is becoming worse." On 6/17/15 at 12:30 a.m., the EDP documented, ".... Case discussed with [HMD], who recommends transfer out to burn center or other outlying facility with dermatology for consult. [Hospital 2], [Hospital 3], and [Hospital 4] declined transfer to their facilities. Patient will likely be referred to [Hospital 2] Dermatology Clinic. Multiple institutions have been called but either do not have hyperbaric chambers [pressure chambers used to deliver oxygen at higher pressures than the atmosphere, used to treat various medical conditions], have no dermatology, or no beds...." On 6/17/15 at 1:52 a.m., the EDP ordered diphenhydramine 25 mg injected IV. Hospital 1 document titled, "Transfer Center Pre-Admit Face Sheet" created by CentralLogic, Hospital 1's transfer center made calls to 12 hospitals, requesting transfer of Patient 1 from Hospital 1's ED to an inpatient bed. No transfer occurred due to lack of services requested at the other facilities or the other hospitals were at maximum capacity at the time the calls were placed. On 6/17/15 at 2:23 a.m., in the facility document, "Patient Care Timeline", the EDP documented, "ED disposition set to Discharge." An explanation or rationale for the change in disposition was not documented. On 6/17/15 at 2:40 a.m. the discharge medication list indicated, "START taking these medications: diphenhydramine (BENADRYL) 25 mg Tab. Take 1-2 Tabs by mouth every 4 hours as needed for itching...." On 6/17/15 at 2:48 a.m., RN 2 documented in Patient 1's clinical record Patient 1's IV was removed. Discharge instructions were printed with a diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED] education was included with the discharge instructions. Patient 1's after care instructions indicate Patient 1 was to "Call [Hospital 2] Dermatology Clinic at 8:30 a.m. I will also call them and give information about you to help you get an appointment. When you call, tell them we spoke with the transfer nurse tonight and they gave you a medical record number..." Patient 1 ambulated (walked) to the lobby. Clinical records from Hospital 2's Dermatology Clinic, signed dated 6/17/15 at 2:45 p.m., indicated Patient 1 was seen with ".... [DIAGNOSES REDACTED]tous-violaceous [red-violet] targetoid confluent plaques [target shaped, joined together flat or raised patches on skin] of the right and left upper extremities, chest, abdomen, back, and legs; Flaccid [weak or soft] and tense blisters with yellow-clear fluid seen on the right upper extremity, right back, left abdomen, and legs; [DIAGNOSES REDACTED]tous sloughing [shedding] of the right ear, back, lateral abdomen, and legs... The patient has flaccid and tense bullae [fluid filled blisters] on the trunk and extremities with evidence of skin sloughing on the left ear, right back/flank, and lower extremities. He is hemodynamically stable now but he is at increased risk for infection and insatiable [possible misspelling of insensible, meaning gradual by very small amounts] loss [of fluid]. Because he is starting to slough and there is development of blisters, I believe the patient should be managed in the hospital... The ER was also notified of his arrival..." On 6/17/15 at 3:57 p.m., Hospital 2's ED record indicated Patient 1 received a Medical Screening Exam (MSE). The Emergency Department Physician at Hospital 2 documented, ".... Patient began taking Prednisone pills and Benadryl 4 days ago with no improvement in rash. Seen in derm clinic today and sent in for admission for SJS. Quality: itching, burning; Severity: 8/10; Time Course: constant; Progression: gradually worsening.... [DIAGNOSES REDACTED]tous ring like lesions, coalescing across bilateral back, arms, legs, chest and abdomen. Some areas of blistering and open blisters on lateral aspect of R[ight] arm, back, and lateral aspect of L[eft] arm... After history and exam, I feel the differential diagnosis includes, but is not limited to [DIAGNOSES REDACTED] multiforme, Stevens Johnso[DIAGNOSES REDACTED], dehydration, electrolyte problems, or super infection.... Patient will be admitted to the hospital for hydration, wound care, possible steroids, supportive care...." Patient 1 was admitted to Hospital 2 on 6/17/15 as an inpatient on a medical surgical unit. On 6/17/15 at 7:40 p.m., Patient 1's History and Physical (H&P) was dictated by a physician at Hospital 2. The H&P indicated, "....DERMATOLOGIC: ... there is a large confluent patches and plaques, right upper and left upper extremities, chest, abdomen, back and legs. There are some tense blisters in the right upper extremity and the right leg. There is some sloughing of the back, lateral abdomen, and legs.... Stevens-Johnso[DIAGNOSES REDACTED]: I discussed the case with Dermatology... I used SCORTEN risk stratification tool to predict his mortality given his age, body surface area, and BUN [a laboratory blood test stand for blood, urea, nitrogen; test to evaluate kidney function], and gives him three risk factors, bringing his mortality rate to 35%. Though the patient looks stable clinically [16 hours 52 minutes after discharge from Hospital 1's ED], given the extensive involvement and body surface area, and his mortality risk, I discussed the case with both Burn Surgery and MICU [Medical Intensive Care Unit]... I will therefore go ahead and admit to a med/surg [medical surgical unit in a hospital] bed with close monitoring, IV fluid, nutritional support, pain control...." Patient 1's discharge summary from Hospital 2, dated 6/21/15, signed 6/22/15 at 2:30 p.m. indicated "The biopsy did come back revealing vacuolar inter[f]ace dermatitis [a connective tissue, which includes skin, condition] which can be seen with both EM [[DIAGNOSES REDACTED] multiforme, a mild to serious skin condition] and SJS.... Skin: multiple [DIAGNOSES REDACTED]tous maculopapular plaques with involvement of bilateral upper extremities, trunk, and lower extremities. Some blisters with serous fluid. Some erosions... overall improved.... The histologic [microscopic study of cells] differential diagnosis [used to diagnose a specific disease] includes [DIAGNOSES REDACTED] multiform[e], but identical changes may be seen in Stevens Johnso[DIAGNOSES REDACTED]." Patient 1 was discharged from Hospital 2 on 6/21/15. On 12/28/15 at 3:15 p.m., during a concurrent observation and staff interview, a tour of Hospital 1's ED took place. The Assistant Emergency Department Director (AEDD) stated, ".... A hospitalist evaluates [patients] when an ED physician wants to admit. Occasionally an ED physician will admit, but usually it is a hospitalist..." On 12/30/15 at 7:23 a.m., during an interview, the EDP stated he was the physician assigned to Patient 1 on the dates in question and was familiar with the course of treatment. He stated he remembered Patient 1 and had an opportunity to review his clinical record prior to the interview. He stated Patient 1 had a number of vesicles. He stated the HMD agreed Patient 1's rash was possibly Stevens Johnson and "if he got worse we wouldn't be able to handle it here." The EDP stated he called multiple facilities but none of them thought Patient 1 "...sounded that bad." When asked to clarify the decision to discharge Patient 1 home as opposed to admission, the EDP stated, "The person I spoke to from [Hospital 2] suggested the dermatology clinic in the morning when they open. They gave [Patient 1] a medical record number... I can't admit him here [at Hospital 1], vitals are normal; no one else will take him, it's just a few hours from now [when the Dermatology Clinic opens at 8:30 a.m.]... That's better than nothing." No other rationale was offered for the decision to discharge Patient 1 home. On 12/30/15 starting at 11:06 a.m., the following individuals agreed to be interviewed in a group setting held in the Boardroom of Hospital 1. All were asked if they were familiar with the clinical care of Patient 1, and all confirmed familiarity and stated they were able to review Patient 1's clinical record. ED Assistant Medical Director (EDAMD) stated the EDP examined Patient 1 and wanted to admit him "here or transfer to another facility. About five hours elapsed between when he was discharged and when his appointment at the burn clinic was." The Medical Director of the Hospitalist Program (MDHP) stated Stevens-Johnso[DIAGNOSES REDACTED] was highly suspected due to the large percentage of skin involvement. Because of the high percentage of involvement, both the EDP and the HMD agreed a burn center would be best for the patient. She stated, "At this point, the hospitalist stepped out of the picture. We think the patient is going to be admitted elsewhere unless told otherwise. If the ED physician does not feel comfortable sending the patient home, we do reassess and will admit. No apparent request [to reassess] was made in this case. It appears [the HMD] was not informed the patient was not being transferred to the burn center... If that patient had been admitted here, he would not have been seen by an expert as soon as he was [at the dermatology clinic]." When asked if she had ever had a patient with SJS, the MDHP she stated she had one in the past and that patient was admitted . The Emergency Department Medical Director (EDMD) stated the physician at the burn center was the expert as related to Patient 1's condition. That physician [at the burn center] recommended an appointment with Hospital 2's dermatology clinic in the morning, a few hours after discharge. The HMD, RN 1 and RN 2 were not available for interview. The hospital policy and procedure titled, "Triage Policy" dated 5/14/15, indicated " Policy: ... B. All patients presenting to the Emergency Department (ED) for treatment will be assessed by a Registered Nurse to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the Emergency Severity Index (ESI) system.... ESI: Emergency Severity Index is a five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... A resource is: labs... specialty consultation.... The RN will initially obtain and document objective information and assessment to include: 1. Presenting complaint/symptoms.... Upon completion of assessment the RN will use the ESI system to assign a triage level.... the triage nurse should consider how many different resources they think this patient is going to consume in order for the physician to reach a disposition decision. 1. ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment.... The facility document "Medical Staff Rules and Regulations" dated 5/12, indicated, "Emergency Care Services... D. No person presenting to [Hospital 1] will be refused emergency services. All persons will be screened and stabilized, within the capability of the hospital...." According to the Mayo Clinic in an article dated 4/22/14, "Stevens-Johnso[DIAGNOSES REDACTED] is a rare, serious disorder of your skin and mucous membranes. It's usually a reaction to a medication or an infection. Often, Stevens-Johnso[DIAGNOSES REDACTED] begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Then the top layer of the affected skin dies and sheds. Stevens-Johnso[DIAGNOSES REDACTED] is a medical emergency that usually requires hospitalization ..." web address http://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/basics/definition/con- 623?p=1 According to an article in the Orphanet Journal of Rare Diseases, referenced by the Center for Disease Control, titled, "[DIAGNOSES REDACTED] and Stevens-Johnso[DIAGNOSES REDACTED]" dated 12/16/10, indicated "Initial symptoms of [DIAGNOSES REDACTED]... The morphology of early skin lesions includes [DIAGNOSES REDACTED]tous and livid macules, which may or may not be slightly infiltrated, and have a tendency to rapid coalescence.... In a second phase, large areas of epidermal detachment develop.... The extent of skin involvement is a major prognostic factor. It should be emphasized that only necrotic skin, which is already detached (e.g. blisters, erosions) or detachable skin (Nikolsky positive) should be included in the evaluation of the extent of skin involvement...." Web address http://www.ojrd.com/content/5/1/39. The Skin Association article titled "Stevens-Johnso[DIAGNOSES REDACTED] Symptoms" indicated, "... Stevens-Johnso[DIAGNOSES REDACTED] and [DIAGNOSES REDACTED] [a rare, life-threatening skin condition that is usually caused by a reaction to a drug] are very serious, potentially deadly conditions and have to be treated accordingly... Patients have to be treated in meticulously hygienic environments to alleviate the risk of further infection, which could result in death. In cases where the patient has lost a lot of fluid through seeping areas where the skin has come away, intravenous fluid replacement may be required. The hospital may also use topical and oral corticosteroids to treat affected areas." Web address <http://www.skinassn.org/stevens-johnson-syndrome-symptoms-treatment.html>