Based on interview and review of the Emergency Department's (ED's) registration log book, it was determined the facility failed to ensure 97 of 6,027 patients had a discharge disposition documented on the ED's registration logbook. The findings include: Review of the ED registration logbook, dated August 2016, revealed there were 6,027 patients registered in the logbook and 97 did not include a discharge disposition on the logbook. Interview on 09/06/16 at 2:00 PM with the Quality Manager revealed the facility did not have a policy regarding documentation in the ED registration logbook. Interview on 09/07/16 at 11:40 AM with Registered Nurse (RN) #1 revealed the nurse that discharged a patient from the ED was the person responsible for completing the discharge disposition on the ED registration logbook. Interview on 09/07/16 at 10:00 AM with RN #4 revealed she thought the Unit Clerk for the ED documented the discharge disposition on the ED registration logbook when a patient was discharged from the ED. Interview on 09/06/16 at 4:00 PM with the ED Manager revealed the nurse that cared for the patient was responsible for documenting the discharge disposition for the patient on the ED registration logbook. The ED Manager stated he didn't think the facility's electronic record system would let the record be finalized without the discharge disposition documented and was not aware this was a problem. Interview on 09/07/16 at 3:00 PM with the Quality Manager and the Chief Nursing Officer (CNO) revealed they thought it was an "electronic glitch" that the disposition was not transferred over from one electronic record system to another electronic record system.

Based on interviews, a review of the facility's Emergency Department (ED) registration logbook, medical records, facility policies, and video footage of the ED, it was determined the facility failed to ensure a medical examination was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for treatment. Interviews and review of Facility #1's ED video footage revealed Patient #1 (MDS) dated [DATE] with facial cellulitis. Patient #1 was registered by Registration Clerk #1 and then went to the triage area. Registered Nurse (RN) #1 informed Patient #1's family member that there were approximately twenty (20) patients to be seen ahead of Patient #1. Patient #1's family member stated RN #1 informed him/her it would be a five (5) to six (6) hour wait to receive a medical screening in the ED. RN #1 failed to assess Patient #1 to determine and assign an Emergency Scale Index (ESI) acuity level (which determines the order in which a patient receives a medical screening). Patient #1 left Facility #1 with family members and went to Facility #2 (45 miles away) and was treated, diagnosed , and admitted with Preseptal Cellulitis (an infection of the eyelid and soft tissue surrounding the eye). The findings include: Review of Facility #1's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised 01/21/15, revealed the facility would provide a medical screening examination by a physician or qualified medical person to any individual that comes to a dedicated ED of the facility seeking an examination or treatment for a medical condition. Continued review of the policy revealed the facility would not delay the provision of a medical screening examination, further treatment, or appropriate transfer to inquire about the patient's method of payment. Review of Facility #1's policy titled, "Nursing Assessment and Documentation," revised 08/20/15, revealed patient assessment in the Emergency Department was the responsibility of the RN. Further review of the policy revealed Rapid Triage Assessment will be performed by an RN to assign an ESI acuity level. This would include chief complaint, ESI acuity level, complete set of vital signs, and weight. Continued review of the policy revealed patients would be escorted to treatment areas based on the Rapid Triage Assessment, ESI acuity level, and/or changes in condition or presentation since arrival. Review of Facility #1's ED video footage revealed Patient #1 (MDS) dated [DATE] at 9:29 PM. Further review of the video footage revealed at 9:32 PM Patient #1 and the family members were observed at the registration desk and a staff member placed an identification band on the patient's ankle area. Continued review of the video footage revealed at 9:38 PM Patient #1 and the family members were observed standing in the triage area and at 9:44 PM Patient #1 and family members left the video footage viewing area. In addition, the video footage revealed at 9:47 PM Patient #1 and the family members were at the registration area and were observed to exit the ED at 9:49 PM. Review of Facility's #1 medical record revealed Patient #1 was registered on 08/28/16 at 9:31 PM with complaints of Cellulitis. Continued review of the medical record revealed Patient #1's discharge disposition stated the patient left the ED before triage on 08/28/16 at 9:59 PM. Interview on 09/06/16 at 2:15 PM with Patient #1's Family Member revealed Patient #1 was treated at Facility #2 on 08/27/16 (the day before admission) with intravenous (IV) antibiotics for an eye infection and was told if the swelling of the patient's eye increased to return to the ED or seek further medical attention. Patient #1's Family Member stated he/she contacted Physician #1 on 08/28/16 and informed the Physician that Patient #1's eye had swollen shut and requested for the patient to be directly admitted (admitted to the facility without having to be assessed in the ED) to Facility #1. Patient #1's Family Member stated Physician #1 informed him/her to take Patient #1 to the ED to be screened and then admitted . Further interview revealed Patient #1's Family Member took the patient to Facility #1's ED on 08/28/16 at approximately 9:30 PM, the patient was registered and then went to the triage area. Patient #1's Family Member stated RN #1 informed him/her they would be at the facility for "five to six hours" before receiving a medical screening examination. Patient #1's Family Member stated RN #1 informed him/her "if you're wanting to go on to [Facility #2] then go ahead." Continued interview revealed RN #3 and ED Technician #1 entered the triage area and stated the Pediatric Unit in Facility #1 was closed and it would take sixty (60) to ninety (90) minutes for the staff to get to the facility even if they could directly admit Patient #1. Patient #1's Family Member stated RN #3 stated, "I legally can't say anything, but if it was my child I would already be on my way to [Facility #2]." Patient #1's Family Member requested for Patient #1's vital signs or at least a temperature to be obtained and RN #1 stated, "I can't do anything to [Patient #1] because I took (him/her) out of the system already." Patient #1's Family Member stated they left Facility #1 and went directly to Facility #2 and were medically screened in the ED and admitted to Facility #2 for treatment. The above information was verified on video footage. Interview on 09/16/16 at 11:40 AM with RN #1 revealed she was working the triage area on the evening of 08/28/16 when Patient #1 presented for triage. RN #1 stated Patient #1's Family Member asked how long the wait to be assessed would be and she stated, "I can't give out a time but there are twenty (20) or more patients ahead of you." RN #1 stated she went and got RN #3 to contact Physician #1 for a possible direct admission to Facility #1 and the next thing she knew Patient #1 was leaving the facility and she "errored out" the account. RN #1 stated she did not do vital signs or an ESI acuity level on Patient #1. Interview on 09/06/16 at 4:50 PM with RN #3 revealed she was a float nurse and was working in the ED on 08/28/16 due to the Pediatric Unit being closed. RN #3 stated she was called to the triage area to speak with Patient #1's Family Member about a possible direct admission to Facility #1. RN #3 stated she informed RN #1 (in the presence of Patient #1's Family Member) that the Pediatric Unit was closed and it would take approximately sixty (60) to ninety (90) minutes for nurses to be available to staff the unit. RN #3 stated she did not contact Physician #1 for any type of direction regarding Patient #1's care and treatment. Interview on 09/06/16 at 2:59 PM with ER Technician #1 revealed she did not obtain vital signs on Patient #1. Continued interview revealed she heard RN #3 inform RN #1 (in the presence of Patient #1's Family Member) that the Pediatric Unit was closed and it would take approximately sixty (60) to ninety (90) minutes for nurses to be available to staff the unit. Interview on 09/06/16 at 4:00 PM with the ED Manager revealed nursing staff in the ED were trained to not give out wait times to patients. Continued interview revealed the triage nurse was to do a Rapid Triage Assessment and assign an ESI acuity level to each patient that presents to the ED for a medical screening examination. Further interview revealed the ED Manager stated all patients that present to the triage area should be triaged per facility policy. Interview on 09/06/16 at 1:25 PM with the Chief Nursing Officer (CNO) of Facility #1 revealed she was aware the facility had issues surrounding wait times and patients leaving without being seen in the ED. The CNO stated the ED was currently being expanded from a twenty (20) bed unit to a forty (40) bed unit. Interview on 09/16/16 at 2:45 PM with Physician #1 revealed she received a telephone call on 08/28/16 from Patient #1's Family Member requesting to be admitted to Facility #1. Physician #1 stated she sent Patient #1 to Facility #1's ED to be medically screened and then expected to be contacted by Facility #1 regarding Patient #1's status. Physician #1 stated she never received a phone call from Facility #1 regarding Patient #1's status. A system was not in place for a communication method for community physicians to speak with the ED physicians or staff about patients they send to the department for admission. Review of Facility #2's medical record revealed Patient #1 arrived at the ED on 08/28/16 at 10:46 PM with a complaint of Cellulitis. Further review of the record revealed Patient #1's vital signs were obtained at 10:49 PM and the patient was placed in a room at 10:54 PM. Continued review of the medical record revealed Patient #1 had physician orders for a wound culture, Herpes Simplex test, laboratory test, and a Clindamycin (an antibiotic) infusion. In addition, the medical record revealed Patient #1 was transferred to an inpatient floor on 08/29/16 at 2:10 AM and diagnosed and treated for Preseptal Cellulitis of the right eye. Patient #1 was discharged from Facility #2 on 08/31/16. The facility failed to provide a medical screening examination and was not seen. Additionally, the patient had an emergency medical condition that was not evaluated, treated or stabilized. ED staff told the family that there was a prolonged wait before they could be seen and patient left foor another facility.

Based on interviews and a review of the facility's Emergency Department registration logbook, medical records, the facility's policies, and video footage of the Emergency Department it was determined the facility failed to ensure a medical examination was provided for one (1) of twenty (20) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment. Interviews and review of Facility #1's ED video footage revealed Patient #1 (MDS) dated [DATE] with facial cellulitis. Patient #1 was registered by Registration Clerk #1 and then went to the triage area. Registered Nurse (RN) #1 informed Patient #1's family member that there were approximately twenty (20) patients to be seen ahead of Patient #1. Patient #1's family member stated RN #1 informed him/her it would be a five (5) to six (6) hour wait to receive a medical screening in the ED. RN #1 failed to assess Patient #1 to determine and assign an Emergency Scale Index (ESI) acuity level (which determines the order in which a patient receives a medical screening). Patient #1 left Facility #1 with family members and went to Facility #2 (45 miles away) and was treated, diagnosed , and admitted with Preseptal Cellulitis (an infection of the eyelid and soft tissue surrounding the eye). Furthermore, the facility failed to ensure 97 of 6,027 patients had a discharge disposition documented on the ED's registration logbook. Refer to 42 CFR 489.24 (a) and (c) Medical Screening Exam (A2406) and 42 CFR 489.20 (r)(3) Emergency Department Registration Log (A2405).