Based on record reviews, observations, and interviews, the hospital failed to ensure a Clinical Professional triaged (assessed) a patient to determine his/her immediate needs when he/she presented to the Emergency Department (ED) for 1 of 10 patients reviewed (Patient #1). This failure resulted in a delay of treatment for a patient, who was found not breathing and without a pulse in the waiting area, 25 minutes after arriving in the ED and prior to being triaged by a Clinical Professional. It was also determined that the hospital's current registration and triage process created a potential negative outcome for any patient presenting to this ED with an emergent need; thus, a determination of immediate jeopardy was made. Finding: Patient #1's clinical record was reviewed and indicated the following: - Documentation on the consent to treat form, that patients normally sign, indicated "patient gave verbally due to medical condition." - Documentation on the ED triage form, part 1, dated 12/15/17 at 12:38 PM, indicated the patient's chief complaint was "cardiac arrest from WR [waiting room], grey, not breathing". - A nursing note, dated 12/15/17 at 2:45 PM, indicated the "Pt [patient] was ambulatory into ED and registration completed. Triage nurse out to bring pt into triage room and pt noted to be slumped down in WC [wheelchair]. No pulse noted. Pt brought directly into CC4 [cardiac care room #4] and placed on stretcher and CPR initiated ...". - Once in the ED room, resuscitation interventions were provided and the patient responded to these interventions. The patient was then transferred to the intensive care unit at 1:52 PM. - On 12/18/17, a neurology consult was obtained and the reported stated the patient ".. does have severe neurological injury, and based on this, the likelihood of functional independent recovery is less than 1%. [He/She] is at high risk for progressing to a persistent vegetative state." - On 12/20/17 at 1:08 PM, the patient expired. Documentation indicated the cause of death was identified as "Patient had workup after [he/she] had a cardiac arrest and [he/she] was found to have severe extensive anoxic [lack of oxygen] brain injury." On 12/27/17, the hospital's "Incident Management Report", regarding the event involving Patient #1, was reviewed. The report, written by the ED Nurse Manager, indicated the following: the patient was in obvious respiratory distress on camera [security video] at 12:15 PM, and again at 12:22 PM.; both triage nurses were busy seeing other patients and that the patient had been left in front of triage room 2 by patient registration; at one point [triage nurse] left Triage Room #2 and grabbed the patient's wrist to check the wristband and then moved on to another patient; the Patient was found unresponsive approximately 13 minutes later by a nursing technician and the patient was brought into the treatment area; and CPR was performed for approximately 25 minutes before a pulse was obtained. The report also indicated "Pt will be admitted to CCU I Am, unsure on severity level at this time, depending on outcome. Nor am I sure if this would have been prevented even if [he/she] was brought to a room immediately." A patient registration document titled "ED Greet" was reviewed. This document indicated upon registration "If the patient states that he/she is having a Stroke or Chest Pain please alert the Triage Nurse right away, do not send the patient to the waiting room. If the patient is sweating, shaking, or looks bad excuse yourself and ask a co-worker to get the nurse or Voicera [a communication device] the Triage nurse to come look at the patient ..." On 12/27/17 at 11:30 AM, a surveyor observed, with the Chief of Security, the video recordings of the hospital's Emergency Department (ED) area for 12/15/17. The following was noted on the video recordings: - At 12:14 PM, Patient #1 arrived at the ED entrance, via personal vehicle, which he/she drove. Security personnel approached the vehicle within 15 seconds of arrival. - At 12:15 PM, a wheelchair was brought to the patient's vehicle; security personnel assisted the patient into the wheelchair; the patient entered the ED; and he/she was wheeled to the registration area. When the patient arrived at registration, there were two other patients at the registration desk. - At 12:17 PM, the patient remained in line at registration and one of the patients at the registration desk was escorted by a registration staff member to the triage area. - At 12:18 PM, the patient was moved to the registration desk. The patient appeared to be having difficulty breathing. - At 12:23 PM, the patient was wheeled to the area in front of the window of Triage Room #2. - At 12:24 PM, the patient remained in the area and was rocking in the wheelchair. A Registered Nurse (RN) left Triage Room #1 and then returned to Triage Room #1. - At 12:24:55 PM, a RN left Triage Room #2, walked by Patient #1 who continued to rock in the wheelchair; and returned to Triage Room #2 at 12:25:20 PM. - At 12:25:43 PM, the RN, from Triage Room #2, made contact with the patient by checking his/her wristband. - Between 12:27 PM and 12:30 PM, the patient was slumped in the wheelchair moving his/her head and moving his/her legs. - At 12:30:20 PM, the patient, who had been in Triage Room #2, left the room and another patient entered Triage Room #2. - At 12:31 PM, Patient #1 continued to be slumped in the wheelchair. - At 12:39 PM, an ED Technician was at Patient #1's chairside and 20 seconds later a RN was at the patient's chairside. Twenty-one seconds after the RN arrived, Patient #1 was moved to a treatment area. On 12/27/17 at approximately 9:30 AM, the Associate Vice President Critical Care/Emergency Department, conducted a tour of the ED with a surveyor. The patient flow process in place on 12/15/17 was reviewed. He stated that patients entered the ED either through the walk-in entrance or the ambulance entrance. Walk-in patients were screened by security and then escorted to patient registration. Patients arriving by ambulance may be immediately placed in a bed, or if determined, by the ambulance staff to be stable for triage, the patient would be dropped off at security by the ambulance and follow the same process as walk-in patients. After registration, the patients then goes to the waiting room to await triage. He stated he identified a need for a nurse or other clinically trained individual at the point of entrance to direct patients to immediate care or to triage when he was hired in November 2017. He shared plans were developed to create these changes, but admitted that the hospital had not implemented any of the changes even after Patient #1's visit to the ED. On 12/28/17 at 9:20 AM, the ED Nurse Manager and the Associate Vice President of Critical Care/ED were interviewed. They reported the hospital had created plans, prior to this incident, to change the patient intake (triage) process including adding a RN at the ED entrance. However, they confirmed that no substantial process changes had been made or put in place following the incident and prior to this onsite complaint investigation. Additionally, they reported an internal investigation was completed and no specific changes had been made after their investigation. On 12/28/17 at 11:55 AM, the Co-Medical Director of the ED was interviewed. He shared a memo, dated 12/20/17, that explained changes that were going to be made to the patient flow process. These changes included adding a "Pivot Nurse" at the ED entrance; adding additional providers in triage; and patient registration would be conducted after the patient was seen by a clinical person and if necessary after treatment initiated. When the surveyor asked why this had not been implemented, he replied, "We don't have a real good interim plan". On 12/28/17 at 12:10 PM, he called the surveyor to state that he had spoken with Associate Vice President Critical Care/Emergency Department who was delegated to implement an immediate action plan as of 12/28/17. On 1/5/18 at 9:28 AM, Employee #16, who was the patient registration clerk on duty on 12/15/17. was interviewed. She indicated that Patient #1 appeared very ill, she was not familiar with the patient, and she had difficulty obtaining information from the patient due to the patient's difficulty breathing. She indicated she wheeled the patient and left him/her in front of the triage room as both triage nurses were busy with patients and she wanted to make sure Patient #1 was seen as soon as possible. She indicated she sent another employee to find a nurse. When asked if a nurse was informed of this patient, she replied, "not by me." When asked if she had a Voicera device to call a nurse, she replied that she did not as she was only covering someone else's break. On 1/15/18 at 1:07 PM, Employee #17, who was also working patient registration, was interviewed. She indicated that Employee #16 asked her to tell the triage nurse about Patient #1 and the patient's difficulty breathing. She stated that both triage nurses were occupied with other patients and that in the past registration staff have been told by the Charge Nurse to "go to the triage nurse". She reported that she was unable to connect with a Nurse as the department was "crazy busy", so she returned to patient registration and informed Employee #16 that she could not find a nurse. Immediate Jeopardy is defined as "a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." This investigation determined the hospital failed to ensure a Clinical Professional triaged a patient to determine his/her immediate needs when he/she presented to the Emergency Department (ED) and this failure resulted in the delay of treatment for a patient. The ED Nurse Manager, the Associate Vice President of Critical Care/ED, and the ED Medical Director, indicated the hospital had identified a need to change the triage process, prior to this event on 12/25/17, and they had created long term plans to change the process. However, as of 12/28/17, 13 days after this event, there was no evidence that indicated the hospital had taken any action to change their triage process even after their internal investigation into this event. The hospital's current triage process continued to create a potential negative outcome for any patient presenting to this ED; thus, a determination of immediate jeopardy was made. On 12/28/17, after consultation with a representative from the Boston Regional Office of the Centers of Medicare and Medicaid Services, a determination of immediate jeopardy was made. On 12/28/17 at 3:30 PM, the hospital was made aware of the determination of immediate jeopardy and an immediate action plan was requested. On 12/28/17, the hospital submitted an immediate action plan. This plan indicated the hospital would place a Registered Nurse at the patient registration area to act as the initial patient contact for all patients entering the ED; if a patient required immediate care, the patient would be moved immediately to an ED bed and registration would occur after stabilization; patients presenting with less severe complaints would be directed to patient registration and then be triaged for a more comprehensive assessment; and training would be conducted to advise all staff of the changes in the ED triage process. On 12/29/17 at 8:20 AM, surveyors verified that the facility implemented their immediate action plan, thus removing the immediate jeopardy situation. Surveyors observed, at the ED entrance, a construction barrier was erected at Patient Registration and a worker was removing the first registration counter; this area was now designated as the temporary location for the Triage Nurse; and a Registered Nurse (RN) and an ED Technician were stationed at the patient registration area to greet patients entering the ED. An interview with a RN was conducted and she stated she had been assigned to screen all patients coming into the ED, both ambulatory and ambulance patients; patients were brought directly to a room in the ED and someone from Registration would go to the cubical and register the patient; and if the rooms were filled, the patient would be assessed until a bed could be found. The RN stated that she had been there since 7:00 AM and would be screening all new ED patients until 7:00 PM. Additional observations for one hour were made and the action plan was being followed. The surveyors also reviewed the acknowledgement forms, signed by ED staff, beginning on 12/28/17 at 7:00 PM.

Based on document reviews and interviews, it was determined that the hospital failed to report to CMS or the State Survey Agency a suspected incidence of an individual transferred in violation of the Emergency Medical Treatment and Labor Act (EMTALA) for one (1) of twenty (20) Emergency Department (ED) records reviewed (Record A). The finding includes: On June 28, 2017, the hospital's Physician Advisor for EMTALA gave the surveyors the "Mayo Regional Hospital EMS Patient Care Report" (ambulance run sheet) to review. Documentation on the ambulance run sheet, dated June 8, 2017, indicated Patient A had been taken to Hospital A after falling from playground equipment. The ambulance arrived on the grounds of Hospital A and before unloading the patient, and the patient being seen, a staff member from Hospital A strongly suggested the ambulance crew take the patient to Eastern Maine Medical Center, which they did. Eastern Maine Health System's Interdepartmental Directive: # 20-085, "Emergency Treatment and Transfer Rules" V.I. ENFORCEMENT AND PENALTIES states, "If the hospital receives a patient in transfer in an unstable emergency medical condition in violation of Part II of this policy, the department head of the receiving unit must contact the Chief, Emergency Medical Service who will determine whether a report must be filed with HCFA, after consultation with the EMHS Vice President and General Counsel." On June 28, 2017, at 9:55 AM, during an interview with the hospital's Physician Advisor for EMTALA, he verified that EMMC personnel, who were working in the Emergency Department on the evening of June 8, 2017, informed him early on June 9, 2017, that EMMC received a patient from Hospital A, which appeared to be in violation of the EMTALA regulations. On June 9, 2017, the EMMC Physician Advisor for EMTALA discussed the situation with multiple Hospital A personnel involved in the situation. He indicated it was decided that Hospital A would make an entity self-report to the State agency. On June 28, 2017 at 3:51 PM, during an interview with the Chief Nursing Officer, she explained that it is the practice of EMMC to discuss any suspected EMTALA violations with the sending hospital. When the sending hospital is willing to self-report, it is EMMC's practice to do nothing. If the sending hospital refuses to self-report, then EMMC makes the report. She stated, "We have done this process forever ...that has been our interpretation [of the EMTALA regulations] ...we talk to the Chief Medical Officer always, to re-evaluate our stance". As of June 29, 2017, the State agency had not received notification from EMMC (the receiving hospital) that there may possibly have been an EMTALA violation.

There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. Based on document review, observation and interview on November 21, 2016 and November 30, 2016, it was determined that Eastern Maine Medical Center failed to ensure that adequate nursing staff was assigned to monitor and provide patient safety. The finding includes: Eastern Maine Medical Center (EMMC) Emergency Depart. Departmental Directive (DD) Safety and Care of Mental Health/Behavioral Patients in the Emergency Department No. 10.5772 states, in part, "A Suicide Risk Assessment will be completed upon presentation to the ED and every 24 hours... for all patients who present: a. With a primary psychiatric complaint;" and "H. Patient Care Considerations 2. An initial Psychiatric Assessment will be performed by nursing staff and updated every shift/ with each change in caregiver on all mental health/behavioral patients." EMMC Interdepartmental Directive Screening for Risk of Suicide Ideation/Attempt and Providing Close Observation No. 20.071 states, in part, "EMMC Emergency Department: A. Patients who present following a suicide attempt, who are displaying suicidal ideation or present with a primary psychiatric complaint will have a suicide risk assessment completed by an RN and placed on close observation until seen by the Acadia physician/Licensed Independent Practitioner (LIP) who dictates otherwise...", and, "D. Patients will be placed in the 'Blue' assignment of the Emergency Department under close observation by security and an assigned staff RN, will be medically evaluated and treated and a psychiatric consult will be obtained to assist with safe discharge planning from the Emergency Department or until patient becomes an inpatient." Patient A's Emergency Department (ED) medical record failed to contain documentation of a Suicide Risk Assessment, Nursing Psychiatric Assessment, or documentation of the patient being placed in the Blue Assignment of the Emergency Department under close observation and an assigned staff RN, as required by EMMC Directive. A nurses note dated November 10, 2016 at 7:42 PM stated, "1942 (7:42 PM) presented to Acadia. To be moved to chair room." A nurses note in the medical record which was dated November 10, 2016 at 9:02 PM stated that between 8:40 PM and 9:05 PM, staff called in the waiting room twice for Patient A and received no answer or response from the patient, so a search of the ED was performed. They were unable to locate the patient and the charge nurse and physician were made aware of this. At 9:50 PM on November 10, 2016, there was a nurse's note that stated, "Assumed patient's care. On assessment, patient stated that he/she has been going to IOP (Intensive Outpatient Program) at [the sending facility]. He/She has a diagnosis of bipolar disorder. Patient stated he/she is afraid and doesn't know why. Patient notably anxious and denied SI (suicidal Ideation) and HI (Homicidal Ideation)." In addition to this nurse's note there was an entry in the electronic medical record titled, "ED Triage Part-2 Adult form" that was documented as being completed on November 10, 2016 at 9:50 PM. In this nursing assessment, the chief complaint is documented as "In from [sending facility] Outpatient Group, positive paranoid, denies SI?HI, recent med changes." This assessment also documented under Behavioral Health Concern "No" with no impaired judgement/safety awareness, no agitation. Additionally, this 9:50 PM nurse assessment documented that Patient A had no fears or worries despite the nurses note documentation for the same time period stating that Patient A, "stated he/she was afraid and doesn't know why." During an interview conducted on November 30, 2016 at approximately 5:00 PM, ED Triage Nurse 1 stated, "I had a "run sheet" (An EMS document completed by the ambulance crew transporting the patient) that he/she came from an outpatient group session and some sort of statement that he/she was paranoid and he/she denied suicidal or homicidal ideation. I asked him/her if he/she was having any visual or auditory hallucinations and he/she denied any. It's kind of a funny thing that he/she is sent here from [sending facility] to get a medical clearance and a psych eval. [evaluation] to go back to [sending facility]...", and, "I didn't do a suicide Risk Assessment ... I asked if he/she was suicidal or homicidal and he/she denied it. It wasn't needed." During an interview conducted on November 30, 2016 at approximately 5:00 PM, when asked if a Suicide Risk Assessment was done for this patient, the Director of Nursing Systems stated, "No. You see the suicide risk assessment didn't fire because this box wasn't checked "yes" (the check box is located on the electronic "ED Triage Part 2 General Assessment" form labeled "Behavioral Health Concern") the suicide Risk Assessment didn't open up and so they didn't need to do it. The initial triage assessment said he/she didn't have suicidality." During an interview conducted on November 30, 2016 at approximately 1:45 PM, the Emergency Department Nurse Manager stated, "The triage nurse in triage 2 is responsible for monitoring the patient in the waiting area...", and, "I don't think there is a policy for that. It is part of the training for the triage nurse." During an interview conducted on November 30, 2016 at approximately 5:15 PM, when asked, when she found out Patient A was missing and what she did, Triage Nurse 2 stated, "I went out in twenty minutes to bring him/her back to the chair room. I told the charge nurse he/she was missing. I said I would go back in twenty minutes and try again. That's our policy. We do that a lot because patients go out to smoke or something and we will wait for a while for them to get back." On November 30, 2016 at approximately 4:50 PM a review of the 2016 triage nurse training slides was conducted. The ESI (Emergency Severity Index) Triage training slide titled "RME [Rapid Medical Exam] Nurse Responsibilities" stated "Monitor lobby patients/re-checks". During an interview conducted on November 30, 2016 at approximately 5:18 PM, the Emergency Department Nurse Manager stated, "There is no RME nurse. It is the triage nurses responsibility to monitor the patients in the waiting area." A review of the security camera transcript for November 10, 2016, provided by security staff denoted that the patient was not on " observation" by security.