Based on medical record review, document review and interviews, in one (1) of (20) records reviewed, the Hospital failed to ensure that a medical screening examination was performed for all patients. This failure may have placed the patient at risk for harm. Review of medical record for patient #20 identified the following: this [AGE]-year-old female was brought to the Emergency Department by ambulance on 11/2/16 at 8:41 P.M. following a motor vehicle accident in which she was struck as a pedestrian. Triage assessment on 11/2/16 at 9:08 P.M. noted the patient complained of pain to the right shoulder and right leg, which she rated at seven (7) on a scale of one (1) to (10), ten being the highest level of pain. The patient was unsure of loss of consciousness during the incident. Vital signs at the time of triage were; T 99.8, F, P 82, R 16, R 16, B/P 125/79. A triage classification of Emergency Severity Index, level 3 (Urgent category) was assigned The medical record documented that the Physician ordered lab work at 9:57 P.M., an x-ray of the shoulder at 9:58 P.M., and a urine drug screen at 10:22 P.M. A Registered Nurses Note on 11/2/16 at 11:31 PM documented the following: "Patient very combative, verbally abusive, and aggressive towards staff. Patient escorted out by security." A Physician's Progress note on 11/3/16 at 12:06 A.M. indicated that the "Patient left prior to being seen by a provider. I am completing this note to remove this patient's name from the tracking screen and did not have any personal contact with this patient. Pt was cursing at security and walked out around 11 p.m." An End of Shift Report from the Security Department dated 11/2/16-11/3/16 at 11:15 p.m. reflected that the patient was escorted out by security at the direction of the Patient Care Coordinator after she was suspected of stealing medical items from the Adult emergency room . There was no documentation in the medical record that the patient had a history and physical examination performed by a physician prior to being escorted out by security staff. There was no documentation that the patient had an x-ray of the left shoulder performed prior to her departure from the Emergency Department. The urine toxicology test resulted on 11/2/16 at 11:36 PM was positive for cocaine; this was after the patient departed from the Emergency Department. At interview with Staff B, ED Nurse Manager, on 12/21/16 at 10:30 A.M., he stated that the physician who ordered diagnostic tests never saw the patient. During interview with Staff A, emergency room Associate Medical Director on 12/21/16 at 2:20 PM, staff stated that this patient was disruptive and she attempted to remove items from the emergency room . When confronted the patient began to throw things around. The patient stated that she wanted leave; as she left the emergency room , security staff followed behind her. Staff A confirmed that this patient was not seen by a physician prior to her departure from the Emergency Department. There was no documentation in the medical record that the patient expressed the desire to leave the Emergency Department before the completion of a medical screening examination and treatment.

Based on review of medical records, documents and staff interviews, it was determined the facility failed to ensure that all patients received care according to its policies and current standards of practice. Specifically, the staff failed to (1) perform complete assessments and reassessments and (2) failed to address abnormal findings. This was found in 2 of 16 medical records reviewed. (MR #1 and MR#2). Findings include: 1). A review of patient MR#2 on August 27, 2015 identified the following information: A forty-five year old patient presented to the Emergency Department (ED) on May 26, 2015 at 10:49 PM in respiratory distress as evidenced by shortness of breath and an oxygen saturation of 79%, on oxygen 10 liters per minute (normal range is 96-100% on room air). The patient's presenting complaint was shortness of breath for 3 days. The patient also had a history of substance abuse. The patient was "diaphoretic, tripoding and had pinpoint pupils." The previous medical history was significant for Hypertension, Diabetes Mellitus (DM), Coronary Artery Disease and Pulmonary Embolus/Deep Vein Thrombosis. Assessment at 11:09 PM that night revealed a Pulse rate of 125 beats per minute (normal is 60-100), Respirations of 32 (normal is 12-20) and the Blood Pressure (B/P) was 205/136 (normal is 90/50 - 120/80). Further review of the medical record revealed the patient was using accessory muscles to compensate for his difficulty breathing. The patient was placed on Bipap and his respirations were not reassessed until it rose to 55 breaths per minute, at which point he was intubated at 11:35 PM that night. This was not a timely intubation and it does meet current standards of practice, given the patient's long history of shortness of breath and labored breathing. In addition, despite the patient's significantly elevated blood pressure and pulse rate, the patient's vital signs were not reassessed until 12:05 AM on May 27, 2015 when he was found pulseless, which was more than an hour after his arrival to the ED. The patient was pronounced dead at 12:29 AM that morning when Advance Cardiac Life Support measures were unsuccessful. Review of the facility's policy "Assessment of The Patients in the Emergency Department," last revised 2/15, revealed: the patients vital signs must be repeated as necessary until stable. The policy also states the vital signs must be reassessed "immediately if abnormal in triage." This policy for reassessment was not followed despite the patient's extremely elevated blood pressure and heart rate upon arrival. 2). A review of patient MR#1 on August 26, 2015 identified the following information: this thirty-two year old patient presented to the ED at 5:18 PM on March 29, 2015 with complaints of right shoulder and head abscesses, nausea and vomiting. The patient's previous medical history was significant for but not limited to Hypertension and Diabetes Mellitus (DM) for which she was taking Lantus Insulin. The patient also had a history of End Stage Renal Disease and she received Hemodialysis Mondays, Wednesdays and Fridays. The triage classification was level III. The patient was admitted to the facility 3 months prior in December 2014 with Diagnoses of Abscesses and Diabetic Ketoacidosis (DKA). Review of the policy titled "The Triage Assessment" revealed the name, dosage and frequency of medications taken at home should be documented in the patient's medical record. There was no documentation that this was done. At 6:30PM, there is documentation of an elevated blood sugar of 268 mg/dl (normal is 70-110 milligram/deciliter), at 6:50PM for this patient. Labs were ordered by the physician at 8:57 PM, but there was no evidence that that labs were drawn nor was there any evidence that the staff followed up on the order or results. Patient MR#1 was found unresponsive at 4:58 AM on March 30, 2015, at which point the finger stick was done and the result was noted to be 486 mg/dl. (A critical result is in excess of 400 mg/dl). The patient was pronounced dead at 5:26 AM that morning when resuscitative measures proved futile. Review of the policy titled "Assessment of patients in the Emergency Department" which was last revised 2/15 revealed a level III patient's vital signs will be repeated every 4 hours if stable until admission, discharge or unless written physician's order specify otherwise. Patient #1's vital signs were not monitored according to this policy. The patient was not reassessed periodically or at a minimum every 4 hours by a physician or a nurse. In addition, there is no documentation that the labs were drawn as ordered. These findings were confirmed with the Medical Director on August 28, 2015 during an interview which was conducted at 1:50 PM.

Based on interviews, review of medical records and other documents, the facility failed to ensure that each patient presenting to the Emergency Department for care is promptly examined. This finding is noted in 5 of 32 patients' records reviewed (Patient #s 1, 2, 3, 4, and 5). Findings include: The review of the facility's Emergency Department log on 5/26/15 noted that Patient #1 and Patient #2 left before they were triaged. Patient #1, a [AGE] year-old male was noted to have arrived in the ED on 4/7/15 and was logged in by the registrar at 2:14 PM. Similarly, Patient #2, a [AGE] year-old female arrived on 4/7/15 at 5:18 PM. The medical record shows that both patients departed the Emergency Department prior to a triage assessment. The records for Patient #1 and #2 lacked an immediate assessment upon their arrival in the ED to determine the priority for medical screening evaluation. The records lacked information on why Patient #1 and Patient #2 sought emergency medical treatment. In addition, the time of departure of these patients were not indicated in their medical record. During the tour of the Emergency Department on 5/26/15 at about 11:15 AM, three of five patients interviewed have been waiting between 45 minutes to 1 ½ hours for triage assessments. At interview with Patient #3 in the ED Waiting Room on 5/26/15 at 11:15 PM, he stated he has waited over one hour and has not been triaged. Patient #4 on 5/26/15 at 11:17 AM reported she has been waiting one hour and a half for triage. The mother for Patient #5 at interview on 5/26/15 at 11:20 AM reported her daughter had not been triaged. She stated they have waited 45 minutes after registration. At interview with Staff #1 during the ED tour on 5/26/15 at 11:21 AM, she confirmed Patient #s 3, 4, and 5 have undergone mini registration, but have not been triaged. She stated a patient upon arrival is directed to the Registrar who obtains the patient's name, date of birth, and the reason for the visit. The information from the patient is immediately available to the triage nurse who determines the order in which patients are called to triage. She stated that a face-to-face assessment of the patient is conducted only at the time of triage. The facility failed to implement its policy for prompt assessment of each patient upon arrival in the ED. Review of the facility's policy titled "Emergency Department Triage" last revised in December 2012 notes, "The purpose of triage is to identify patients who require immediate, definitive care. It is the process by which patients are sorted and classified according to the type and urgency of their conditions based on a rapid focused assessment of each patient's chief complaint". In addition, the policy titled "Assessment of Patients in the Emergency Department" notes "An initial triage assessment is performed by a registered nurse upon a patient's arrival in the Emergency Department.

Based on interviews, review of medical records and other documents, it was determined the facility failed to ensure that each patient in the Emergency Department receives appropriate medical screening examination and treatment. This finding was noted in 1 of 32 medical records reviewed (Patient #6). Findings include: Patient #6 is a [AGE] year-old female who (MDS) dated [DATE] at 5:18 PM with a chief complaint of shoulder abscess. The patient had multiple medical conditions including chronic hepatitis C, hypertension, diabetes mellitus, [DIAGNOSES REDACTED], recurrent abscesses, [DIAGNOSES REDACTED], End Stage Renal Disease, and was on dialysis three times weekly. Physician assessment of the patient documented on 3/29/15 at 11:03 PM notes a 6 centimeters (cm) x 8 cm abscess on the patient's right arm and the back of her head. The patient was started on antibiotics on 3/29/15 at 11:32 PM and she later underwent an incision and drainage of the abscess at about 12:26 AM on 3/30/15. The facility failed to provide ongoing evaluation and timely treatment of the patient's medical condition. An elevated glucose level of 268 milligrams per deciliter (mg/dl) taken on 3/29/15 at 6:50 PM was not addressed, consequently the patient's glucose further elevated to 486 mg/dl on 3/30/15 at 5:09 AM. Laboratory tests ordered by the physician on 3/30/15 between 8:57 to 8:58 PM included Complete Blood Count, Basic Metabolic panel, Liver tests, Lipase, Magnesium, Prothrombin time, APTT, Phosphorous, Blood culture, Urinalysis and urine culture were not implemented. There was no indication the patient was continuously assessed and monitored after receiving multiple pain medications. The Medication Administration Record revealed Morphine 4 milligrams (mg) intravenous (IV) injection ordered on [DATE] at 8:58 PM was administered on 3/29/15 at 11:39 PM. Hydromorphone 1 mg IV and Diphenhydramine 50 mgs IV were both administered on 3/29/15 at 11:44 PM. In addition, a second dose of Morphine 4 mg IV was documented by the nurse to have been administered on 3/29/15 at about 11:43 PM. The patient's vital signs were last recorded on 3/29/15 at 10:49 PM prior to pain management intervention. The patient was found unresponsive on 3/30/15 at 4:58 AM and pronounced dead at 5:26 AM following failed resuscitation efforts. At interview with Staff #2, on 5/27/15 at 12:15 PM, he stated at the time of patient's presentation on 3/29/15, the Emergency Department was exceedingly crowded, a patient was being coded and patients' care was being transferred to the incoming shift. He stated he recognized there was a lack of communication that resulted in untimely implementation of laboratory test orders. He also added that Patient #6's vital signs could have been monitored more frequently based on patient's condition. At interview with Staff #1 on 5/27/15 at 2:20 PM, she stated that a glucose level of 268 mg/dl, although abnormal, was not a critical value that requires emergency treatment. Regarding vital signs monitoring, Staff #1 stated the first dose of Morphine was given shortly after it was ordered on [DATE] at 8:58 PM and not at 11:39 PM as documented in the Medication Administration Record. Regarding patients triaged as ESI level -3, Staff #1 stated that vital signs are monitored, at a minimum, every four hours in accordance with the Emergency Department policies. Review of the Emergency Department policy titled "Assessment of Patients in the Emergency Department" last revised in March 2012, notes "All level three (3) patients should have a brief evaluation within 2 hours by the MD to determine the patients' stability. If stable vital signs will be repeated every (4) four hours until admission, discharge, or unless written MD orders specify otherwise". The patient's record revealed lack of vital signs for over six (6) hours before the patient was found unresponsive on 3/30/15 at 4:58 AM.

Based on interview, the review of medical record and other documents, it was determined the facility did not ensure the implementation of its policy to assure that (1) each patient evaluated in the Emergency department receives a written discharge plan for continued treatment and follow-up care; and (2) abnormal vital signs are repeated and stabilized prior to discharge. These findings were noted in 3 of 30 applicable records reviewed (Patient #5 and #6 and #7). Findings include: 1 (a). Patient #5 is a [AGE]-year-old female, Gravida 1 (a woman's first pregnancy) , Para (number of pregnancies of a duration greater than 20 weeks) 0, at 24 weeks gestation who (MDS) dated [DATE] at 9:30 AM with complaint of "low abdominal pain since yesterday". The patient had a Trans-abdominal sonographic examination that was within normal limit and physical examination was unremarkable. A reassessment of the patient by the nurse on 10/2/14 at 11:00 AM, notes the patient's abdominal pain had completely subsided. The physician diagnostic impression was "Pregnancy". The patient was discharged home on 10/2/14 at 11:15 AM with instructions to follow up with an obstetrician. The registration information provided by the patient on 10/2/14, during the ED visit notes, "NO Primary Care Physician AT ALL". However, the patient's discharge instruction did not indicate information necessary for the patient to make a follow up appointment; the name of the obstetrician, office location, and contact number were not noted. The Emergency Department Manual titled "Discharge Planning and Instructions", last reviewed in November 2011, notes that upon completion of each patient's visit, "The physician documents the plan for continued treatment and or follow-up care in the Emergency Department record. The physician or Registered Nurse completes the patient's Discharge Instructions and Follow-up section of the ED record". 1 (b). Patient #6 is a 48 -year-old female who presented to triage on 9/10/14 with a chief complaint of chest pain for three hours radiating to the left shoulder. The patient's past medical history included pulmonary fibrosis (Scarring in the lungs that ca be caused by many conditions) and heart palpitations. Following medical screening evaluation and diagnostic tests, the physician's diagnostic impression was "Atypical chest pain". The patient was discharged on [DATE] at 6:10 PM with instruction for follow up care with Primary Care Physician (PCP) in one week. Although the patient's ED registration record on 9/10/14 indicated, the patient had no PCP, the physician failed to document a plan for continued treatment and follow-up care of the patient in accordance with the discharge policy. At interview with Staff #3 on 2/5/15 at 11:30 AM, she stated that when a patient reports not having a PCP, the treating physician will make appropriate referral depending on the services needed. 2. Patient #7, a [AGE]-year-old female was triaged in the Emergency Department on 1/21/15 with a complaint of cough and yellow phlegm for three weeks. The patient had multiple medical conditions including hypertension, asthma, Multiple Sclerosis, [DIAGNOSES REDACTED], and renal failure. Vital signs obtained at triage at 10:00 PM were as follows: Temperature - 98.5, Blood pressure - 162/99 millimeter of mercury (mm/Hg), Pulse - 100 and Respirations - 12. The triage classification was Emergency Severity Index (ESI) IV (4). ESI is a five level emergency department triage based on the acuity of patients' health care problems and the number of resources (complex interventions or diagnostic tools) their care is anticipated to require. ESI Level 1 - Resuscitation - Immediate, life-saving intervention required without delay; Level 2 - Emergent - High risk of deterioration, or signs of a time-critical problem; Level 3 - Urgent - Stable, with multiple types of resources needed to investigate or treat; Level 4 - Less Urgent Stable, with only one type of resource anticipated; and Level 5 - Nonurgent - Stable, with no resources anticipated except oral or topical medications, or prescriptions. The physician's diagnostic impression following a chest x-ray was Upper Respiratory Infection. The patient was discharged home with prescription for Robitussin for management of cough/cold and was instructed to follow up with her PCP. Although the patient's current medications included antihypertensive medications, Clonidine and Diovan, the nurse failed to include in the triage assessment when these medications were last taken. In addition, the treating physician in his assessment failed to acknowledge the patient's elevated blood pressure and document a plan for treatment. The patient was discharged home without a reassessment of her blood pressure and instructions for prompt management. At interview with Staff #4 on 2/4/15 at 3:45 PM, he stated the patient had a history of hypertension and was on medications. He added that the recent administration of bronchodilators to the patient prior to her arrival in the ED might have caused elevation in her blood pressure. The review of the Emergency Department Manual titled "Assessment of Patients in the Emergency Department" last revised in March, 2012 notes "All patients including psychiatric who are determined to be Level IV or Level V will be reassessed and have vital signs recorded: (a) The primary RN should repeat vital signs immediately if abnormal in triage." The patient's triage blood pressure was 162/99 mm/Hg on 1/21/15 at 10:00 PM. The primary nurse did not reassess the patient's blood pressure prior to her discharge on 1/22/15 at 2:40 AM.

Based on interviews, the review of medical records and the Emergency Department (ED) log, it was determined that the facility failed to maintain an ED log that reflects the accurate disposition of patients who were evaluated in the ED. This finding was noted in 4 of 5 patients whose disposition were entered as transfers in the ED log (Patient #1, #2, #3 and #4). Findings include: The review of five randomly selected patients from the ED log for September 2014 to January 2015 revealed the disposition of four patients was not accurately documented. Patient #1 is a 4-year-old who was evaluated at the Emergency Department on 12/18/14 and was transported to the facility's Emergency Department at another location to rule out appendicitis. The ED log did not indicate the final disposition of the patient; instead, it notes the patient was transferred. Patient #2, a [AGE]-year-old female was evaluated on 1/19/15 for severe headache. The attending radiologist recommended Magnetic Resonance Imaging (MRI) following a CT scan (X-ray computed tomography is a technology that uses computer-processed X-rays to produce virtual 'slices' of specific areas of a scanned object, allowing the user to see inside the object without cutting) that showed possible pituitary apoplexy (sudden neurologic impairment, usually due to a vascular process). The patient was transported to the facility's ED at another location for MRI. The ED log did not capture the final disposition of Patient #2. Patient #3 is a [AGE]-year-old female, Gravida 2 (a woman in her second pregnancy), Para 1 (a woman that has had one pregnancy that achieved more than 20 weeks of gestation age), at 5 weeks gestational age who (MDS) dated [DATE] at 6:30 PM with complaint of abdominal cramping and vaginal bleed. The patient was evaluated by the ED physician with a diagnostic impression of "Threatened abortion". She was transported to the hospital's ED at another location for continued care. The final disposition of the patient was not entered into the ED log. Patient #4 is a [AGE]-year-old female who was evaluated in the ED on 8/5/24 at 5:34 PM with complaints of abdominal pain, nausea, and vomiting. The physician's diagnostic impression was "Acute Gastroenteritis". Following a CT scan of the abdomen and pelvis, she was transported to another ED of the hospital for surgical consultation. The ED log notes the patient was transferred. The review of the ED log found that thirty-one patients were transferred in August 2014; however, upon interview with Staff #1 on 2/5/15 at 1:20 PM, she provided a document that confirmed that only one patient out of the thirty-one had been transferred to another facility, the rest were transferred to other campuses of the hospital. At interview with Staff #2 on 2/5/15 at 1:39 PM, she stated that regardless of whether patients were transferred to another facility or to the hospital's ED at another location, their disposition is entered into the log as transfers. The staff stated she is unable to determine the final disposition of Patient #1, #2, #3, and #4.