Based upon medical record review, document review and interview, the facility did not comply with all the provisions for conducting a medical screening exam. Please reference findings under Tag A 2406.

Based on document review, medical record review and interview the hospital did not provide a medical screening exam (MSE) for 1 of 26 patients who presented to the Emergency Department (Patient #1). A lack of a MSE could result in an emergency medical condition not being identified and treated. Findings include: Review of Patient #1's ED medical record dated 01/25/19 revealed at 11:31 AM she presented and was registered for a chief complaint of mental health evaluation. At 11:52 Patient #1 is documented as left without being seen and discharged from the ED at 11:53AM. There is no evidence of documentation that Patient #1 was triaged. Interview on 02/07/18 at 11:30AM with Staff (F), Registered Nurse (RN) Psychiatric ED, revealed that she noticed Patient #1 was in ED by the electronic board. She went out to talk to Patient #1 and her mother at registration. Patient #1's mother was looking for somewhere to go that had adolescent psychiatric services so her daughter could be evaluated upon recommendation by her school. Staff (F) stated that she talked to Patient #1's mother who was aware of the services that the hospital provides, as she has a relative that is employed there. Staff (F) stated that Patient #1 was calm, did not have suicidal thoughts and was just depressed. Patient #1's mother did not have funds for transportation, and was given a cab voucher so they could go to another facility. Staff (F) further stated that Patient #1 and her mother left the ED from waiting room and that she did not document any of this information in Patient #1's medical record. Staff (F) stated that she was trained that anytime she saw a child/adolescent on the board for a psychiatric/mental health exam and/or if she is requested by the Medical ED staff, she goes out to the lobby and explains that the facility does not have inpatient adolescent behavioral health services and that children/adolescents would have to be transferred. Staff (F) stated that she would also explain the process and that the parent would have to stay with the child/adolescent while they are examined and transferred and that this can be a lengthy process. Interview on 02/08/19 at 09:25AM with Staff (O), ED Registration Clerk, revealed she remembered Patient #1 coming into ED with her mother. Staff (O) stated Patient #1's mother told her that her daughter was having suicidal thoughts. Staff (O) stated Patient #1's mother was looking for transportation and was already aware that they did not have adolescent psychiatric services at the facility and her daughter would ultimately need to be transferred. Staff (O) stated a nurse came out and talked with Patient #1 and her mother, they were given a cab voucher, and a cab was called so they could be taken to another facility. Staff (O) stated when an adolescent psychiatric patient comes in she tells them that they don't have adolescent psychiatric services here, they can be taken back for assessment and would be transferred to another facility. Staff (O) stated that a nurse will come out to talk with the patient and explain this process as well. Review on 02/08/19 of the "Rules and Regulations of the Medical and Dental Staff", last revised 01/31/19 indicates that medical screening examinations are performed to determine whether an emergency medical condition exists. If a decision to transfer is made, the hospital must, prior to transfer, provide whatever medical treatment it can, within its capacity, to minimize the risks to the individual with an unstable medical condition. Review on 02/08/19 of policy #A-28, "Screening, Stabilization and Transfer of Patients Pursuant to the Emergency Medical Treatment and Active Labor Act of 1986" last revised 12/2018, indicates that patients presenting to the Emergency Department and who request examination or treatment or has such a request made on his or her behalf, or if a prudent layperson observer would believe that an individual needs examination or treatment for a medical condition, will be evaluated, treated and transferred when appropriate. A medical screening examination must be provided to all patients who present to the hospital's emergency department. Review on 02/08/19 of policy "Triage: ED-31" last revised 01/2016 revealed triage will be performed upon arrival. The registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department. Review on 02/08/19 of policy "Medical Clearance of a child or adolescent presenting to the Psychiatric Emergency Department: ED-48," last revised 02/2019 revealed, given the absence of child/inpatient psychiatric services at Niagara Falls Memorial Medical Center, if the patient requires admission, transfer to another facility is required. The arrangements for transfer can only be initiated after the medical clearance is completed; therefore, timely nursing assessment and medical clearance is essential. Review on 02/08/19 of policy "Child/Adolescent Assessment Procedure: H-11" last revised 01/2019 revealed upon arrival, child or adolescent patients seeking or appearing to be in need of behavioral health services will be triaged in the ED by the triage nurse. The triage nurse will then walk the patient to the locked Psychiatric ED door, accompany patient into the Psych ED and provide a verbal report to the Psychiatric nurse. The Psychiatric nurse will notify the ED medical staff for medical clearance. A comprehensive behavioral health Assessment including Mental Status Exam, Lethality Assessment and Drug and Alcohol Screen will be completed by the Psychiatric ED nurse. Review on 02/08/19 of policy "Elopement of Psychiatric Patient from emergency room : H-2," last revised 10/2017 revealed all patients who have requested psychiatric services but leave premises prior to Medical Staff's disposition decision, shall be considered elopement. Complete documentation of the course of events is to be made in the chart including time of elopement, who was notified, condition of patient prior to leaving including patient behavior and any other pertinent and reflective information.

Based on policy review, document review and medical record review, the medical staff do not adhere to facility policy related to midlevel practitioners involved in the transfer of patients to an higher level of care for 2 of 4 patients (Patient #10 and # 17). Findings Include: Review on 11/16/16 of policy A-28 " EMTALA/COBRA " last revised 12/15 indicates physician assistants (PA) are authorized to conduct medical screening examinations under the direction of the ED physician or attending physician. However, the physician completes the transfer form including medical orders for transfer. The policy indicates PA's are under the direct supervision of an emergency room physician. "Nothing in this policy shall give the PA the sole authority to execute a Physician Certificate for Transfer which must be completed by a physician unless no physician is present in the emergency department (ED) at the time of the patient transfer. In that circumstance, the certificate may be completed by a PA, but only after consultation with a physician." Review of the Keystone Healthcare Management ED physician schedule for November 2016 revealed an attending physician is onsite 07:00 AM to 07:00 PM and 07:00 PM to 07:00 AM every day covering all shifts. Review on 11/16/16 of the medical record for Patient #10 dated 11/09/16 revealed at 09:04 PM a medical assessment is performed by the PA. At 10:00 PM care is transferred to another PA. Both PA notes are signed off by an ED physician on 11/10/16 at 05:43 AM, however, there is no indication that either PA consulted with the attending physician prior to the transfer at 03:30 AM. The transfer form/order and the physician certification of medical necessity for ambulance transfer both dated 11/10/16 are signed by the PA, not the ED attending physician. Review on 11/16/16 of the medical record for Patient # 17 dated 11/11/16 revealed a medical assessment is performed by the PA. The PA notes are signed off by an ED physician on 11/12/16 at 07:17 AM (the next shift), however, there is no indication the PA consulted with the attending physician prior to the transfer. The Transfer form/order dated 11/11/16 is signed by the PA, not the ED attending physician.

Based upon medical record review, interview and document review, the facility did not comply with all of the provisions for conducting a medical screening exam. Please reference findings under Tag # A2406.

Based upon medical record review, interview and document review, the hospital does not ensure all patients presenting to the emergency department (ED) receive a medical screening examination (MSE) in a timely manner, along with ongoing monitoring and beginning with triage, to determine if an emergency medical condition (EMC) exists in 7 of 24 records reviewed. A lack of a medical screening exam could result in an emergency medical condition not being identified and treated in a timely manner. Findings Include: Review on 10/08/15 of policies ED-30 "Assessment of the Emergency Department Patient" last revised 2/14 and ED-34, " ER Staff Responsibilities " last revised 4/15 revealed all patients presenting to the ED will be triaged and categorized as: Level 1- critical, Level 2- Emergent, Level 3- Semi emergent, Level 4- urgent and Level 5 non urgent. Timeframe's for triage to MD/PA for non-urgent patients is 60 minutes, urgent patients is 45 minutes, semi-urgent patients is 40 minutes, emergent patients is 30 minutes and critical patients is 15 minutes. Review on 10/8/15 of policy A-28 " EMTALA/COBRA " last revised 12/10 revealed a medical screening examination for all patients who present to the ED is to be performed by a physician upon the patient ' s arrival to determine whether an emergency medical condition exists. Review on 10/8/15 of policy ED-34, "ER Staff Responsibilities" last revised 4/15 revealed the triage nurse performs a "quick triage" for all patients and assesses the waiting room in between patients to identify any patients in distress, explain delays and answer questions. Patient partners greet and perform a quick registration process on patients. They will check on patients who return to the waiting room after triage due to a lack of ED beds. They will document their observations at least every 30 minutes, obtain vital signs, oxygen saturation, pain scale rating and report significant findings to the RN. Medical record review on 10/8/15 for Patient A revealed on 7/27/15 at 10:22pm the patient presented to the ED and reported to the Patient Partner that they were experiencing general weakness and loss of appetite. The patient was sent to the waiting room and on 7/28/15 at 1:45am the RN documents the patient was called from the waiting room (for triage) but was found to be unresponsive with no pulse. Resuscitative efforts were initiated at 1:45am and at 2:36am the patient was pronounced. No evidence was found to indicate the patient had been triaged or monitored during the three and a half hours that had elapsed between presentation to the ED and being found unresponsive in the waiting room. Interview on 10/7/15 at 2:10pm with Staff # 28 revealed the ED is divided into 3 zones: zone 1 is assigned to the charge nurse and includes the code room, zone 2 includes the fast track and zone 3 includes triage. The Patient Partners check on patients in the waiting room. Most of them are Emergency Medical Technicians. They do not obtain vital signs. Interview on 10/7/15 at 1:00pm with Staff # 30 revealed she does patient intake and keeps an eye on the patients in the waiting room. After triage, if a patient comes back out to the waiting room, we are supposed to check on them every 30 minutes." Eyeball" them but we don't do vital signs. The triage nurse starts at 9:30am and is usually the Zone 3 nurse. She is located in the back, not in the triage room. Interview on 10/6/15 at 3:45pm with Staff # 12 revealed Patient Partners perform pre-triage screening of patients who present to the ED waiting room. She is responsible to obtain intake information on a patient but does not obtain vital signs. She "eyeballs" patients in the waiting room. There is not always a triage nurse, usually "whoever is up next to take a patient will triage them". Medical record review on 10/8/15 revealed no evidence to indicate the following patients were triaged in a timely manner or monitored following their arrival in the ED. - Patient R (MDS) dated [DATE] at 12:53pm with a complaint of facial swelling. At 3:17pm the RN documents "not in waiting room". -Patient S (MDS) dated [DATE] at 10:13am with a complaint of diarrhea, vomiting and syncope. At 1:30pm the patient leaves without being triaged. -Patient W (MDS) dated [DATE] at 4:05 PM via ambulance with a complaint of syncope. At 7:24pm the RN documents Patient R "left without being seen". - Patient X presented to the ED at 10:09am with a complaint of abdominal pain and nausea. At 11:46am the patient was triaged as an ESI(Emergency Severity Index) Level 3. Medical record review on 10/08/15 revealed no evidence the following patients received a MSE in a timely manner: -Patient C (MDS) dated [DATE] at 11:02am with a complaint of taking an overdose of pills and was triaged as ESI Level 2. An MSE was not conducted until 1:04pm. -Patient U presented to the ED via ambulance and was triaged as an ESI Level 3 at 7:46pm with complaints of status post seizure and head injury. At 10:45pm the RN documents the patient "left without being seen" by a physician. Interview on 10/08/15 at 1:50pm with Staff #2 verified the above noted findings. Review on 10/08/15 of emergency room /Stroke Quality Assurance committee meeting minutes revealed the following data: July 2015: - 212 patients who presented to the ED left before triage. - 122 patients were triaged but left before being seen by the physician. August 2015: - 124 patients who presented to the ED left before triage. - 126 patients were triaged but left before being seen by the physician. September 2015: - 151 patients who presented to the ED left before triage. - 124 patients were triaged but left before being seen by the physician. No evidence was found to indicate the facility has implemented actions to address the number of patients who leave before triage or before being seen by a physician.

Based on document review, medical record review and interview, the facility did not ensure that all patients received care according to its policies and current standards of practice related to vital sign monitoring for 1 of 15 patients. This could cause staff to have lack of awareness that a patient was unstable. Findings: Review on 10/06/15 of policy ED-30 "Assessment of Emergency Department Patient", last reviewed 02/2004, revealed that patients who are triaged as a Level 3 should have vital signs performed every 2 hours or as needed per ED attending order. Medical record review on 10/06/15 of documentation dated 08/12/15 for Patient G revealed the following: - At 10:20 AM: Patient G presented to the ED and was triaged at an ESI Level 3 due to a complaint of feeling hot and congested. Vital signs included a temperature of 36.7 C (degrees centigrade) and pulse of 140. - At 10:43 AM: Temperature was 37.7 C. - At 1:31 PM: Temperature was 38.0 C and pulse was 180. These findings were confirmed with Staff #1 on 10/07/15 at 4:00 PM.