Based on medical record review and interviews, in 1 of 15 medical records reviewed, it was determined that there was a lack of integration of emergency services with surgical services resulting in a delay of emergency surgical services. (Patient #1). This deficiency has the potential for patient harm. Findings include: Review of the medical record for patient for patient #1 found that the patient presented to the ED (Emergency Department) via EMS ambulance on 5/24/16 at 2:02 PM with complaint of pain to the left lower extremity after a bite by an unknown insect which resulted in a cool, edematous, pale lower leg with ruptured blisters up to the groin. The PCR pre-hospital care report summary by EMS noted that the patient's skin was " diaphoretic "and no blood pressure reading was able to be obtained by the emergency medical technicians (EMT's). The patient was triaged at 2:33 PM and assigned an ESI (emergency severity index) of "2", which is very urgent. The triage nurse noted that the patient was pale and had pain in the Left leg rated at a score "8" out of "10" (the highest level of pain severity is ranked as "10".) The pulse oximetry rating was documented as not able to be measured. The ED MD's assessment at 2:23 PM documented that the leg was cool, edematous with ruptured bullae extending upward to the groin. The patient was diagnosed with [DIAGNOSES REDACTED]"soft tissue gas." The surgery consult was called at 2:23 PM. The surgical resident was documented as being at the bedside at 2:52 PM, while patient was being intubated at 2:52 PM due to the fact that the oxygen saturation could not be detected and the patient was lethargic with labored breathing. A nursing note reported that at 3:00 PM the " surgical team " was at the patient's bedside. The note also reported that the patient " was placed on a cardiac monitor. " The patient's mother signed consents for surgery for: possible amputation of the left lower extremity, debridement and incision and drainage, and amputation above and below left knee at 3:00 PM. The surgical consult note at 4:51 PM stated that he was consulted by ED medical staff to evaluate and assess whether the LLE was " [DIAGNOSES REDACTED]" . The surgical consultant performed a cutdown was performed at the bedside. The discharge from the surgical wound was " only serous drainage." It further stated that the fascia was " intact with no definitive findings of [DIAGNOSES REDACTED]." The consult reported that " necrotizing soft tissue infection " and " not [DIAGNOSES REDACTED] was very likely." The surgical plan was noted as " critical care evaluation, IV antibiotics, and ID (infectious disease) consult. " It specifically stated " surgery will continue to evaluate patient, will determine need for emergent debridement or amputation vs. aggressive medical management with supportive care and IV antibiotics. " The CCM (Critical Care Medicine) MD note at 6:09 PM refers to receiving a 4:20 PM call from the ER to evaluate the patient. Specifically, the note refers to a discussion with the trauma chief and the surgery resident that the plan "is now for the patient to undergo emergent surgery for suspected [DIAGNOSES REDACTED] and to be transferred to the SICU after surgery. " Review of consents obtained for the leg cutdown (which was done at ED bedside) , the debridement of the lower left extremity, and/or the above knee amputation found that the mother signed consent forms on 4/24/16 at 3:00 PM. There was an initial provider note at 5:04 PM, 2.5 hours after a patient re-assessment note, that stated that the patient is in toxic shock, septic shock, and [DIAGNOSES REDACTED], with the planned disposition of ICU, pending Critical Care Management, and surgery evaluation. At 4:51 PM the general surgery resident noted that "surgery will continue to evaluate patient and will determine the need for emergent debridement or amputation versus aggressive medical management with supportive care and IV antibiotics. " At 4:51 PM, surgery noted that a cutdown was performed at the bedside in the ER to determine if there was [DIAGNOSES REDACTED] and he documented that " the fascia was intact with no definitive signs of [DIAGNOSES REDACTED] however, necrotizing extensive soft tissue infection was very likely. " The patient remained in the ED until 7:39 PM when he clinically deteriorated with bradycardia of 30 BPM (heart beats per minute) and PEA (pulseless electrical activity) . Resuscitative measures, conforming to ACLS (Advanced Cardiac Life Support) failed and the patient was pronounced dead at 8:06 PM. In a ED provider progress note on 5/24/16 at 2124 (9:24PM) (following the patient's death)it was noted that severe hyperkalemia (high blood potassium levels (6.1)) was discussed with anesthesia team concerning peri-operative arrhythmias, acidosis, and hyperkalemia were aggressively corrected with several liters of IV hydration, insulin, glucose, and calcium, however the patient coded and was pronounced dead. Further review of the medical record found an attending note, entered at 8:27 PM (after the patient's death), noted, "K (Potassium) level was 5.6 to 6.1 and therefore, OR/SICU was deferred until the hyperkalemia was corrected ." Review of a post-mortem surgical note at 9:37 PM, found that the patient's hyperkalemia (high potassium (K), was "corrected" and that he was "being prepared to go to OR and went into PEA (pulseless electric activity) - arrest and expired at 8:06 PM." At interview with the Chief of Surgery on 7/8/16 at 2:05 PM, it was stated that the surgery should have been performed sooner. He stated that the potassium probably would not have decreased without dialysis. At interview with the Surgery Attending consultant on 7/19/16 it was stated that he saw the patient that evening and at 5:00 PM he added the patient to the OR schedule , however, he waited to see if the patient's potassium level would decrease before he would perform the surgery. Review of the medical record found no urine output for the entire ED visit. Therefore, correction of the hyperkalemia would have required the initiation of hemodialysis. Failure of the Emergency Department physicians, critical care medicine consultants, and surgery consultants to coordinate care resulted in the patient remaining in the ED for a protracted period of time during which time the patient clinically deteriorated.

Based on interviews, review of medical records and other documents, it was determined the facility failed to ensure that each patient presenting to the Emergency Department receives timely evaluation and treatment in accordance with its written policy and procedure. This finding was noted in 1 of 9 applicable medical records reviewed (Patient #3). Findings include: Patient #3 (MDS) dated [DATE] at 7:16 AM with complaint of abdominal pain. The patient was triaged at 07:50 AM with vital signs as follows: Temperature 99.7 Fahrenheit; Pulse 102; Respirations 18; Blood Pressure 130/80; Pulse oximetry- 99%; Pain rated at 8 on a scale of 1-10. Triage nurse noted the patient was alert and oriented, no overt distress or vomiting noted, patient is not guarding his stomach and sepsis was not suspected. The triage classification was a Level-3. The patient was noted to have departed the Emergency Department on 5/7/15 at 10:15 AM without a Medical screening evaluation; this was about three hours from the time of arrival. During the tour of the Emergency Department on 6/09/15 at 11:40 AM, Staff #10, Director of Adult ED was interviewed regarding triage process and wait times for medical screening evaluation. She stated that upon arrival of a patient, a nurse (E-Fast Nurse) greets the patient and conducts a quick assessment of the patient and determines if the patient needs to be seen immediately, or can wait in the waiting area for a full triage assessment. She stated patients with chest pains, breathing difficulties and other patients with trauma or in acute distress are taken into the ED treatment area and triaged at the bedside. She reported the average time from door to triage is about 10 minutes and the average timeframe for initiation of treatment for a patient classified as a Level-3 is within 1 to 2 hours. The facility failed to implement its triage policy for prompt evaluation and treatment of the patient's medical condition. The facility's policy titled "Triage of adult/Pediatric Emergency Department Patients" last revised in August 2012 notes the timeframe for initiation of treatment for patients triaged as Level- 3 is 1-2 hours. In addition, the policy notes "Reassessment of patients waiting for diagnostic evaluation and treatment is based on the triage level assigned. Level 3 patients must be reassessed within 2 hours in the event that they were not evaluated within the specified timeframe." The patient did not receive a Medical Screening Evaluation within one to two hours of arrival in the Emergency Department, and he was not reassessed within two hours of triage as specified in the facility's triage policy. At interview with the Patient #3 over the phone on 6/15/15 at 3:17 PM, he stated he departed the ED after waiting over three hours for physician evaluation and treatment of his medical condition. He reported that after three hours of waiting in the ED, he approached a staff member who told him there were four people ahead of him and the wait time was going to be at least another hour before he is evaluated. He stated that when he departed the ED sometimes after 10:30 AM, his abdominal pain had worsened and was unbearable. He reported he went directly to an outpatient clinic where he was triaged with a temperature of 102 degrees Fahrenheit and he was later diagnosed as having a colon infection.