Based on review of facility documentation and staff interviews (EMP), it was determined that patients who present to the Emergency Department (ED) and leave prior to triage by a registered nurse or registration are not entered into a central log for one of one patients (PT1). Findings include: Review of the Titusville Area Hospital Policy and Procedure (P&P), "Emergency Department Completion of Medical Record," revised April 2014, revealed, "I. Definition: All patients seeking Emergency Care anywhere in the facility will receive an emergency room medical record. This medical record will provide clear, concise information regarding the patient, promoting continuity of patient care. ... V. Procedure: ... 6. The assigned team member will routinely complete the forms. *Patient sign-in sheet will be filled out by the patient and signed by the nurse prior to registration. If a patient is unable to fill out or deemed necessary to be brought directly back to a emergency room bed, then this form is not be [sic.] part of the medical record. ... I. Emergency Department Log 1. The log is a computer-generated record on all patients seeking services in the emergency department. 2. The ward clerk initiates the log at the time of registration and is completed upon discharge. 3. The log will include the following information: a. Patient's Name b. Doctor c. Diagnosis/Chief complaint d. Date e. Patient medical record number f. Patient visit record number g. Time of arrival and departure h. Sex and age of the patient i. Disposition J. All patients with emergency room records including waiting room leaves, AMA's, and elopements will be maintained on file in the electronic medical record and/or Medical Records Department." Review of the Titusville Area Hospital Administrative Policy "EMTALA MEDICAL SCREENING EXAM," revised April 2014 revealed, "NURSING PROCEDURES: ... 9. All nursing staff shall record the details and times of all relevant medical information, history, observations, patient complaints, vital signs, tests ordered, medical orders received and care treatment rendered on the triage form or Emergency Department record for each patient. 10. ... Time of triage, time of arrival, time of placing in a treatment room, time of physician Medical Screening examination and time of call to and arrival of on-call physicians shall be specifically noted in the record." Review of the Titusville Area Hospital P&P "Patient Elopement," revised July 2003 revealed, "I. DEFINITION: A. An elopement occurs when a patient leaves the facility without signing an AMA form. B. An elopement occurs after the point the patient undergoes a medical screening exam or after the patient enters an area/exam room to wait for a physician to perform the medical screening exam. ... III. INFORMATION: ... B. An elopement shall be deemed to have occurred when: ... 4. An Emergency Department patient that has been registered, assessed by nursing and placed in an exam room awaiting physician evaluation or completion of treatment, leaves the facility without the knowledge and consent of the treating physician." Review of the Titusville Area Hospital Emergency Department P&P "Patients Leaving emergency room Against Medical Advice," revised July 2007 revealed, "... 2. The date and time must be noted. Documentation should include what specific treatment is being refused and the patient's reason for leaving." 1. A review of the Titusville Area Hospital Policy and Procedures "Patient Elopement" and "Patients Leaving emergency room Against Medical Advice" revealed no category for patients identified as having left prior to being triaged and/or registered. 2. On August 2, 2016, PT1 stated that [he/she] presented to the Emergency Department at Titusville Area Hospital with complaints of hand pain on July 30, 2016. PT1 stated that an employee at the front desk, in the ED waiting area, asked for the patient's first name and chief complaint. The employee then proceeded to tell the patient that the ED was really busy, and the patient could drive down the street to a care center. PT1 stated [he/she] drove down to the care center, which was closed, and then returned to the ED. PT1 stated the same employee asked the patient to sit in the waiting area, and said [he/she] would see if there was a nurse that could come out and look at the patient. The patient subsequently eloped, as [he/she] felt [he/she] would not get help. 3. A review of the Titusville Area Hospital Emergency Department Log for the time period February 1, 2016, through August 9, 2016, revealed patients who left against medical advice (AMA), patients who eloped and patients who left prior to the visit being completed/before seeing a physician. There were no patients identified as having left prior to being triaged and/or registered. The review further revealed no documentation that PT1 had presented for either of the alleged visits on July 30, 2016. 4. On August 10, 2016, at approximately 11:00 AM, EMP2 stated that there is 24/7 coverage at the registration desk and stated that patients are always triaged prior to registration. EMP2 stated that when a patient presents to the desk [he/she] writes down their first name only and maybe chief complaint on a tablet. [He/She] then goes to the back to let a nurse know there is a patient needing to be seen. When asked if [he/she] opens a chart for the patient, EMP2 stated "No. Charts are generated in triage." EMP2 stated that if several people come in at the same time or there is no nurse immediately available, [he/she] will write their first names and sometimes complaint or descriptor (i.e., Mary with the bandage on her hand or Jim in the blue shirt) on a plain piece of paper and gives it to the nurse so they know the order in which patients have presented. EMP2 confirmed that the paper with the patient name and complaint are placed in the shredding box when there is no more room on it. EMP2 confirmed also that patients may come in and decide to leave before treatment without ever getting to the ED log if they are not triaged prior to leaving. 5. During an interview on August 10, 2016, at approximately 1:20 PM, EMP6 confirmed that it was very busy on July 30, 2016. EMP6 confirmed that it is possible for a patient to present to the Emergency Department, leave before being triaged and not be entered into the ED registration log. EMP6 further stated, "We wouldn't know if someone left. If we see someone leaving we try to catch them. If a patient is not triaged, we will not have record of them. ..." 6. On August 10, 2016, at approximately 1:25 PM, when asked if the facility ED utilizes a "patient sign-in sheet" as noted in the ED "Completion of Medical Record" policy, EMP8 stated, "No." When asked if there would be a log or record of patients presenting but not triaged and/or registered, EMP8 stated "... we have never done that. ... Registration may have seen them but no. We have not. ... I don't ever know why they were here." 7. On August 10, 2016, at approximately 1:30 PM when asked to confirm that a patient could present to the ED for care, see Registration and leave (prior to triage and/or registration) and not be placed in the ED log, EMP8 stated, "Correct. There is no way to capture that." 8. On August 10, 2016, at approximately 1:31 PM when asked how long it had been since the facility had used a patient sign-in sheet, EMP8 stated, "I'm going to say two years roughly." When further asked what information had been included on the sign-in sheet, EMP8 stated, "It had name, date and method of arrival." 9. On August 10, 2016, at approximately 1:35 PM when asked if there was a category in the ED Log that would meet the definition of a patient who presented to the ED for care, was seen by reception/registration (prior to triage and/or registration) and then left, EMP8 stated, "No. We don't (have a category)." 10. On August 10, 2016, at approximately 2:50 PM, when asked how patients who presented to the ED for care and left prior to triage and/or registration would be tracked, EMP8 stated, "... until they are triaged, there is no way to do that." Cross reference: 489.24(a)(1)(i)

Based on review of facility documentation and staff interviews (EMP), it was determined that the facility failed to provide a medical screening examination within the capabilities of the hospital's Emergency Department (ED) for one of one patient (PT1). Findings include: Review of the Titusville Area Hospital Administrative Policy "EMTALA MEDICAL SCREENING EXAM," revised April 2014 revealed, "It is the policy of Titusville area hospital that all persons presenting for unscheduled procedures or evaluation shall receive a medical screening examination within the capabilities of the Emergency Department and the ancillary services routinely available to the Emergency Department, including the services of appropriate on-call physicians where indicated. ... NURSING PROCEDURES: 1. Except in the case of scheduled tests and/or procedures or direct admissions, all persons presenting at the Emergency Department or any other department of the hospital requesting treatment or examination, shall be provided a medical screening Examination in the Emergency Department of this hospital. ... 5. Initial triage of all presenting patients in the Emergency Department, except those presenting by ambulance, shall be provided by the nurse performing triage or other registered nurse assigned to perform triage. ... Where indicated, the emergency physician may provide a medical screening Examination without prior triage and in lieu thereof. 6. No patient presenting shall be denied triage or Medical Screening Examination by any employee or medical staff member of this hospital. The patient shall not be discouraged from utilization of these services due to means or ability or method of payment ... 9. All nursing staff shall record the details and times of all relevant medical information, history, observations, patient complaints, vital signs, tests ordered, medical orders received and care treatment rendered on the triage form or Emergency Department record for each patient. 10. ... Time of triage, time of arrival, time of placing in a treatment room, time of physician Medical Screening examination and time of call to and arrival of on-call physicians shall be specifically noted in the record. 11. Patients refusing examination, treatment or transfer shall be documented consistent with the Refusal of Care policy or AMA (against medical advice) guidelines. ... 'MANAGED CARE' PATIENTS: ... 3. The Medical Screening Examination must be provided without a delay to obtain information about the patient's ability to pay. Inquiries about ability to pay are permitted as part of the routine registration process but must not delay care." Review of the Titusville Area Hospital Policy and Procedure (P&P), "Emergency Department Completion of Medical Record," revised April 2014, revealed, "I. Definition: All patients seeking Emergency Care anywhere in the facility will receive an emergency room medical record. This medical record will provide clear, concise information regarding the patient, promoting continuity of patient care. ... V. Procedure: ... 6. The assigned team member will routinely complete the forms. *Patient sign-in sheet will be filled out by the patient and signed by the nurse prior to registration. If a patient is unable to fill out or deemed necessary to be brought directly back to a emergency room bed, then this form is not be [sic.] part of the medical record. ... I. Emergency Department Log 1. The log is a computer-generated record on all patients seeking services in the emergency department. 2. The ward clerk initiates the log at the time of registration and is completed upon discharge. 3. The log will include the following information: a. Patient ' s Name b. Doctor c. Diagnosis/Chief complaint d. Date e. Patient medical record number f. Patient visit record number g. Time of arrival and departure h. Sex and age of the patient i. Disposition J. All patients with emergency room records including waiting room leaves, AMA's, and elopements will be maintained on file in the electronic medical record and/or Medical Records Department." Review of the Titusville Area Hospital Administrative Policy "EMTALA PATIENT TRIAGE," revised April 2014 revealed, "All patients presenting in the Emergency Department shall be evaluated by the nurse performing triage or a Registered Nurse in the absence of the Triage Nurse, to determine the nature of their presenting complaints, their condition and their priority for receiving a medical screening examination. They shall be designated in a triage priority and monitored consistent with that category. ... Triage Process and Standards ... 6. The duty to provide a medical screening examination and stabilizing treatment is not limited by the Triage Category assigned. All patients, regardless of Triage Category, are required to be provided a medical screening examination and stabilizing treatment. See Medical Screening Exam EMTALA policies." 1. On August 2, 2016, PT1 stated that [he/she] presented to the Emergency Department at Titusville Area Hospital with complaints of hand pain on July 30, 2016. PT1 stated that an employee at the front desk, in the waiting area, asked for the patient's first name and chief complaint. The employee then proceeded to tell the patient that the ED was really busy, and the patient could drive down the street to a care center. PT1 stated [he/she] drove down to the care center, which was closed, and then returned to the ED. PT1 stated the same employee asked the patient to sit in the waiting area, and said [he/she] would see if there was a nurse that could come out and look at the patient. The patient subsequently eloped, as [he/she] felt [he/she] would not get help. 2. A review of the Titusville Area Hospital Emergency Department Log for the time period February 1, 2016, through August 9, 2016, revealed patients who left against medical advice (AMA), patients who eloped and patients who left prior to the visit being completed/before seeing a physician. There were no patients identified as having left prior to being triaged and/or registered. The review further revealed no documentation that PT1 had presented for either of the alleged visits on July 30, 2016. 3. During an interview on July 10, 2016, at approximately 1:20 PM, EMP6 confirmed that it was very busy on July 30, 2016. EMP6 confirmed that it is possible for a patient to present to the Emergency Department, leave before being triaged and not be entered into the ED registration log. EMP6 further stated, "We wouldn't know if someone left. If we see someone leaving we try to catch them. If a patient is not triaged, we will not have record of them. ..." 4. On August 10, 2016, at approximately 2:58 PM, when asked if [he/she] recalled anyone on July 30, 2016, who presented to the ED twice, leaving both times without being seen for care, EMP10 stated, "No. There were a lot of people in and out." Cross reference: 489.20(r)(3)