Flagstaff Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to assess 10 out of 20 patients who presented to the Emergency Department (ED), per the hospital’s policies and procedures, that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases. This deficient practice poses a risk to the health and safety of patients if the patient’s condition starts to deteriorate and goes unnoticed while waiting for care in the ED. Findings include: Hospital policy titled, “Northern Arizona Healthcare Emergency Departments,” revealed: “ ...Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....Scope of Services ...a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity (see reassessment guideline below). The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing (see reassessment guideline below), planning, implementing and evaluating all nursing care performed for that patient. i. Admissions are subject to patient evaluation by ED Physicians and based on admission criteria determinate by ED Physician and accepting hospitalist Physician group ....b. Pediatric (ages 17 years of age or younger) assessment must be performed specific to the patient’s age, weight, and developmental stage....All patients need to have discharge vital signs within 30 minutes....Other staff responsibilities: i. The Emergency Department provides continuity of patient care through the integration of hospital services performed by ancillary departments and nursing units within the hospital. ii. Nursing services are provided to emergency patients include the (nursing) assessment ....Assessment & Reassessment Guidelines: The ED provides evaluation and treatment to patients of various ages and varying levels of illness from minor to critical. All patients presenting to the facility, requesting emergency treatment, are medically screened by appropriate individuals. The ED patients are then evaluated for response to treatment and are admitted to the hospital transferred for further necessary treatment not provided by the facility, or discharged with follow-up instructions as appropriate ....A. Vital Signs & Re-Assessment Documentation in Triage/Waiting Room Areas ...a. ESI Level 2: A set of vital signs should be reassessed at least every 1 hour until brought back to an ED bed. b. ESI Levels 3, 4, & 5: A set of Vital signs, should be reassessment at a minimum of every 3 hours until brought back to an ED bed. B. ED Bed Assigned Patients - Vital Signs Re-assessment Documentation ...a. ESI Level 1: Vital signs documented minimum - every 5-15 minutes for first 2 hours. i. Then minimum every 30 to 60 minutes if clinically stable*. b. ESI Level 2: Vital signs documented minimum - every 15 to 30 minutes for the first 2 hours ...i. Then a minimum of every hour if clinically stable*. ii. For patients with isolated psychologic/social complaints: vital signs should be reassessed no less frequently than every 1 hour for the first 4 hours, then every 6 hours if clinically stable*. c. ESI Level 3: Vital signs documented a minimum every 3 hours if clinically stable. d. ESI Level 4 & 5: Vital signs documented a minimum - every 3 hours ...*Clinically Stable defined: Vital signs in the initial 3 hours show improvement or minor change from the initial presentation ....” Patient #3’s medical record revealed they arrived at the Emergency Department (ED) on 08/07/2025 at 10:25, triaged at 10:41 with emergency severity index (ESI) of 3, received medical screening examination at 20:15, and admitted to intensive care unit (ICU) at 23:12. Patient #3’s medical record dated 08/07/2025 identified a physician note titled, “FMC ER Report,” and it revealed: “ ...Time Seen: ...08/07/2025 20:15 ...PMHx of daily alcohol use, who presents to the ED for jaundice, abdominal bloating, and feeling “foggy.” ...used to be a very heavy daily drinker ...not sure how much ...was drinking daily, but that it was “a lot.” ...says that starting around 4 July ...began to cut back ...drinking but ...still having 1-2 shots a night or a beer ....says that over the last few days ...noticed ...belly was a bit more bloated than usual, but ...denies any significant pain. However today ...roommate noticed that (Patient #3) skin and eyes were very yellow and so they decided to come in ....Physical Exam ...Constitutional: ...Jaundiced ...Eyes: Scleral icterus ...Abdominal: Distended, +fluid wave ...Medical Decision Making ...On arrival patient was very mildly tachycardic, afebrile, normal blood pressure ...does have rather significant jaundice and scleral icterus ...also has some mild abdominal distention with a slight fluid wave ...Initial labs came back showing significant leukocytosis with a left shift ....INR was elevated at 3.6. Patient’s CMP concerning for acute decompensated liver failure with hepatorenal syndrome and severe hyponatremia ...MELD score calculates 46, giving a 71% 3-month mortality. I ordered the patient a 0.9% NS bolus, and albumin. A RUQ US was ordered. I spoke with ...nephrology ...recommended giving just the 500cc of NS, and then rechecking BMP ....Ultrasound showed significant hepatomegaly and cirrhosis with only mild ascites. There is some gallbladder sludge and wall thickening, although this could all be related to ...liver failure ....At this time on ultrasound patient does not have an area of ascites that I could safely remove at bedside ....have a rather significant leukocytosis and so will get blood cultures and treat ...empirically ...with ceftriaxone ...I spoke with ...the admitting intensivist, who agreed to see and admit the patient ....” Patient #3’s medical record dated 08/07/2025 revealed after they were triaged at 10:25, next documented vital signs in the ED at 15:59, 18:52, and 23:00 before going to ICU. Review of additional 19 randomly selected ED medical records revealed nine (9) patients were not reassessed according to policies and procedures: 1. Patient #5 triaged on 08/14/2025 16:56 with ESI 4, no other documentation of vital signs, ED departure: LWBS at 21:03; 2. Patient #7 triaged on 08/30/2025 16:05 with ESI 2, MSE at 16:25, next documented vital signs at 19:04, 19:30, 20:00, 08/31/2025 02:00, 04:00, 06:23, 0800, ED departure: transferred at 08:45; 3. Patient #11 triaged on 09/27/2025 13:35 with ESI 2, MSE at 14:00, next documented vital signs at 15:17, ED departure: admit order placed 15:00; 4. Patient #12 triaged on 10/06/2025 14:18 with ESI 3, no other documentation of vital signs, ED departure: LWBS at 19:27; 5. Patient #13 triaged on 10/08/2025 12:32 with ESI 2 for suicidal ideation, MSE at 15:25, next documented vital signs at 15:30, ED departure: transferred on 10/09/2025 09:43; 6. Patient #14 triaged on 10/15/2025 08:03 with ESI 3, MSE at 09:50, next documented vital signs at 13:57, ED departure: home at 14:21; 7. Patient #18 triaged on 11/19/2025 13:36 with ESI 2, MSE at 14:03, next documented vital signs at 15:40, ED departure: admit order placed 15:34 8. Patient #19 triaged on 11/03/2025 10:51 with ESI 3, MSE at 12:41, last documented vital signs at 15:45, ED departure: home at 18:03; 9. Patient #20 triaged on 11/29/2025 14:03 with ESI 3 for depression and anxiety, no other documentation of vital signs, ED departure: LWBS at 19:38; Employee #7 confirmed during an interview conducted on 12/01/2025 that the aforementioned patients were not reassessed according the facility’s policies and procedures.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to provide an appropriate medical screening examination (MSE) to four (4) out of 20 patients who presented to the Emergency Department (ED) for examination and treatment. This deficient practices poses the risk of patients leaving with an unrecognized emergency medical condition and may lead to death. Findings include: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Compliance,” revealed: “ ...Purpose: It is Flagstaff Medical Center’s practice to comply with the Emergency Medical Treatment and Labor Act (“EMTALA”) and related laws and requirements ....This guideline applies to the examination and treatment of persons who come to FMC’s dedicated Emergency Departments seeking examination and treatment for a medical condition ....Procedure: All hospital personnel must comply with EMTALA and related laws and requirements, including the following: 1. Registration and Triage: a. Registration: FMC personnel may follow reasonable registration processes for a person who comes to the dedicated Emergency Department and may have an emergency medical condition as long as the registration processes do not delay the person’s medical screening examination and necessary stabilizing treatment ....c. Triage: A registered nurse, nurse practitioner, physician assistant, or physician will conduct a triage examination to determine the order in which persons receive the medical screening examination. If the person must wait to receive a medical screening examination for an extended period of time, the registered nurse, nurse practitioner, physician assistant, or physician, or his or her designee, will periodically re-triage the person to determine whether the person should have a higher medical screening priority. 2. Medical Screening Examination ...a. General: FMC will provide a medical screening examination to any and all persons with a medical condition who come to the hospital’s dedicated Emergency Department ...regardless of the person’s financial status or ability to pay ....The purpose of the medical screening examination is to determine whether the person has an emergency medical condition. FMC will use any necessary ancillary services, such as laboratory and radiology services, that are routinely available at the hospital to complete the medical screening examination. The Emergency Department physician that is on duty is the qualified and responsible personnel to conduct the medical screening examination in the Emergency Department ....d. Documentation: Hospital personnel and the physician will document in the person’s medical record the medical screening examination offered or provided to that person ....3. Stabilizing Treatment ...a. General: If the medical screening examination demonstrates that the person has an emergency medical condition, FMC will provide stabilizing treatment within its capabilities to resolve the person’s emergency medical condition ...b. Documentation: FMC personnel and the qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency condition has been stabilized. Once the person is stabilized FMC may provide additional or continuing care, discharge the person home, transfer the person to another facility, or refer the person to a physician’s office or another facility as appropriate for additional or continuing care ....4. Transfer ...a. General: If the medical screening examination reveals that the person has an emergency medical condition, FMC may transfer the person to another hospital or facility that has the capability and capacity to provide additional stabilizing treatment to resolve the person’s emergency medical condition ....” Hospital policy titled, “Northern Arizona Healthcare Emergency Departments,” revealed: “ ...Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....Scope of Services ...a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity (see reassessment guideline below). The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing (see reassessment guideline below), planning, implementing and evaluating all nursing care performed for that patient. i. Admissions are subject to patient evaluation by ED Physicians and based on admission criteria determinate by ED Physician and accepting hospitalist Physician group ....b. Pediatric (ages 17 years of age or younger) assessment must be performed specific to the patient’s age, weight, and developmental stage ....Other staff responsibilities: i. The Emergency Department provides continuity of patient care through the integration of hospital services performed by ancillary departments and nursing units within the hospital. ii. Nursing services are provided to emergency patients include the (nursing) assessment ....Assessment & Reassessment Guidelines: The ED provides evaluation and treatment to patients of various ages and varying levels of illness from minor to critical. All patients presenting to the facility, requesting emergency treatment, are medically screened by appropriate individuals. The ED patients are then evaluated for response to treatment and are admitted to the hospital transferred for further necessary treatment not provided by the facility, or discharged with follow-up instructions as appropriate ....A. Vital Signs & Re-Assessment Documentation in Triage/Waiting Room Areas ...a. ESI Level 2: A set of vital signs should be reassessed at least every 1 hour until brought back to an ED bed. b. ESI Levels 3, 4, & 5: A set of Vital signs, should be reassessment at a minimum of every 3 hours until brought back to an ED bed. B. ED Bed Assigned Patients - Vital Signs Re-assessment Documentation ...a. ESI Level 1: Vital signs documented minimum - every 5-15 minutes for first 2 hours. i. Then minimum every 30 to 60 minutes if clinically stable*. b. ESI Level 2: Vital signs documented minimum - every 15 to 30 minutes for the first 2 hours ...i. Then a minimum of every hour if clinically stable*. ii. For patients with isolated psychologic/social complaints: vital signs should be reassessed no less frequently than every 1 hour for the first 4 hours, then every 6 hours if clinically stable*. c. ESI Level 3: Vital signs documented a minimum every 3 hours if clinically stable. d. ESI Level 4 & 5: Vital signs documented a minimum - every 3 hours ...*Clinically Stable defined: Vital signs in the initial 3 hours show improvement or minor change from the initial presentation ....” Patient #3’s medical record revealed they arrived at the Emergency Department (ED) on 08/07/2025 at 10:25, triaged at 10:41 with emergency severity index (ESI) of 3, received medical screening examination at 20:15, and admitted to intensive care unit (ICU) at 23:12. Patient #3’s medical record dated 08/07/2025 1041 identified an Emergency Department (ED) ED triage note, and it revealed: “ ...Chief Complaint: Bloating and SOB, “foggy Headed”, Pt jaundiced with firm ABD. Daily ETOH ...BP Systolic: 128 mmHg ...BP Diastolic: 73 mmHg ...Heart Rate: 108 bpm ...Respiratory Rate: 20 br/min ...Acuity ...3 - Urgent FMC ....” Patient #3’s medical record dated 08/07/2025 identified a physician note titled, “FMC ER Report,” and it revealed: “ ...Time Seen: ...08/07/2025 20:15 ...PMHx of daily alcohol use, who presents to the ED for jaundice, abdominal bloating, and feeling “foggy.” ...used to be a very heavy daily drinker ...not sure how much ...was drinking daily, but that it was “a lot.” ...says that starting around 4 July ...began to cut back ...drinking but ...still having 1-2 shots a night or a beer ....says that over the last few days ...noticed ...belly was a bit more bloated than usual, but ...denies any significant pain. However today ...roommate noticed that (Patient #3) skin and eyes were very yellow and so they decided to come in ....Physical Exam ...Constitutional: ...Jaundiced ...Eyes: Scleral icterus ...Abdominal: Distended, +fluid wave ...Medical Decision Making ...On arrival patient was very mildly tachycardic, afebrile, normal blood pressure ...does have rather significant jaundice and scleral icterus ...also has some mild abdominal distention with a slight fluid wave ...Initial labs came back showing significant leukocytosis with a left shift ....INR was elevated at 3.6. Patient’s CMP concerning for acute decompensated liver failure with hepatorenal syndrome and severe hyponatremia ...MELD score calculates 46, giving a 71% 3-month mortality. I ordered the patient a 0.9% NS bolus, and albumin. A RUQ US was ordered. I spoke with ...nephrology ...recommended giving just the 500cc of NS, and then rechecking BMP ....Ultrasound showed significant hepatomegaly and cirrhosis with only mild ascites. There is some gallbladder sludge and wall thickening, although this could all be related to ...liver failure ....At this time on ultrasound patient does not have an area of ascites that I could safely remove at bedside ....have a rather significant leukocytosis and so will get blood cultures and treat ...empirically ...with ceftriaxone ...I spoke with ...the admitting intensivist, who agreed to see and admit the patient ....” An additional 19 ED medical records were randomly selected for review including patients who were transferred, admitted, discharged home, and left without being seen (LWBS). Further review of patients who LWBS revealed three (3) out of three (3) patients did not receive nursing reassessment and medical screening examination (MSE): 1. Patient #5 arrived 08/14/2025 16:16 for tinging in hands, triaged at 16:56 with ESI 4, no documentation of nursing reassessment, no documentation of MSE, ED deposition as LWBS at 21:03, time elapsed from arrival: four hours and 47 minutes; 2. Patient #12 arrived 10/06/2025 14:04 for emesis and weakness, triaged at 14:18 with ESI 3, no documentation of nursing reassessment, no documentation of MSE, ED disposition as LWBS at 19:27, time elapsed from arrival: five hours and 23 minutes; 3. Patient #20 arrived 11/29/2025 13:33 for depression and anxiety, triaged at 14:03 with ESI 3, no documentation of nursing reassessment, no documentation of MSE, ED disposition as LWBS at 1938, time elapsed from arrival: six hours and five minutes; Employee #7 confirmed during an interview conducted on 12/01/2025 that Patients #5, #12, and #20 did not receive nursing reassessment and medical screening examination. Employee #7 confirmed Patient #3 did not receive continued monitoring prior to waiting nearly 10 hours before being evaluated by physician. Employee #7 confirmed Patient #3’s laboratory findings returned critical, and they had an emergency medical condition and was admitted to the intensive care unit (ICU).”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for 10 out of 20 patients, who presented to the Emergency Department (ED) seeking medical treatment. Failure to provide timely medical screening examination and treatment poses a potential risk that the patient’s condition deteriorates, and they do not receive life-saving medical treatment. Findings include: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Compliance,” revealed: “ ...Purpose: It is Flagstaff Medical Center’s practice to comply with the Emergency Medical Treatment and Labor Act (“EMTALA”) and related laws and requirements ....This guideline applies to the examination and treatment of persons who come to FMC’s dedicated Emergency Departments seeking examination and treatment for a medical condition ....Procedure: All hospital personnel must comply with EMTALA and related laws and requirements, including the following: 1. Registration and Triage: a. Registration: FMC personnel may follow reasonable registration processes for a person who comes to the dedicated Emergency Department and may have an emergency medical condition as long as the registration processes do not delay the person’s medical screening examination and necessary stabilizing treatment ....c. Triage: A registered nurse, nurse practitioner, physician assistant, or physician will conduct a triage examination to determine the order in which persons receive the medical screening examination. If the person must wait to receive a medical screening examination for an extended period of time, the registered nurse, nurse practitioner, physician assistant, or physician, or his or her designee, will periodically re-triage the person to determine whether the person should have a higher medical screening priority. 2. Medical Screening Examination ...a. General: FMC will provide a medical screening examination to any and all persons with a medical condition who come to the hospital’s dedicated Emergency Department ...regardless of the person’s financial status or ability to pay ....The purpose of the medical screening examination is to determine whether the person has an emergency medical condition. FMC will use any necessary ancillary services, such as laboratory and radiology services, that are routinely available at the hospital to complete the medical screening examination. The Emergency Department physician that is on duty is the qualified and responsible personnel to conduct the medical screening examination in the Emergency Department ....d. Documentation: Hospital personnel and the physician will document in the person’s medical record the medical screening examination offered or provided to that person ....3. Stabilizing Treatment ...a. General: If the medical screening examination demonstrates that the person has an emergency medical condition, FMC will provide stabilizing treatment within its capabilities to resolve the person’s emergency medical condition ...b. Documentation: FMC personnel and the qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency condition has been stabilized. Once the person is stabilized FMC may provide additional or continuing care, discharge the person home, transfer the person to another facility, or refer the person to a physician’s office or another facility as appropriate for additional or continuing care ....4. Transfer ...a. General: If the medical screening examination reveals that the person has an emergency medical condition, FMC may transfer the person to another hospital or facility that has the capability and capacity to provide additional stabilizing treatment to resolve the person’s emergency medical condition ....” Hospital policy titled, “Northern Arizona Healthcare Emergency Departments,” revealed: “ ...Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....Scope of Services ...a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity (see reassessment guideline below). The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing (see reassessment guideline below), planning, implementing and evaluating all nursing care performed for that patient. i. Admissions are subject to patient evaluation by ED Physicians and based on admission criteria determinate by ED Physician and accepting hospitalist Physician group ....b. Pediatric (ages 17 years of age or younger) assessment must be performed specific to the patient’s age, weight, and developmental stage ....Other staff responsibilities: i. The Emergency Department provides continuity of patient care through the integration of hospital services performed by ancillary departments and nursing units within the hospital. ii. Nursing services are provided to emergency patients include the (nursing) assessment ....Assessment & Reassessment Guidelines: The ED provides evaluation and treatment to patients of various ages and varying levels of illness from minor to critical. All patients presenting to the facility, requesting emergency treatment, are medically screened by appropriate individuals. The ED patients are then evaluated for response to treatment and are admitted to the hospital transferred for further necessary treatment not provided by the facility, or discharged with follow-up instructions as appropriate ....A. Vital Signs & Re-Assessment Documentation in Triage/Waiting Room Areas ...a. ESI Level 2: A set of vital signs should be reassessed at least every 1 hour until brought back to an ED bed. b. ESI Levels 3, 4, & 5: A set of Vital signs, should be reassessment at a minimum of every 3 hours until brought back to an ED bed. B. ED Bed Assigned Patients - Vital Signs Re-assessment Documentation ...a. ESI Level 1: Vital signs documented minimum - every 5-15 minutes for first 2 hours. i. Then minimum every 30 to 60 minutes if clinically stable*. b. ESI Level 2: Vital signs documented minimum - every 15 to 30 minutes for the first 2 hours ...i. Then a minimum of every hour if clinically stable*. ii. For patients with isolated psychologic/social complaints: vital signs should be reassessed no less frequently than every 1 hour for the first 4 hours, then every 6 hours if clinically stable*. c. ESI Level 3: Vital signs documented a minimum every 3 hours if clinically stable. d. ESI Level 4 & 5: Vital signs documented a minimum - every 3 hours ...*Clinically Stable defined: Vital signs in the initial 3 hours show improvement or minor change from the initial presentation ....” Patient #3’s medical record revealed they arrived at the Emergency Department (ED) on 08/07/2025 at 10:25, triaged at 10:41 with emergency severity index (ESI) of 3, received medical screening examination at 20:15, and admitted to intensive care unit (ICU) at 23:12. Patient #3’s medical record dated 08/07/2025 1041 identified an ED triage note, and it revealed: “ ...Chief Complaint: Bloating and SOB, “foggy Headed”, Pt jaundiced with firm ABD. Daily ETOH ...BP Systolic: 128 mmHg ...BP Diastolic: 73 mmHg ...Heart Rate: 108 bpm ...Respiratory Rate: 20 br/min ...Acuity ...3 - Urgent FMC ....” Patient #3’s medical record dated 08/07/2025 identified a physician note titled, “FMC ER Report,” and it revealed: “ ...Time Seen: ...08/07/2025 20:15 ...PMHx of daily alcohol use, who presents to the ED for jaundice, abdominal bloating, and feeling “foggy.” ...used to be a very heavy daily drinker ...not sure how much ...was drinking daily, but that it was “a lot.” ...says that starting around 4 July ...began to cut back ...drinking but ...still having 1-2 shots a night or a beer ....says that over the last few days ...noticed ...belly was a bit more bloated than usual, but ...denies any significant pain. However today ...roommate noticed that (Patient #3) skin and eyes were very yellow and so they decided to come in ....Physical Exam ...Constitutional: ...Jaundiced ...Eyes: Scleral icterus ...Abdominal: Distended, +fluid wave ...Medical Decision Making ...On arrival patient was very mildly tachycardic, afebrile, normal blood pressure ...does have rather significant jaundice and scleral icterus ...also has some mild abdominal distention with a slight fluid wave ...Initial labs came back showing significant leukocytosis with a left shift ....INR was elevated at 3.6. Patient’s CMP concerning for acute decompensated liver failure with hepatorenal syndrome and severe hyponatremia ...MELD score calculates 46, giving a 71% 3-month mortality. I ordered the patient a 0.9% NS bolus, and albumin. A RUQ US was ordered. I spoke with ...nephrology ...recommended giving just the 500cc of NS, and then rechecking BMP ....Ultrasound showed significant hepatomegaly and cirrhosis with only mild ascites. There is some gallbladder sludge and wall thickening, although this could all be related to ...liver failure ....At this time on ultrasound patient does not have an area of ascites that I could safely remove at bedside ....have a rather significant leukocytosis and so will get blood cultures and treat ...empirically ...with ceftriaxone ...I spoke with ...the admitting intensivist, who agreed to see and admit the patient ....” Patient #3’s medical record dated 08/07/2025 identified abnormal laboratory findings collected at 20:28, and they revealed: “ ...WBC H 28.3 (4.0-11.0) ...Abs Neutro Auto H 26.0 (1.8-8.0) ...PT H 39.9 (9.4-12.5) ...INR H 3.6 (0.8-1.1) ...Sodium C (sic)(critical) 104 (136-145) ...Potassium H 4.6 (3.4-4.5) ...Chloride L 75 (98-107) ...BUN H 41 (9-23) ...Creatinine H 3.4 (0.7-1.3) ...eGFR L 24 (>=60) ...Bili Total H 33.2 (0.3-1.2) ...Alk Phos H 408 (46-116) ...Albumin L 2.7 (3.2-4.8) ...ALT H 58 (10-49) ...AST H 123 (0-34) ...Lipase H 212 (12-53) ...Lactic Acid H 2.6 (0.5-2.2) ....” Review of additional 19 randomly selected ED medical records revealed nine (9) patients had a delay in examination or treatment: 1. Patient #2 arrived 08/04/2025 15:10 for right leg wound, triaged at 15:18 with ESI 3, MSE at 20:37, time elapsed from arrival: five hours and 27 minutes; 2. Patient #5 arrived 08/14/2025 16:16 for tinging in hands, triaged at 16:56 with ESI 4, no documentation of nursing reassessment, no documentation of MSE, ED deposition as LWBS at 21:03, time elapsed from arrival: four hours and 47 minutes; 3. Patient #7 arrived 08/30/2025 13:59 for left arm pain and swelling with history of liver transplant, triaged at 16:05 with ESI 2, MSE at 16:25, time elapsed from arrival: two hours and 26 minutes; 4. Patient #9 arrived 09/15/2025 13:52 for abdominal pain, triaged at 14:37 with ESI 3, MSE at 15:56, time elapsed from arrival: two hours and four minutes; 5. Patient #12 arrived 10/06/2025 14:04 for emesis and weakness, triaged at 14:18 with ESI 3, no documentation of nursing reassessment, no documentation of MSE, ED disposition as LWBS at 19:27, time elapsed from arrival: five hours and 23 minutes; 6. Patient #13 arrived 10/08/2025 12:23 for suicidal ideation, triaged at 12:32 with ESI 2, MSE at 15:25, time elapsed from arrival: three hours and two minutes; 7. Patient #14 arrived 10/15/2025 07:54 for cough, triaged at 08:03 with ESI 3, MSE at 09:50, time elapsed from arrival: one hour and 56 minutes; 8. Patient #19 arrived 11/03/2025 10:51 for left shoulder pain with history of clots, triaged at 11:06 with ESI 3, MSE at 12:41, time elapsed from arrival: one hour and 50 minutes; 9. Patient #20 arrived 11/29/2025 13:33 for depression and anxiety, triaged at 14:03 with ESI 3, no documentation of nursing reassessment, no documentation of MSE, ED disposition as LWBS at 1938, time elapsed from arrival: six hours and five minutes; Employee #7 confirmed during an interview conducted on 12/01/2025 Patient #3 waited in the ED waiting room for nearly 10 hours before being evaluated by a physician. Employee #7 confirmed Patient #3’s laboratory findings returned critical and they had an emergency medical condition. Employee #7 confirmed Patient #3 was admitted to the ICU less than three hours after their medical screening examination was initiated. Employee #1 confirmed the facility is taking actions to improve the time in which patients coming through the ED are seen by a physician. Employee #1 confirmed the facility has adopted the split flow model to speed up patient flow and reduce wait time in the ED. Employee #1 confirmed the ED does not utilize mid-level providers. Employee #1 confirmed the ED has at least two physicians 24 hours a day, and five physicians at peak times between 1300 through 2100.”