Jackson-Madison County General Hospital

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking care were provided appropriate medical treatment and monitoring for 1 of 5 (Patient #3) sampled patients. The findings included: 1. Review of the hospital’s Medical Screening Examination (MSE) policy last revised 10/2024 revealed, “...All individuals presenting to a Hospital ED or other hospital property requesting examination or treatment are entitled to receive an appropriate MSE performed by qualified individuals to determine whether or not an Emergency Medical Condition exists...PROCEDURE: Any individual presenting to the ED or other Hospital property and requesting emergency care will receive an MSE within the capabilities of the Hospital’s ED to determine whether or not and Emergency Medical Condition exists. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and the ED...Qualified Medical Persons: Qualified Medical Persons (QMPs) will conduct MSEs in the ED...The MSE will determine, within reasonable medical probability, whether a person presenting to the Hospital requesting an examination or treatment is suffering from an Emergency Medical Condition. The MSE will be performed in accordance with standard protocols established by the ED...as appropriate and approved by the Medical Staff...” Review of the hospital’s “Triage Process” policy revised 11/2024 revealed, “Purpose: To provide guidelines to Emergency Department (“ED”) staff regarding triaging patients in order to evaluate each ED patient and establish the priority of care...Policy: The Triage at [named Hospital #1] is designed to ensure the patients presenting to the ED are seen promptly by a registered nurse who has, at minimum, one year of Emergency Department experience ...and has completed ESI [emergency severity index] training...The Triage RN also assures initiation of necessary treatment protocols. The triage assessment is not the equivalent of a Medical Screening Examination...The triage nurse determines the order in which patients will be seen in the ED based on ESI acuity and clinical presentation Procedure: Patient Triage Classification...Upon arrival patients will present to the registration/triage desk where the Patient’s name, date of birth, and presenting complaint are recorded by the Registration Clerk. The Triage Nurse will then review the list of patients obtained by the Registration Clerk and complete Triage assessment on those patients based on acuity as determined by the patient’s presenting complaint. Classifications for purposes of triage assessment include...ESI level 3 - Patients in this category have conditions that could potentially progress to a serious problem requiring emergency intervention. Patients who are ESI level 3 will be expected to use 2 or more resources according to the ESI severity category. A QMP will perform a Medical Screening Examination to determine the existence of an Emergency Medical Condition. ESI level 4- Patients in this category have conditions that related to patient age, or potential deterioration/complications would benefit from intervention or reassurance...ESI level 4 will be expected to use only one resource. A QMP will perform the medical Screening Examination to determine the existence of an Emergency Medical Condition...Patient Routing 1. A Qualified Medical Person as determined by the Hospital Medical Staff Rules and Regulations will evaluate the patient and provide a Medical Screen Exam (MSE). The triage from and ESI level assignment is completed in triage. 2. If no rooms are available in the ED, Triage Protocol orders will be entered in the EMR by the triage nurse based on patient presenting complaint...5. Waiting room patients are monitored for decline or change in condition and changes communicated to the ED staff...Reassessment and Monitoring of Patients 1. All patients/families waiting will be instructed to inform Triage Nurse of any changes in the condition or status of patient while waiting for room assignment. Any change will be recorded in the patient medical record and appropriate interventions initiated. 2. The ED also utilizes a Nurse Liaison in the Waiting Area to round on patients/family. The Nurse Liaison will notify the triage nurse of any reported change of condition or complaint voiced. 3.Vital Signs will be reassessed while patients are in waiting room based on the patient’s acuity level. Leaving the ED Without Being Seen by a Physician 1. Waiting room patients are paged by last name as beds become available. If there is no answer when the patient is paged, the triage nurse should make at least 3 attempts to locate the patient via overhead page with time and results noted in the chart if possible. If there is no answer by the third attempt, the patient is noted to have left without being seen...The patient is classified as ‘Left Without Being Seen’ if the patient left ED prior to Medical Screening Exam...” 2. Medical record review revealed Patient #3 presented to the hospital’s ED via private vehicle on 12/27/2024 at 4:38 PM via private vehicle with complaint of fever and chills. A triage assessment was performed at 4:51 PM. There was no documentation Patient #1 was re-assessed or monitored by hospital staff after the triage assessment was performed at 4:51 PM. (Patient #1 was determined to be an ESI level 3 during triage, which required reassessment of vital signs at a minimum of every 4 hours). There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #3 was discharged from the ED on 12/27/2024 at 10:33 PM, when she was called 3 times and could not be located. The Nurse paging Patient #3 did not know she had been placed in a family room adjacent to the ED waiting room, and Patient #3’s family could not hear them calling for her to be taken to the ED. On 12/27/2024 at approximately 10:47 PM, another ED visit was created for Patient #3 when Patient #3’s daughter approached the triage area and asked why her mother had not been re-evaluated. Patient #3 was then triaged a second time on 12/27/2024 at 11:50 PM. Patient #3 received a MSE on 12/28/2024 12:47 AM, 8 hours 9 minutes hours after her initial presentation for treatment for fever and chills. Refer to A1104.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking care were provided appropriate medical treatment and monitoring for 1 of 5 (Patient #3) sampled patients. The findings included: 1. Review of the hospital’s Medical Screening Examinations (MSE) policy last revised 10/2024 revealed, “...All individuals presenting to a Hospital ED or other hospital property requesting examination or treatment are entitled to receive an appropriate MSE performed by qualified individuals to determine whether or not an Emergency Medical Condition exists...PROCEDURE: Any individual presenting to the ED or other Hospital property and requesting emergency care will receive an MSE within the capabilities of the Hospital’s ED to determine whether or not and Emergency Medical Condition exists. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and the ED...Qualified Medical Persons: Qualified Medical Persons (QMPs) will conduct MSEs in the ED...The MSE will determine, within reasonable medical probability, whether a person presenting to the Hospital requesting an examination or treatment is suffering from an Emergency Medical Condition. The MSE will be performed in accordance with standard protocols established by the ED...as appropriate and approved by the Medical Staff...” Review of the hospital’s “Triage Process” policy revised 11/2024, revealed, “Purpose: To provide guidelines to Emergency Department (“ED”) staff regarding triaging patients in order to evaluate each ED patient and establish the priority of care...Policy: The Triage at [named Hospital #1] is designed to ensure the patients presenting to the ED are seen promptly by a registered nurse who has, at minimum, one year of Emergency Department experience ...and has completed ESI [emergency severity index] training...The Triage RN also assures initiation of necessary treatment protocols. The triage assessment is not the equivalent of a Medical Screening Examination... The triage nurse determines the order in which patients will be seen in the ED based on ESI acuity and clinical presentation Procedure: Patient Triage Classification...Upon arrival patients will present to the registration/triage desk where the Patient’s name, date of birth, and presenting complaint are recorded by the Registration Clerk. The Triage Nurse will then review the list of patients obtained by the Registration Clerk and complete Triage assessment on those patients based on acuity as determined by the patient’s presenting complaint. Classifications for purposes of triage assessment include...ESI level 3 - Patients in this category have conditions that could potentially progress to a serious problem requiring emergency intervention. Patients who are ESI level 3 will be expected to use 2 or more resources according to the ESI severity category. A QMP will perform a Medical Screening Examination to determine the existence of an Emergency Medical Condition. ESI level 4- Patients in this category have conditions that related to patient age, or potential deterioration/complications would benefit from intervention or reassurance...ESI level 4 will be expected to use only one resource. A QMP will perform the medical Screening Examination to determine the existence of an Emergency Medical Condition...Patient Routing 1. A Qualified Medical Person as determined by the Hospital Medical Staff Rules and Regulations will evaluate the patient and provide a Medical Screen Exam (MSE). The triage from and ESI level assignment is completed in triage. 2. If no rooms are available in the ED, Triage Protocol orders will be entered in the EMR by the triage nurse based on patient presenting complaint...5. Waiting room patients are monitored for decline or change in condition and changes communicated to the ED staff...Reassessment and Monitoring of Patients 1. All patients/families waiting will be instructed to inform Triage Nurse of any changes in the condition or status of patient while waiting for room assignment. Any change will be recorded in the patient medical record and appropriate interventions initiated. 2. The ED also utilizes a Nurse Liaison in the Waiting Area to round on patients/family. The Nurse Liaison will notify the triage nurse of any reported change of condition or complaint voiced. 3.Vital Signs will be reassessed while patients are in waiting room based on the patient’s acuity level. Leaving the ED Without Being Seen by a Physician 1. Waiting room patients are paged by last name as beds become available. If there is no answer when the patient is paged, the triage nurse should make at least 3 attempts to locate the patient via overhead page with time and results noted in the chart if possible. If there is no answer by the third attempt, the patient is noted to have left without being seen...The patient is classified as ‘Left Without Being Seen’ if the patient left ED prior to Medical Screening Exam...” 2. Medical record review revealed Patient #3, an 85-year-old female, presented to the hospital’s ED on 12/27/2024 at 4:38 PM via private vehicle with complaint of fever and chills. The ED triage notes revealed, “Pt [patient] presents...co [complains of] Leukemia pt fever starting today with highest temp of 103.7 [degrees Fahrenheit]...chills with temperature, waiting on room placement.” The triage nurse initiated a Respiratory viral panel via a nasopharyngeal swab at 4:48 PM. Triage was started at 4:51 PM, with vital signs recorded at 4:53 PM as: Temperature-102.2 degrees Fahrenheit, heart rate-92, Oxygen- 100%, respirations-18, blood pressure- 120/66. Patient #3 was assigned Acuity Level 3, with the triage destination of the waiting room. At 6:06 PM, the respiratory labs resulted negative for all respiratory illnesses tested. There were no further assessments or vital signs documented for Patient #3. At 9:46 PM, an ED bed was documented as available for Patient #3. At 9:53 PM, RN #4 documented room 25 was available. At 10:30 PM, RN #4 documented Patient #3 was OTF (off the floor). At 10:33 PM, RN #4 documented Patient #3 was discharged. There was no documentation RN #4 called for Patient #3 three times, per hospital policy. Patient #3 had no reassessment by nursing from 4:53 PM until 10:33 PM (over 5 hours), when RN #4 discharged Patient #3 from the system due to unable to locate Patient #3. (Patient #3 was in a family room adjacent the ED waiting area). Patient #3 did not have a medical screening exam provided, and the only service performed was a viral respiratory panel. There was no documented treatment for Patient #3’s fever during this ED visit. Medical review for Patient #3 revealed a second ED record on 12/27/2024. Patient #3’s presentation time to the ED was documented as 10:47 PM, 14 minutes after Patient #3 was discharged by RN #4. The arrival complaint was “medical issue”. Triage was started at 11:50 PM with vital signs recorded as: temperature 103.5 degrees Fahrenheit (1.3 degrees Fahrenheit higher than when Patient #3 was triaged at 4:53 PM, 6 hours 57 minutes earlier), heart rate- 95, oxygen- 97%, blood pressure-147/64. Patient #3 was assigned an acuity level 2 and labs were initiated for complete blood count (CBC- a routine blood test that measure the components of blood), comprehensive metabolic profile (CMP-blood test that measures multiple substances in the body to assess overall health and metabolism), lactic acid (measures the amount of lactic acid in the blood, and a chest x-ray. On 12/28/2024 at 12:29 AM, Patient #3 was administered Zofran (a medication to prevent nausea and vomiting) 4 milligrams (mg), 1 disintegrating tablet by mouth. The nurse documented Patient #3 vomited after administration of the medication. On 12/28/2024 at 12:30 AM, a peripheral intravenous (IV) line was placed. At 12:40 AM, blood culture specimens were collected. The MSE was initiated on 12/28/2024 at 12:47 AM, 8 hours 9 minutes after Patient #3’s initial presentation on 12/27/2024 at 4:38 PM, for complaints of fever and chills. Review of the Nurse Practitioner (NP) note revealed Patient #3 had a history of Acute Myeloid Leukemia and right breast cancer with concern of fever, weakness and nausea that started earlier today. The NP documented Patient #3 reported fever of 103.7 at 2:00 PM. The NP documented Patient #3 vomited once upon arrival to the emergency room and has noticed a decrease in urine output. Review of systems by the NP revealed Positive for activity change, appetite change, fatigue and fever. Positive for cough and shortness of breath. Positive for leg swelling. Positive for vomiting. Positive for decreased urine volume. The physical exam revealed “She is ill appearing...Decreased air movement...She is lethargic, easily aroused...” Patient #3 had a computed tomography (CT) of the chest abdomen and pelvis with impression documented as “CT chest demonstrates some mild diffuse interstitial prominence and parabronchial thickening (suggests mild thickening of the connective tissue and the walls around the airways, which can be a sign of inflammation or fluid accumulation)... Findings may be indicative of mild edema as seen in recent chest radiograph. The Chest Xray results revealed an enlarged heart, with some vascular engorgement and early edema. The NP documented, “No obvious source of infection (some labs still pending); will be admitted for neutropenic (condition characterized by an abnormally low number of neutrophils in the bloodstream) fever. Cultures/abx [antibiotics] ordered, hospitalist to admit.” Patient #3 was administered Toradol (anti-inflammatory medication used to treat pain) 30 mg IV at 1:50 AM for pain and Zofran 4 mg IV at 1:58 AM. Patient #3’s CMP resulted at 1:50 AM with glucose (measures amount of sugar in blood) 145 (normal range 65-105), sodium (measures concentration of sodium in blood) 133 (normal range 137-145) creatinine (measured to assess kidney function) 1.28 (normal range 0.52- 1.04) BUN ( measures the amount of urea nitrogen in the blood) 20 (normal range 7-17) AST (aspartate aminotransferase measures the level of an enzyme found primarily in the liver ) 94 (normal range 14-36) ALT (measures alanine aminotransferase in the blood. ALT is an enzyme primarily found in the liver. Elevated ALT levels can indicate liver damage or disease) 60 (normal range less than 35). Patient #3’s CBC resulted at 2:37 AM with critical values for white blood cells- 0.5 (measures the total number of leukocytes in your blood, helping to assess your immune system’s health and detect potential infections or other condition-normal range 4.8-11.0) and platelets- 11(measures for blood clotting normal range 140-440). Patient #3 was administered Tylenol (medication used to treat pain and reduce fever) 650 milligrams orally at 3:13 AM. Patient #3 was administered Zosyn (an antibiotic used to treat infections) 3.375 grams in Sodium Chloride IV at 4:45 AM. On 12/28/2024 at 6:10 AM, Patient #3 was admitted to Hospital #1’s oncology floor in stable condition. Review of Patient #3’s History and Physical dated 12/28/2024 revealed, “...Plan: Maintain patient in telemetry monitor for electrolyte derangements. Pan cultured (the practice of obtaining microbiological cultures; blood, urine, sputum, stool from a patient, often in response to a fever or suspected infection) in the ER. Continue empiric IV vancomycin and cefepime (IV antibiotics) for fever and neutropenia. Receives blood transfusions and platelets every Monday and platelets on Thursday. Neutropenia/leukopenia and platelet count seemed to be at baseline...” Review of the physician discharge note dated 12/28/2024 revealed, “Spoke with daughter who is POA [power of Attorney] and agreed to transition to CMO [comfort measures only]; also stated would like home with hospice setup if patient is stable enough. SW [social work] CM [case management] consulted...paged by nursing this afternoon that patient had expired...” During an interview on 3/31/2025 at 2:28 PM, the Assistant ED Nursing Director was asked how Patient #3 was monitored while she waited for over 8 hours for a medical screening exam. The Assistant ED Nursing Director verified there were no other vital signs documented after the triage assessment on 12/27/2024 at 4:53 PM. The Assistant ED Nursing Director stated, “They should have re-checked vital signs...I do not see that for this patient.” During an interview on 3/31/2025 at 2:40 PM, the Registered Nurse (RN) Clinical Manager provided the survey team with a copy of ED staff training dated 4/12/2024, which outlined the re-assessment requirements for patients in the ED waiting room. The RN Clinical Manager stated “This is what we follow, patients with triage level 2 should have vital signs and be re-assessed every 2 hours, all triage level 3, 4 and 5 should have vital signs and be re-assessed every 4 hours. The RN Clinical Manager verified Patient #3 was not re-assessed according to the nurse training requirements from 4/12/2024. During a telephone interview on 4/1/2025 at 10:00 AM, Patient #3’s daughter stated Patient #3 was taken to Hospital #1’s ED on 12/27/2024 for fever with a history of Leukemia. Patient #3’s daughter stated after triage Patient #3 was placed in Family Room #1; Patient #3’s daughter described where Family Room #1 was located near the ED waiting room. Patient #3’s daughter stated the traige nurse swabbed her mother and did not give any medication or draw any blood for lab work. Patient #3’s daughter stated after 2 hours she requested her mother be reassessed, but she was told by the nurses at the desk, they reassess after 4 hours. Patient #3’s daughter stated at the 4-hour mark, the family again requested reassessment for Patient #3. Patient #3’s daughter stated she was told by triage staff that Patient #3 would be getting the next room, but the nurses did not reassess her mother. Patient #3’s daughter stated after 6 hours, she again requested someone reevaluate Patient #3 because she seemed to be getting worse, had vomited and her breathing was becoming more labored, but the triage staff refused to reevaluate her mother. Patient #3’s daughter stated by hour 7, her mother was no longer coherent, and her breathing was very labored and she then requested a supervisor. Patient #3’s daughter stated a female charge nurse approached her and apologized for the delay stating the ED had been very busy, and at that time her mother was taken back for evaluation. During an interview on 4/1/2025 at 11:15 AM, RN #2, a triage nurse working in the ED on 4/1/2025, stated the 2 family rooms adjacent to the ED waiting room were used for families of a deceased ED patient to wait in privacy to speak with a physician, or for ED patients who present that were deemed immunocompromised. RN #2 stated immunocompromised patients were placed in a family room to protect then from other patients in the ED waiting room who may have COVID or Flu. RN #2 stated the nurse who assigned the patient in a family room would make a note on the tracker board so all ED staff would know where to locate the patient. RN #2 then pulled up the electronic ED tracker board and demonstrated where she would add a note if a patient was in a family room. During an interview on 4/1/2025 at 11:22 AM, the Assistant ED Nursing Manager stated due to a shortage, there was no nurse liaison working in the ED in December 2024. The Assistant ED Nursing Manager stated it would have been triaging nurse responsibility to re-assess and take vital signs for Patient #3 while she waited for a room in the ED. During an interview on 4/1/2025 at 11:34 AM, the Director of Clinical Risk stated RN #5, who worked as ED Charge Nurse on 12/27/2024 from 7:00 PM to 7:00 AM, was on leave all week and unavailable for interview. During an interview on 4/1/2025 at 11:40 AM, RN #1 verified he was working as the Charge Nurse in the ED on 12/27/2024 from 7:00 AM- 7:00 PM. RN #1 stated he did not recall Patient #3, nor did he provide care to Patient #3. RN #1 stated the family rooms in the ED waiting area were used for ED Patients who were immunocompromised, or for families of a deceased patient in the ED for medical staff to meet with those families privately. RN #1 stated based on the review of Patient #3’s medical record, her diagnosis of cancer, fever and age would prompted staff to place her and her family in a family room, instead of the main ED waiting area. When asked how a patient presenting with a history of leukemia, recent blood transfusions and a fever would be evaluated, RN #1 stated, “We have a fever sepsis protocol.” RN #1 stated the fever/sepsis protocol included initiating a CBC, CMP, lactic acid and administering Ibuprofen to treat the fever. RN #1 verified this protocol was not initiated for Patient #3. RN #1 verified there were no other vital signs documented after the triage vitals. During an interview on 4/1/2025 at 12:40 PM, the Assistant ED Nursing Director verified the ED Medical Director had developed protocol for fever/sepsis for nursing staff to follow to initiate labs and testing. The Assistant ED Nursing Director stated a CBC, CMP, Lactic acid, Chest X-ray and administering Ibuprofen tablet 600 milligram (mg) one dose for fever was the approved protocol. The Assistant ED Nursing Director provided an example printout of the approved protocols for fever/sepsis to the survey team. The Assistant ED Director verified for Patient #3 on 12/27/2024, the triage nurse did not initiate the physician approved protocol. The Assistant ED Nursing Director stated, “I agree they didn’t follow protocols in this particular time, I know we were busy...she [Patient #3] met sepsis criteria...” The Assistant ED Nursing Director stated if she were the triage nurse, she would have initiated the protocol based on Patient #3’s presentation. During a telephone interview on 4/1/2025 at 12:45 PM, Nurse Practitioner #1 stated she did not recall specifically Patient #3. Nurse Practitioner #1 stated she had looked at the medical record, and Patient #3 was admitted to the hospital based on her fever and history of Leukemia. Nurse Practitioner #1 stated she did not recall Patient #3’s family sharing any complaints about the care received in the ED prior to her evaluation of Patient #3. During an interview on 4/1/2025 at 1:00 PM, the Vice President (VP) of Operations/ED Nursing Director stated the expectation for documentation for patients that left without being seen was to call the patient overhead 3 times and document the times the patient was called with no response. The VP Operations/ED Nursing Director stated with the previous electronic medical record (EMR) system, the practice was to write the three attempts to call a patient for a room on the ED patient’s face sheet, then the face sheet would be scanned into the EMR. The VP Operations/ED Nursing Director stated for Patient #3 on 12/27/2024, there was no face sheet scanned into the EMR. The VP Operations/ED Nursing Director stated with the new EMR system nursing staff had been encouraged to document in their notes the three attempts to call an ED patient. The VP Operations/ED Nursing Director stated, “What probably happened was [Patient #3] was in the family room and didn’t hear the name called, and the nurse thought the patient had left without being seen and put OTF [off the floor] and discharged the patient.” The VP Operations/ED Nursing Director stated the staff then realized Patient #3 was in the family room and initiated a second ED visit with a completely new triage instead of cancelling the discharge and created a new ED record. The VP Operations/ED Nursing Director stated OTF meant an ED patient was off the floor in another area of the hospital, for example imaging, and was not the same as left without being seen. During an interview on 4/2/2025 at 10:20 AM, RN #3 verified he was working as a Triage Nurse in the ED on 12/27/2024 when Patient #3 presented for treatment. RN #3 stated he did not recall Patient #3 but he had looked at his notes prior to the interview. RN #3 stated Patient #3 had an elevated temperature, normal vital signs and was alert and oriented during his triage assessment. RN #3 stated “I would have asked the Patient to take a seat to the right in the ED waiting room if there was no available bed in the ED.” When asked if he took Patient #3 to the family room adjacent the ED waiting room, RN #3 stated he did not. RN #3 stated he did not know who assisted Patient #3 to a family room. RN #3 was asked what care, or treatment would be initiated by nursing, based on approved protocols for a patient presenting with fever, history of cancer and elderly. He stated, “we have some order sets...but for her I did a respiratory panel...her vitals were great.” When asked about the reassessment for patients in the ED waiting room, RN #3 stated Patient #3 was a level 3, so vital signs should be checked every 4 hours. RN #3 stated he had never put a patient in one of the family rooms to wait for a bed in the ED. RN #3 stated he went off shift at 7:00 PM, about 2 hours after Patient #3 was triaged and put in the ED waiting area. When asked about medication to address Patient #3’s temperature, RN #3 stated no medication was administered. During an interview on 4/2/2025 at 11:00 AM, RN #4 verified he came on shift at 7:00 PM on 12/27/2024 as a triage nurse in the ED. When asked if he recalled caring for patient #3 he stated, “I remember the scenario ...RN #3 made me aware of the patient, I did not know she was in a family room.” RN #4 stated when an ED room was available at 9:46 PM, he paged overheard for Patient #3. He stated a tech would have also walked in the ED waiting room to help locate the patient. RN #4 stated Patient #3 did not respond to the pages/call for ED room. RN #4 stated he called for the patient 3 times and thought Patient #3 had left without being seen, so he moved her to OTF status in the EMR. RN #4 stated OTF meant “off the floor”. RN #4 stated he moved her to that status because he was busy, and he could then go back and discharge the patient when time allowed. RN #4 verified he discharged Patient #3 from the ED in the EMR on 12/27/2024 at 10:33 PM. RN #4 stated, “I didn’t know Patient #3 was in a family room ...” RN #4 stated Patient #3’s daughter then approached the desk and was upset because her mother had not been treated. RN #4 stated at that time Patient #3 was put back into the system and triaged again. RN #4 verified Patient #3 never left the hospital ED but was in a family room and unable to hear them calling for her. RN #4 verified patients with an acuity level 3 were to be reassessed every 4 hours. RN #4 verified Patient #3 was assessed during triage at 4:53 PM and was not reassessed until she was put back into the ED log and had a triage assessment on 12/27/2024 at 11:50 PM, 7 hours later. RN #4 verified there was a fever/sepsis protocol nurses could initiate. RN #4 verified he initiated the fever/sepsis protocol on 12/27/2024 at 11:54 PM including a chest Xray, lactic acid, CBC and CMP. RN #4 verified he had used the family room in the past as a triage nurse for patient placement. RN #4 stated the process was to put on the tracker board a patient was in a family room so all ED staff would be able to locate a patient. RN #4 stated ED techs also had the capability to enter on the tracker board, if an ED tech moved a patient to a family room. RN #4 stated Patient #3 was not identified as being in a family room on the ED tracker.”

“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: 35244 Based on policy review, document review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients. The findings included: Review of the facility’s “ED (Emergency Department) STANDARDS OF CARE” document (July 2020) revealed, “...The triage system is based on the 5 level Emergency Severity Index (ESI) ...emergency room nurse triages each patient to obtain pertinent and objective data while providing physical, emotional and psychosocial support for the patient ...VITAL SIGNS ...ESI 4: reassessed per acuity and clinical assessment but no less frequently than four (4) hours...” Medical record review revealed Patient #1 presented to the hospital’s ED via private vehicle on 1/29/2024 at 8:30 PM with complaint of hearing loss. A triage assessment was performed at 8:40 PM. There was no documentation Patient #1 was re-assessed or monitored by hospital staff after triage assessment was performed at 8:40 PM. (Patient #1 was determined to be an ESI level 4 during triage, which required reassessment of vital signs at a minimum of every 4 hours). There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1’s total time in the ED from arrival to being determined Left Without Being Seen (LWBS) was 6 hours. Refer to A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) 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 (b) 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) Nonapplicability of provisions of this section. Sanctions under this section for inappropriate transfer during a national emergency 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 located in an emergency area, as specified in section 1135(g)(1) of the Act. 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 for by 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: 35244 Based on policy review, document review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients. The findings included: 1. Review of the facility’s “TRIAGE PROCESS” policy (August 2022) revealed, “ ...Classifications for purposes of triage assessment include... ESI [Emergency Severity Index] level 4 - Patients in this category have conditions that, related to patient age, distress or potential for deterioration/complications would benefit from intervention or reassurance. Patients who are ESI level 4 will be expected to use only one resource. A QMP [Qualified Medical Provider] will perform a Medical Screening Examination to determine the existence of an Emergency Medical Condition ...Waiting room patients are monitored for decline or change in condition and changes communicated to the ED staff ...Leaving the ED Without Being Seen by a Physician ... Waiting room patients are paged by last name as beds become available. If there is no answer when the patient is paged, the triage nurse should make at least 3 attempts to locate the patient ...If there is no answer by the third attempt, the patient is noted to have left without being seen... The patient is classified as “Left Without Being Seen” if the patient left ED prior to Medical Screening Exam...” 2. Review of the facility’s “ED (Emergency Department) STANDARDS OF CARE” document (July 2020) revealed, “...The triage system is based on the 5 level Emergency Severity Index (ESI) ...emergency room nurse triages each patient to obtain pertinent and objective data while providing physical, emotional and psychosocial support for the patient ...VITAL SIGNS ...ESI 4: reassessed per acuity and clinical assessment but no less frequently than four (4) hours...” 3. Medical record review revealed Patient #1 presented to the hospital’s ED via private vehicle on 1/29/2024 at 8:30 PM with complaint of hearing loss. A triage assessment was performed at 8:40 PM and revealed, “Chief Complaint Description: onset x [times] 1 year with “muffled hearing” and has seen ENT [Ear Nose Throat] and had done round of abx [antibiotics] with no improvement/also reorts [reports] anxiety ...” Triage vital signs revealed Temperature 98.1 degrees Fahrenheit, Respirations 20, Heart Rate 100, Blood Pressure 138/87, Oxygen Saturation 97%. Functional pain scale documented, “No pain”. Patient #1 was assigned Tracking acuity (ESI) of 4. Patient #1’s lab work, including a Comprehensive Metabolic Profile (CMP; a blood test that measures the body’s fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) and Complete Blood Count (CBC; a blood test that looks at conditions including anemia, infection and leukemia) was collected at 1:00 AM on 1/30/2024, 4.5 hours after arrival to the ED. White Blood Cell count was 11.5 (normal range between 4.8 and 11.0). Depart Documentation revealed, “Patient left ED: 01/30/24 02:30 [2:30 AM] ...attempt to call pt [patient] x3 with no response ...” Discharge Disposition documented as “Left Without Being Seen” There was no documentation Patient #1 was re-assessed or monitored by hospital staff after triage assessment was performed at 8:40 PM. (Patient #1 was determined to be an ESI level 4 during triage, which required reassessment of vital signs at a minimum of every 4 hours). There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1’s total time in the ED from arrival to being determined Left Without Being Seen (LWBS) was 6 hours. In an interview on 3/5/2024 at 11:37 AM, the Executive Director of the Emergency Department verified any reassessment vital signs, would be found in the flowsheet section of the record. The Director verified the triage assessment vital signs were the only vital signs documented in the record.”