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Based on review of hospital surveillance video, staff interviews, medical record reviews, and facility policy and procedure, Greenwood Leflore Hospital failed to comply with 489.24. Specifically, the facility staff failed to immediately initiate emergency interventions for treatment of Patient #1's presenting complaints of respiratory distress for one (1) of 20 patient records reviewed (Patient #1).

Findings Include:

Registered Nurse (RN) #1 failed to initiate immediate interventions to Patient #1 who presented in respiratory distress. Instead, RN #1 directed Patient #1's mother, who was holding the patient in her arms, to the registration desk prior to triage or placement in the Emergency Department clinical area.

During the exit conference on 06/28/2024 at 12:33 p.m. with Chief Nursing Officer, Chief Financial Officer, Director of Quality Management, Vice President of Administrative Services, and Director of Accreditation, survey findings were discussed, and no further documentation was submitted for review.

Cross Refer to A-2406

Based on review of hospital surveillance video, staff interviews, medical record reviews, and facility policy and procedure, Greenwood Leflore Hospital failed to immediately initiate emergency interventions for treatment of Patient #1's presenting complaints of respiratory distress for one (1) of 20 patient records reviewed (Patient #1). The hospital's failure to immediately take Patient #1 to the Emergency Department (ED) clinical area for initiation and treatment of her presenting medical complaints upon arrival to the ED posed an immediate threat to the health and safety of Patient #1.

Findings Include:

A review of hospital video footage dated May 30, 2024, at 2208 hours showed Patient #1's mother arriving to the front of the hospital ED and entering the hospital with Patient #1 in her arms in a chest to chest holding position. Patient #1 was limp with no signs of muscle control. Patient #1's mother encounters a moment with Registered Nurse (RN) # 1, Triage Nurse, while a hospital Security Guard stands behind the mother and Patient #1 with a wheelchair. RN # 1 sends the mother and Patient #1 to the registration area. At 2211 hours the Security Guard escorts Patient #1 and her mother to the treatment area of the ER.

A hospital document titled "Nurse Notes" documented by Registered Nurse # 1 stated in entirety, "2211 presented to ER [Emergency Room] via Mothers arms Mother states that she was in the bath had an asthma attack and a seizure and can't breath (sic) wheezing and gurgling noted patient sat. [oxygen saturation] 50% [percent] on RA [room air] rushed to ER 1 via Mothers arms in w/c [wheelchair] patient naked except for towel breathing and tight/gurgling. Multiple staff to bedside working to apply monitors and start ivs [intravenous lines]. Child collapses at 1018 [2218 hours] and CODE called at 1018 [2218 hours]."

Medical record review of "Patient Agreement and Consent Form," dated May 30, 2024, for Patient #1 reveals a registration time of 2212 hours [10:12 p.m.]. There is a signature of Patient #1's mother and hospital employee name who administered the agreement documented on the consent form. This was three (3) minutes after arrival and prior to RN #1 or the Security Guard assisting the patient to the ED clinical area for treatment.

A hospital document titled "General Medicine (Pediatric) - Nurse Initial Assessment Note" dated May 30, 2024, at 2259 hours, documented by RN #3 states, "Constitutional Pt [patient] presents to the ER accompanied by mother for complaints of seizure/asthma attack - pt obtunded [dulled or reduced level of alertness or consciousness] on arrival, O2 50% at triage desk. Pt brought immediately to RM1 [room 1], ED staff and MD [medical doctor] at beside. Pt found to be pulseless. CPR/ACLS protocol initiated at this time."

A hospital document titled "General Medicine (Pediatric) - Provider Note" dated May 30, 2024, at 2306 hours documented by Medical Doctor #3, under the history of present illness, " ...This is a 7-year-old female who presents to the emergency room with her mother for altered mental status. The patient was apparently at home when she had a seizure and afterwards had some trouble breathing. The patient apparently came to her mother and said she was having a lot of difficulty breathing. The mother put the patient in the bathtub which did not help. Upon arrival to the emergency room the patient was minimally response. Apparently in triage she was moving a little bit. She was immediately brought to the emergency department. When I walked into the room the patient was not breathing. She did not have a pulse. We started CPR immediately and intubated the patient. She was PEA [pulseless electrical activity] on the monitor for the entire resuscitation. After about 30 minutes of CPR the patient was pronounced dead." Medical Doctor #3's physical examination findings documented Patient #1 had "Copious vomitus around the mouth and in the airway. Pupils fixed and dilated. Pulseless." Patient #1's time of death was recorded as May 30, 2024, at 2249 hours, with a preliminary cause of death documented as respiratory arrest.

Interview with Emergency Department (ED) Director on 06/25/2024 at 3:47 p.m. confirms patients presenting to the ED receive a quick triage assessment that consist of vital signs and complaint. They will then go to the registration department to register and return to the Triage Department to receive a full triage assessment and Emergency Severity Index (ESI) Level rating. Patients will then wait for their Medical Screening Examination (MSE). The ED Director also confirmed emergency medical treatment is provided for patients who present to the ED requiring immediate assistance such as cardiac arrest, respiratory arrest, and stroke signs and symptoms.

Interview on 06/26/2024 at 10:03 a.m. with Medical Doctor (MD) #2 confirms, when a patient walks through the door there is a triage nurse present to assess and determine if a patient is non-emergent/emergent. If non-emergent, the patient goes to registration. If the patient is emergent, they are brought immediately back to one of the rooms and the provider will take it from there so we can put orders in the system. MD #2 also said, if the ED is full, which frequently it is, the non-emergent patients are triaged per protocol and then they're brought back in the order of triage level.

Interview on 06/26/2024 at 2:28 p.m. with RN #3, confirmed when Patient #1 arrived, the mother was sitting in a wheelchair with Patient #1 in her lap and was taken to Emergency Room (ER) room one (1), our pediatric room. RN #3 said, the nurse that brought her around the corner said you know we need respiratory stat in ER room one (1). RN #3 stated, "I got up and called respiratory. I paged for them and told them that we had a pediatric patient that needed some attention. Several other staff members and I as well as Medical Doctor #3 got up and went into the room and saw the patient and that she was clearly not breathing, she was undressed, damp, and cold to the touch she was draped in a towel from home. We started CPR and put her on the monitor and called Code Blue."

An interview on 06/26/2026 at 2:43 p.m. with the Director of Emergency Services (DES) revealed she was not working on 05/30/2024, the night Patient #1 was brought to the ED. The DES said, if you are triaging, it's obvious if patient is stable, throwing up, having respiratory issues and breathing. If you are triaging a stable person, and a patient in obvious distress arrives you should end the triage and perform a brief assessment and determine distress, that patient should immediately be transferred to the back. She further said, in this incident the nurse didn't tend to the child, she leads them to registration and then takes dyna map to patient and measures oxygen saturation and gets a reading of 50% and then goes back to type on the computer. This incident happened on May 30, 2024, but I know the first and only meeting to identify the "root cause" was held yesterday, June 25, 2024, at 9:00 p.m. There has been no corrective action as far as I know except termination. I did reach out to our education provider for an Emergency Medical Treatment and Labor Act (EMTALA) training presentation. I have not yet heard a reply from them.

Interview on 06/26/2024 at 3:40 p.m. with the Director of Risk Management (DRM) confirms the facility performs a quick triage assessment prior to the registration process. After registration a full Triage Assessment is performed. The DRM also confirmed an internal investigation was performed after an incident that occurred on 05/30/2024 and there has not been a change in the ED registration process at this time.

Interview on 06/26/2024 at 4:11 p.m. with Chief Nursing Officer confirmed RN #1 was terminated from employment and was not available for interview.

Hospital policy titled "Admission Admitting Process" effective November 21, 2006, last revised October 17, 2023, stated the purpose was "To ensure patients are treated in an efficient and courteous manner and accurate receipt of patient information." Under the policy "Procedure" item six (6), letter "b." documented "Patients in acute distress or for whom any delay getting to the appropriate care unit would be detrimental, are transported immediately to the care unit and the Admissions process will be completed in the Admitting Department by a family member, ambulance transporter or by facsimile from the nursing unit if no family is available."

Review of the facility's, "Emergency Services Policy and Position Statement for Evaluating, Treating and Transferring Emergency Department Patients (EMTALA)," dated 10/21/2019, " ...To ensure the Hospital complies with the requirements ...and associated regulations ...Definitions ...Emergency Medical Condition ...A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in ...serious dysfunction of any bodily organ or part ...When an individual presents to the Emergency Department ...evaluation must be conducted in conformity ...established by Medicare guidelines ..."

Review of the facility's "Emergency Department Triage Classifications," last revised date 12/2019, " ...Ensure patients are properly classified after an assessment has been carried out by a registered nurse ...A registered nurse will be responsible for triaging all patients presenting to the Emergency department and classifying complaints or condition ...of the following classifications ...Class III-Emergent, include, but not limited to: Cardiopulmonary arrest, Airway obstruction...Security or the triage nurse takes the patient to the appropriate treatment room..."

Review of the facility's "Emergency Department Emergency Severity Index (ESI) Triage," last revision date 03/25/2022, "Purpose: To establish an appropriate triage system/process for use in establishing standardized criteria for the nursing staff in the triage role in assigning an appropriate triage level ...ESI Level 1: Those patients who require life-saving interventions. These patients are immediately placed in a treatment area ..."

Review of the facility's "Nursing Service Pediatric Code" policy, dated 05/2024, "Purpose...to provide life supporting treatments to pediatric patients experiencing cardiac or respiratory arrest ...Policy: Maintain procedures to ensure a Pediatric Code is initiated immediately upon noting a pediatric patient without discernible pulse and/or respiration ...Procedure: 1. A pediatric patient is defined as a patient 12 years old or less."

During the exit conference on 06/28/2024 at 12:33 p.m. with Chief Nursing Officer, Chief Financial Officer, Director of Quality Management, Vice President of Administrative Services, and Director of Accreditation, survey findings were discussed, and no further documentation was submitted for review.