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Based on observation, interview, and record review, the hospital failed to perform an initial triage (prioritization of patient care) assessment and a Medical Screening Examination (MSE) for a patient (1) who presented to the Emergency Department (ED) with chest pain.

As a result, Patient 1's acuity level (measure of a patient's severity of illness or medical conditions) and emergent medical condition was not determined, did not receive stabilizing treatment, and died.

Findings:

On 12/29/21 at 10:10 A.M., an investigation was initiated due to the hospital's self-reported incident of an unusual occurrence related to the death of a patient in the ED.

Per the hospital's Patient Information record, Patient 1 was a 68-year-old, male, who presented to the ED with chief complaints of chest pain and was registered as a patient on 12/17/21 at 8:46 A.M.

Per the record titled Final Report, dated 12/17/21 at 10:10 A.M., completed by the ED physician, Patient 1, while waiting for EKG (records the electrical signal from the heart to check for different heart conditions), became unresponsive, was found to be pulseless. This record also indicated that after one hour of CPR (lifesaving technique in many emergencies) time of death was called at 11:13 A.M., due to cardiac arrest (abrupt loss of heart function, breathing and consciousness).

On 12/29/21 at 11:30 A.M., an interview with the Manager for Regulatory Compliance and Accreditation (MRCA) was conducted. Additional records were requested for review, however, there was no ED timeline documentation found on Patient 1's electronic medical record. The MRCA confirmed there was no documentation to support Patient 1 was triaged or had received a medical screening examination in the ED.

On 12/30/21 at 9:45 A.M., an interview with the ED Charge Nurse (CN) was conducted. The CN stated when a patient arrived in the ED; a quick registration was completed, and the patient showed in the tracking system. The CN stated it was a busy day at the ED on 12/17/21 and she was not informed that Patient 1 came through the back door (ambulance bay) of the ED. The CN stated she became aware of Patient 1's condition when one of the correctional officers asked her to check on Patient 1 and was found to be pulseless and resuscitation efforts were performed.

On 12/30/21 at 10:05 A.M., the Access Management Representative (AMR) was interviewed. The AMR stated her role in the ED was to register patients when they arrive. The AMR stated Patient 1 came through the ambulance bay door brought in by two correctional officers with chief complaints of chest pain. The AMR stated she had registered Patient 1 into the system and looked for the CN. The AMR stated when she placed the registration band on Patient 1, he was cold and clammy and "looked bad". The AMR also stated she was not able to find the CN and went back to her task. The AMR acknowledged she had not utilized the ED radio and telephone for communication to the CN or any other clinical staff in the ED to report that Patient 1 was in the back of the ED and had chest pain.

A review of the AMR's transcript of annual training, this indicated that the AMR received training and education on Stroke, Low Blood Sugar and MI (Myocardial Infarction-heart attack).

On 12/30/21 at 10:28 A.M., an interview with the Manager for Patient Access (MPA) was conducted. The MPA stated it was her expectation that AMRs in the ED were able to utilize the ED radio or telephone for communication with the ED clinical staff.

On 12/30/21 at 1:20 P.M., a tour of the ED and a concurrent interview with the ED Director (EDD) was conducted. Patients came in through the front door, a triage team in a room was able to see the front door. A designated EKG room was available for patients who came in with chest pain via the main entrance. The EDD stated that patients arriving via the ambulance entrance with chest pain did not automatically go to the EKG room. The ambulance bay was towards the back of the ED. The registration room had a telephone and was close to the ambulance bay. An observation of where Patient 1 was kept was in a corridor alcove behind the triage area not in direct line of sight of ED clinical staff.

On 12/30/21 at 1:30 P.M., an interview with the EDD and the MD was conducted. Both the EDD and the MD had expectations that when patients arrived at the ED with chest pain, communication amongst all team members should have happened and not missed the triage process of Patient 1.

The hospital's policy titled Triage of Emergency Patients, dated 5/17, indicated, "...3. a. All patients presenting for treatment are assessed by a Registered Nurse, receive a first-tier triage assessment and are assigned an acuity level based on Emergency Severity Index...Emergency Severity Index Acuity Levels: Level 1: f. Chest pain..."

The hospital's policy titled EMTALA: Emergency Medical Screening, dated 4/17, indicated, "...3. Each patient seeking treatment in the ED is entitled to an emergency MSE..."