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Based on interview and document review it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the medical record failed to reflect continued monitoring until it was determined whether or not the patient had an Emergent Medical Condition to an individual seeking care in the Emergency Department for 1 of 35 patients (#7), see A 2406.

Based on document review and interview the facility failed to provide continued monitoring until it was determined whether the individual had an Emergent Medical Condition for one (#7) of thirty five patients, resulting in the potential for adverse patient outcomes. Findings include:

Medical Record Review Revealed:

Patient #7 was a 44-year-old female with history of hypertension & diabetes. Patient #7 began having chest pain in the evening of Friday 08/16/2019. She came to the Emergency Department (ED) Saturday evening/Sunday morning 08/17/2019 at 0124, Triage was documented at 0124 08/18/2019 with reported burning chest pain, assigned "level 2 Emergent". Patient #7 was documented as anxious, sweaty and nauseated.
Seen by ED physician staff L at 0130, orders written for: EKG, chest X-Ray, Laboratory blood tests (Complete blood count, Complete metabolic profile, cardiac enzymes, drug toxicology, Urine analysis), cardiac Monitor, Vital signs, Intravenous (IV) medications-Phenergan (nausea) and Diphenhydramine (calming.)
IV line started at 0145, laboratory blood tests were drawn and sent to the lab, Medications given at 0157.
Patient #7 remained anxious and unable to cooperate with EKG, additional order for Haldol IV push at 0201.
Portable chest x-ray documented as complete at 0211.
Patient #7 had episodes of vomiting in the ED and was documented as uncooperative with IV restart (patient pulled out her IV line) and EKG (not completed until post code blue at 0347). Her son and daughter were in the room with her throughout her ED stay.
Patient #7 ambulated to the restroom at approximately 0230.
At approximately 0300, patient #7 was moved to another room with a cardiac monitor (as ordered by the physician) and was placed on the cardiac monitor (1.5 hours after physician order). Patient #7 was noted to be pulseless and without coordinated rhythm. Advanced Cardiac Life Support (ACLS) protocol with cardiac resuscitation was initiated. Per documentation from nursing notes, cardiac resuscitation took place over a period of 45 minutes. She received 8 rounds of defibrillation as well as 9 doses of epinephrine, 300 mg amiodarone, 2 ampoules of sodium bicarbonate, 1 g calcium chloride and 5 g magnesium sulfate. She was noted to have ventricular fibrillation as well as asystole. Prior to being discharged and transported to a sister campus for a cardiac Catheterization (Cath), Patient #7 was intubated (with a ventilator for respirations) and had a right Intra-Jugular Central Venous Catheter (CVC) placed (for fluids and medications.)
Patient #7 was transported to the Cardiac Cath Lab at a sister campus on 08/18/2019 at 0523, the cardiac catheterization was performed with findings of occluded dominant circumflex vessel, 3 drug-eluting stents were successfully placed.

11/13/2019 at 1420 Staff L the ED Physician for the Patient of concern was interviewed. Staff L stated "It is our expectation that an EKG will be performed within 10 minutes for every chest pain that presents to our ED. Staff L also stated, "Chest pain patients are expected to be placed on a monitor."

11/14/2019 at 0900 the policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance Policy" version 1, effective date 8/2010 was reviewed. On page 1 of 11 under Capability: it states, "The capability of Hospital staff refers to the level of care that Hospital personnel can provide within the training and scope of their professional licenses."

11/14/2019 at 0910 the policy titled "Emergency Department-Scope of Services" version 2, effective date 01/03/2017 was reviewed. On page 1 of 3 under scope of service: it states, "The Emergency Department utilizes 5 level Emergency Severity Index (ESI) to triage the severity of illness to prioritize care. The ED specializes in prioritization, stabilization, resuscitation..."
11/14/2019 at 0920 the form titled "Emergency Department Chest Pain Triage/Evaluation Sheet" #277 dated 04/05 was reviewed. On page 1 of 2 is the assessment information intake: "Symptom onset...description of pain...associated symptoms...nausea...emesis...diaphoresis...Vital signs...general appearance...anxious...mild/moderate stress..." On page 2 under A. Inclusion criteria for reperfusion therapy: "Chest pain > 20 minutes and up to 12 hours duration if clinically indicated...ST-segment elevations...in 2 or more leads..."

11/14/2019 at 0923 The form titled "5 level Triage Algorithm" (no date on form) under requires immediate life-saving intervention or high risk situation or severe pain/distress...level 2, resources: labs, EKG, X-rays, CT, IV fluids, IV medications, specialty Consultations..."

11/14/2019 1000 the form titled "ED...Time is Muscle" (no date on form) was reviewed. On Page 1 of 1 under #2. "Time EKG #1 completed...accountable Party...ED RN...3-5 minutes..." Under #3. Time EKG Verified...by ED Physician-time and initial...accountable party...ED Doctor/ED RN 10-12 minutes..."