HospitalInspections.org

Based on two (2) out of five (5) medical records reviewed for adult patients presenting to the emergency room with complaints of chest pain (Medical Record #1 and Medical Record #5), review of facility policy, and staff interview, it was determined that the facility failed to implement its policy for the treatment of patients with chest pain.

Findings include:

Reference: Facility Emergency Medicine policy titled, Chest Pain Protocol, states, "... Procedure: ... 6. If the qualified medical provider deems the EKG not to be STEMI or suggestive of ischemia, the patient will be sent to the medical screening exam area where medical screening exam will be initiated. ..."

1. A review of Medical Record #1, in the presence of Staff #4, revealed that the patient arrived at the Emergency Department (ED) on 4/28/21 at 19:45. The patient was triaged by a registered nurse (RN) at 19:50. Documented evidence on the triage note states, "... Chief Complaint : [sic] Pt [patient] states "I'm having chest pain, bodyaches and a fever that started today" (+) N/V/D [nausea, vomiting, diarrhea), denies SOB [shortness of breath]. Pt also stated that [he/she] received 1st COVID vaccine today ..."

a. The patient had an EKG at 19:52 which indicates, "Sinus tachycardia ... Left axis deviation ... Abnormal ECG". The EKG was reviewed and signed by a physician at that time.

b. A Medical Screening Exam (MSE) was initiated on 4/28/21 at 21:42, one (1) hour and 50 minutes after the EKG was reviewed by the physician. This was not in accordance with the above referenced Chest Pain Protocol which states that after the EKG was reviewed by a qualified medical provider the patient would be sent to a medical screening exam area and have an MSE initiated.

2. A review of Medical Record #5, in the presence of Staff #4, revealed that the patient arrived at the ED on 4/28/21 at 18:55 and was triaged by an RN at 19:02. Documented evidence on the triage note states, "... Chief Complaint : [sic] Electric-like CP [chest pain] radiates to LUE [left upper extremity] for two weeks ..."

a. The patient had an EKG at 18:59 which indicates, "Normal sinus rhythm ... Normal ECG ..." The EKG was reviewed by the physician at 19:05.

b. At 21:32 the patient was called and at 21:33 it was documented that the patient left without being seen by a physician, two (2) hours and 28 minutes after the EKG was reviewed by the physician. This was not in accordance with the above referenced Chest Pain Protocol which states that after the EKG was reviewed by a qualified medical provider the patient would be sent to a medical screening exam area and have an MSE initiated.

3. During an interview on 5/5/21 at 2:27 PM, the above findings were confirmed with Staff #5 and Staff #6.