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Based on observation, interview and record review, the facility failed to provide an appropriate and complete medical screening exam (MSE) for one of 22 sampled patients (Patient 22). Refer to A-2406.

This deficient practice resulted in Patient 22 not receiving a complete MSE for a developing emergent medical condition to go unrecognized and untreated, and was not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirement. EMTALA requires hospitals with emergency departments to provide a MSE to any individual who comes to the emergency department (ED) and requests such an examination and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition (EMC - emergency medical condition manifested by acute [severe and sudden] symptoms of sufficient severity [including severe pain ...] is such that the absence of immediate medical attention could reasonably be expected to result in any or all of the following: placing the patient's health in serious jeopardy, serious impairment to bodily function, serious dysfunction to any bodily part organ or part).

Findings:

During a review of the facility's policy and procedure (P&P) titled, "Basic Unit Care Standards - Emergency Services," dated 3/2021, the P&P indicated, "4.4 Triage: an initial evaluation completed by a licensed provider including Registered Nurse, Physician, or Allied Health Provider in order to prioritize patients to be seen by a Physician or Allied Health Provider. The initial evaluation includes an assignment of an Emergency Severity Index (ESI - a five-level system that assigns severity of illness to patients in order to assign priority for assessment by a healthcare provider from 1 [most urgent] to 5 [least urgent]) level to each patient) ...

4.6 Qualified Medical Professional (QMP) - healthcare professional designated in the Professional Staff Bylaws, Rules & Regulations (and consistent with state licensure) to perform medical screening examinations ...

4.7 Focused System Assessment: a Registered Nurse (RN) performs a focused chief-complaint based system assessment and evaluation upon assuming care of the patient ...

5.2 A triage is promptly initiated by an RN, Physician or Allied Health Provider for all patients requesting care in the ED, regardless of arrival modality. An ESI level is assigned for all patients ...

5.3 The medical screening exam is completed by the Physician or Allied Health Provider ...

5.5.1 Reassessment will include vital signs, pain assessment and any change in ESI level ...

5.6 The triage nurse(s) are responsible to visually monitor patients in the waiting room and intervene immediately when clinical and/or safety concerns are identified ...

5.10.2 Frequency of vital signs will adjust as warranted by patient's condition or physician order."

During an interview on 11/9/23, at 11:40 a.m., with Chief of Emergency Department (CED), CED stated, Patient's 22 MSE was not completed, and every patient needed an MSE.

5.1.1 This policy is mandated by Section 1867 ("Medical screening requirement ... if any individual ... comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination") of the Social Security Act, as amended, regulations adopted by Center for Medicare and Medicaid Services (CMS) ...

5.1.4 The hospital will provide a MSE by a QMP to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf) to determine if the individual seeking care has an EMC; and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the EMC or arrange for transfer of the individual to another facility ..."

During a review of hospital's, "Professional Staff Bylaws (regulations and rules established by an organization for internal management) (Name of Hospital)," dated 2021, did not include any references to comply with EMTALA regulations or 489.20 (l) ( ... "required under EMTALA to do the following: provide an appropriate MSE to any individual who comes to the emergency department") and 489.24(a) (" ...provide an appropriate medical screening examination ... to determine whether or not an emergency condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations ...)."

Based on observation, interview, and record review, the facility failed to provide an adequate and appropriate medical screening examination (MSE-process to determine if an emergency medical condition exists and is an ongoing process until patient is stabilized or transferred), for one of 22 sampled patients (Patient 22). Patient 22 had a severely, elevated blood pressure (BP) and severe abdominal pain. Staff failed to maintain assessments while Patient 22 waited for care in agony.

These failures resulted in Patient 22 not receiving the appropriate triage level (preliminary assessment of patients in order to determine the urgency of care and treatment) for Patient 22's condition and need for a complete MSE. Patient 22 became unresponsive in the waiting room and subsequently died after cardiopulmonary resuscitation (CPR- rescue breathing and chest compressions) efforts were unsuccessful.

Findings:

A review of the ambulance record titled, "Patient Care Report" indicated Patient 22, age 55 years old, was transported from home to the emergency department (ED), on 8/29/23 at 12:22 p.m. for abdominal pain. Further review of the ambulance record indicated at 12:00 noon, Patient 22's pain level was 9/10 (pain scale 0-10 and 10 being the worst). At 12:10 p.m., his O2 sat was 97% (normal 95% or higher) on room air. At 12:11 p.m., Patient 22's blood pressure (BP) was 220/112 (normal 120/80), pulse 112 (normal 60-100 beats per minute), and respiration rate (RR) 15 (normal 12-20 breaths per minute). At 12:21 p.m., Patient 22's BP was 208/95 and pulse 104. At 12:22 p.m., Patient 22's pain level continued to be severe at 9/10.

A review of Patient 22's "Intake" in the ED dated 8/29/23 at 12:26 p.m., indicated the ambulance triage nurse, Registered Nurse (RN) 1, recorded Patient 22's BP of 208/95, temperature 97.5 degrees Fahrenheit (F-normal 97.5 F- 98.9 F), RR 16, pulse 104, O2 sat 97% on room air and pain 9/10. RN 1's assessment of Patient 22's general appearance-distress level was documented as mild.

During an interview on 11/7/23, at 2:30 p.m., RN 1 stated, Patient 22's V/S at the time of his ED arrival, BP 208/95, pain level 9/10, and his presentation, RN 1 assigned Patient 22's Emergency Severity Index (ESI) of 3. ESI 3 represented Urgent - patients that do not have immediate life or limb threatening illnesses or injuries. When Patient 22 was in the waiting room, a full set of V/S were not retaken. RN 1 stated she saw missed V/S happening all the time and full V/S included BP, pulse, O2 sat, pain, and RR.

During an interview on 11/7/23, at 2:50 p.m., with ED Registered Nurse (RN) 2, RN 2 stated she was talking to another patient in the ED waiting area when she heard Patient 22 moaning. RN 2 went back to her triage desk area and when she returned, Patient 22 was quiet. RN 2 noticed Patient 22's head leaned back and called for Patient 22's attention. Patient 22 was unresponsive. Per RN 2, she checked Patient 22's neck pulse and could not recall if he had a pulse. RN 2 called for assistance. RN 2 and ED Registered Nurse (RN) 3 transferred Patient 22 from his seat to a wheelchair and took Patient 22 to the code room (room where life-sustaining efforts are initiated). RN 2 stated the ED was extremely busy and the lobby was packed.

During an interview on 11/8/23, at 9:00 a.m., with ED Nurse Manager (NM), NM stated when doing triage, a visual presentation of the patient was needed. A pain level of 9 may be considered for a higher acuity (priority). NM further stated full V/S will include the heart rate, BP, RR, O2, and pain levels. The ambulance triage nurse was supposed to inform the triage nurse of the patient's condition for reassessment.

The (P&P) titled, "Basic Unit Care Standards - Emergency Services," dated 3/2021 indicated, "Reassessment will include vital signs, pain assessment and any change in ESI level. The triage nurse(s) are responsible to visually monitor patients in the waiting area and intervene immediately when clinical and/or safety concerns are identified. Frequency of vital signs will adjust as warranted by patient's condition or physician order."

During an interview on 11/8/23, at 9:45 a.m., with ED Assistant Nurse Manager (ANM) 1, ANM 1 stated the elevated BP and pain level were concerning. ANM stated Patient 22's 208/95 and pain of 9, indicated the ESI would have been ESI 2 and the patient closely monitored.

The policy and procedure (P&P) titled, "Basic Unit Care Standards - Emergency Services," dated 3/2021 indicated, "ESI Priority Levels: Priority 2 - Emergent - patients with illnesses or injuries that place them at a high risk and/or in severe pain or distress or present with unstable vital signs and require prompt intervention. Priority 3 - Urgent - patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention."

During an interview on 11/8/23, at 10:10 a.m., with Registered Nurse (RN) 3, RN 3 stated while in the waiting room, Patient 22 complained of shortness of breath, and took his O2 level and RR. RN 3 stated there was nothing alarming about Patient 22's condition. Per RN 3, Patient 22 complained of belly pain and stood out because he used a louder voice when he asked when he would be seen and that he had shortness of breath. RN 3 stated he did not check Patient 22's BP. Furthermore, RN 3 stated Patient 22 kept complaining of belly pain and shortness of breath. RN 3 also stated the ED was hunting (looking) for a room for Patient 22 but there was no sense of urgency.

A review of the V/S flowsheet for Patient 22 indicated, on 8/29/23 at 12:26 p.m., Patient 22's BP was 208/95, RR 16, O2 sat 97% on room air and pain score 9/10. At 1:50 p.m., RR 20, and O2 sat was 100%. However, no BP or pain level was documented.

During an interview on 11/8/23, at 12:09 p.m., with ED Assistant Nurse Manager (ANM) 2, ANM 2 stated that day (8/29/23) was busier in the ED. Patient 22's elevated BP and pain level were concerning; ANM 2 stated pain is whatever the patient says and the triage nurses are to keep an eye on patients in the waiting area.

During a review of the hospital's videotape (no audio) of the ED waiting room lobby, on 11/9/23 at 10:30 a.m., with the Inpatient Adult Care (IACM) Manager, Clinical Quality Director (CQD), and Quality Leader (QL), the videotape taken on 8/29/23 showed the following ED events of Patient 22:

-At 12:33 p.m., An ill appearing, Patient 22 arrived in the ED waiting area in a wheelchair brought in by an EMT (emergency medical technician) and transferred himself onto a seat. Patient 22 was observed not being able to sit still, had facial grimacing, clenched teeth, and frequently looked towards the triage nurses desk area.
-At 1:41 p.m., Patient 22 moved to another seat closer to the triage desk, unable to sit still, and hunched over.
-At 1:49 p.m., RN 3 brought out the V/S machine equipped with a BP cuff to the waiting room area and took Patient 22's O2 level on the right finger and no BP check.
- At 1:53 p.m., Patient 22 hit the seat's armrest twice with his right palm and took deep breaths.
-At 1:57 p.m., Patient 22 touched his abdominal area with his right hand with facial grimacing. At 1:58 p.m., RN 3 walked past in front of Patient 22 and did not stop to assess.
-At 1:59 p.m.to 2:01 p.m., Patient 22 continued to touch his abdomen and took deep breaths. -At 2:02 p.m., RN 2 was about to hand Patient 22 ice packs. RN 2 placed her left hand on Patient 22's right upper abdomen, then went back to her desk to get gloves. As RN 2 was putting on gloves in front of Patient 22, Patient 22 took deep breaths, and was slouched in his seat, placing both hands on his abdomen.
-At 2:03 p.m., Patient 22's head and body tilted back in the chair and RN 2 pulled Patient 22's torso forward. RN 2 gave a few chest compressions before summoning help and transferred Patient 22 into a wheelchair with assistance from RN 3 and took Patient 22 to the code room (resuscitation treatment room).

During an interview on 11/9/23, at 11:40 a.m., with Chief of Emergency Department (CED), CED stated the normal BP reading is 120/80 and a BP reading of 208/95 is elevated. CED, further stated, Patient's 22 MSE (process to determine if an emergency medical condition exists and is an ongoing process, until patient is stabilized or transferred) was not completed. CED stated, he was not aware of Patient 22's BP and pain level. CED further stated there was a lag (delay) time between triage and the change of condition regarding Patient 22's unresponsiveness.

Review of the ED physician's provider notes dated 8/29/23 indicated the physician received Patient 22, "unresponsive when I assumed care." ..."Cardiac arrest."

Record review of the ED nurse's notes, dated 8/29/23 at 3:58 p.m., showed CPR was started in the code room at 1405 (2:05 pm) and time of death pronounced by the physician at 1434 (2:34 pm).

During a review of the P&P titled, "Basic Unit Care Standards - Emergency Services," dated 3/2021 indicated, "An emergency medical condition manifested by acute symptoms of sufficient severity (including severe pain) is such that the absence of immediate medical attention could reasonably be expected to result in any or all of the following: placing the patient's health in serious jeopardy, serious impairment to bodily function, serious dysfunction to any bodily part organ or part."

During a review of the P&P titled, "Emergency Medical Screening Examination, Treatment and Transfer," dated 06/2023, the P&P indicated, "Medical Screening Exam (MSE) - the process required to determine within reasonable clinical confidence whether an emergency medical condition exists. It is an ongoing process, including monitoring of an individual until the individual is either stabilized or transferred."