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Based on review of medical record and interview with staff this requirement was not met.

Findings:

A. The patient of concern ( Pt#1) presented to the emergency department at Christus Spohn Corpus Christi-Shoreline hospital with complaints of chest pain after a fall two days prior that was due to dizziness. Pt#1 was triaged in the emergency department and received a medical screening examination (MSE) that was incomplete. The patient was seen by an emergency department (ED)advanced registered nurse practitioner (ARNP) provider on triage at 12:39 pm on December 03, 2018. The patient had a history of an abdominal aortic aneurysm. Labs were ordered as well as an EKG and chest x-ray. The exam was completed at 2:34pm. The pt. had not gotten to a room, nor been reassessed by an ED provider. The chart was documented that the patient left and this was documented at 8:50 PM. At 8:46 PM it was documented at 7:54 pm a supervisor was requested because the patient wanted to speak with somebody about her wait. She had been in the waiting room for 5 hours. By the time the house administrator arrived, the patient had already left to go to Christus Spohn Corpus Christi-South campus.

The patient did have an emergency medical condition because she presented to the emergency department with chest pain.

There was a delay in completion of the medical screening exam because after waiting in the ER lobby for 5 hours the patient left without treatment. The patient did not have stabilizing treatment because of the delay in being seen and because the patient left the emergency department. Since the pt. was not seen and the MSE was not completed, the stability of the patient could not be determined.

B. Interviewed staff #4, Advanced Registered Nurse Practitioner at 4:05 pm on February 13, 2019 via telephone. Staff confirmed she was the provider who provided medical screening for patient of concern (Pt#1). Staff #4 said she reviewed the patient's vital signs which were within normal limits. She said she ordered labs including cardiac test on the patient, chest x-rays and immediately had an EKG done on the patient. She said she did not have chance to review the labs until later that day The provider said her plans were to have the patient on bedside monitoring and have the emergency physician evaluate and further treat her. She said the emergency room was so busy that day that there were no treatment beds and the patient was sent to the waiting room and left the facility before the emergency room physician had a chance to see the patient. She said the emergency room was extremely crowded and the average wait for less acute patient was up to 8 hrs. Staff #4 said during her evaluation of the patient,the patient clinical picture at the time she saw the patient was not indicative of the patient having a dire medical emergency/emergent medical condition.

Staff #4, admitted that she did not have the chance to have any communication with the day shift emergency physician about this patient to discuss the lab, x-ray and ecg findings. The patient could not be in a treatment room and be on a cardiac monitor as staff #4, FNP wanted because there were no availabilities of treatment beds. These beds were already being taken by the higher acuity patients and those patients needing to be admitted as inpatients. She does not recall seeing this patient again other than her initial medical screening examination on this patient.

Staff #4 explained they have a patient evaluator/communicator who is a nurse who goes around in the emergency room treating /waiting areas and main waiting area to assesses the patient who are waiting for further evaluation and treatment. This person help keeps the lines of communication open between the patient and the staff. This is the person who alerts the provider if there are any special needs of a patient waiting. She said this person did inform her later in the day that a friend of the patient was concern about the patient. The nurse did vitals on the patient and spoke to the patient. This person also refreshed her (staff #4 FNP) on the patient's clinical picture which was not at all alarming to staff #4, FNP. She had other patients with chest pain that showed signs that were more alarming to her than this patient. The patient was still very alert and oriented and in good spirits vital signs were within normal limits. She said she did not want to order any narcotics or treatments to the patient until the emergency physician was able to see the patient. She just gave the patient Tylenol to help alleviate some of the pain since this is what the patient requested. Staff #4 again said she herself did not provide another hands on physical evaluation on the patient again.
C. Interviewed staff #5 Nurse Navigator at 4:30 pm on February 13, 2019 in the administration conference room of the facility who attested to the fact that they had no one to monitor the waiting room during the whole period of time patient #1 was waiting in the lobby. The hospital emergency department was extremely busy and staff #5 was trying to monitor patient in both the emergency department and the lobby waiting room and could not make frequent assessments on patients waiting. In the patient of concern although the patient's vital signs when checked were appropriate and there appeared to be no acute decompensation.

Based on the age of the patient, the complaint, and the length of time she waited, she would have required more frequent assessments based on her chief complaint, while waiting in the emergency department waiting for an open bed.

Based on review of medical record, policies and interview with staff further medical examination and treatment as required to stabilize the medical condition was not met.

Findings:
A. Review of medical record-Christus Spohn Corpus Christi Shoreline 1st visit:

"X-ray chest 2 views conducted at 2:34pm on December 3, 2018. Two views PA and lateral of the chest was performed. Findings: Heart and Mediastinum- Normal cardiac size, Aorta is dilated and probably aneurysmal., lungs normal.

Impression: Abnormal thoracic aorta, probably aneurysmally dilated. If there is clinical suspicion for potential aortic dissection or leak a contrast-enhanced CTA is recommended for the future."

B. Review of medical record Christus Spohn Corpus Christi Shoreline: At 8:46 pm on December 3, 2018 it was documented in the medical record that at 7:54 pm while the patient was at Christus Spohn Corpus Christi Shoreline hospital emergency room that a supervisor was requested because the patient wanted to speak with somebody about her wait. She had been in the waiting room 5 hours. By the time the house administrator arrived, the patient had already left to go to Christus Spohn Corpus Christi South hospital emergency room

The patient left the emergency room because of her long wait and her medical screening examination was not completed and she did not receive stabilizing treatment.

C. Review of medical record Christus Spohn Corpus Christi South: It is documented that the nurse at Christus Spohn South spoke with the nurse at Christus Spohn Shoreline and the patient was now in the emergency department at Christus Spohn South. The physician on duty was notified. Upon arrival to Christus Spohn South the patient had increasing pain and ultimately became unresponsive. The patient had a CT scan which showed a type B aortic dissection with mediastinal hematoma and moderate to large right hemothorax.

History of patient:
" 84-year-old female complaining of severe chest pain that radiates to her back that started this morning. Patient states that she was already at Spohn Shoreline and never got seen by a doctor for treatment. Patient states she was still in the lobby at Shoreline and decided to come to Spohn South to be seen here (South Campus). Patient states that she did go to her primary care doctor and was told to go to Spohn Shoreline for further evaluation of an AAA."

"The patients pain scale was 9/10 when she arrived at Christus Spohn Corpus Christi - South campus. This was relieved by nothing."

Medical Record review: Christus Spohn Shoreline ER Physician attestation during the 1st visit to Shoreline on Dec. 3, 2018, the note was included in the patients record on January 1, 2019:

" "I have reviewed this dictation; I did not evaluate the patient. I was available for consultation, if needed. The evaluation, treatment, and disposition of this patient was conducted independently by the advanced practice provider."

C. Review of Policy: "Five Level Triage-ED" last revised December 2017. Page 1 of 2:

" Level 3 (Urgent):

These patients require two or more resources for a disposition to be reached. The patient is stable for the interim but requires emergency department resources including diagnostics, treatments, interventions or consultations. Reassessments as indicated by patients condition, or as warranted by change of patients condition while in the waiting area"

The patient was triaged as an ESI -3 (Urgent).


D. Staff #4, advanced registered nurse practitioner interviewed at 4:05 pm on February 13, 2019 via telephone admitted that she did not have the chance to have any communication with the day shift emergency physician about this patient to discuss the lab, x-ray and ecg findings. The patient could not be in a treatment room and be on a cardiac monitor as staff #4, FNP wanted because there were no availabilities of treatment beds. These beds were already being taken by the higher acuity patients and those patients needing to be admitted as inpatients. She does not recall seeing this patient again other than her initial medical screening examination on this patient.

Based on review of medical record and interview with staff there was a delay in medical screening completion and providing necessary stabilizing treatment.

Findings:

A. The pt. was not seen by the ED physician. This caused a delay in the completion of a medical screening exam and further inpatient stabilizing treatment. the emergency department was busy and the patient was never placed in room. She was waiting in the emergency department waiting room for greater than five hours when she left.

B. Review of Medical Record documentation from a late excerpt entry -January 1, 2019 (by the emergency room physician at on the day shift at Christus Spohn Corpus Christi Shoreline hospital on December 3, 2019}:

"" "I have reviewed this dictation; I did not evaluate the patient. I was available for consultation, if needed. The evaluation, treatment, and disposition of this patient was conducted independently by the advanced practice provider."

C. Interview by provider at 4:08 pm on February 13, 2019 via telephone. Staff #4 said she reviewed the patient's vital signs which were within normal limits. She said she ordered labs including cardiac test on the patient, chest x-rays and immediately had an EKG done on the patient. She said she did not have chance to review the labs until later that day She said her plans were to have the patient on bedside monitoring and have the emergency physician evaluate and further treat her. She said the emergency room was so busy that day that there were no treatment beds and the patient was sent to the waiting room and left the facility before the emergency room physician had a chance to see the patient. She said the emergency room was extremely crowded and the average wait for less acute patient was up to 8 hrs. She said but during her evaluation of the patient and the patient clinical picture at the time she saw the patient was not indicative of the patient having a dire medical emergency/emergent medical condition.

Staff #4, admitted that she did not have the chance to have any communication with the day shift emergency physician about this patient to discuss the lab, x-ray and ecg findings. The patient could not be in a treatment room and be on a cardiac monitor as staff #4, FNP wanted because there were no availabilities of treatment beds. These beds were already being taken by the higher acuity patients and those patients needing to be admitted as inpatients. She does not recall seeing this patient again other than her initial medical screening examination on this patient.