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3801 SOUTH NATIONAL AVENUE

SPRINGFIELD, MO 65807

COMPLIANCE WITH 489.24

Tag No.: A2400

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on interview, record review, policy review and review of video surveillance, the hospital failed to provide a timely, appropriate medical screening examination (MSE) within the hospital's capability and capacity for one patient (#15) out of 31 Emergency Department (ED) patient records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's ED average monthly census over the past six months was 9,361.

Findings included:

Review of the hospital policy titled, "Patient Rights, Emergency Medical Treatment and Labor Act (EMTALA)," revised 10/04/22, showed it was the policy of Cox Health to provide an appropriate MSE and stabilizing treatment to any individual who presents to its facilities and requests examination or treatment for a medical/psychiatric (relating to mental illness) condition, or has such request made on his/her behalf by a party authorized to make such a request.

Review of the hospital policy titled, "Emergency Services Patient Flow," effective 09/02/22, showed patients who presented to the ED and determined after rapid visual assessment to not require immediate care, would receive a primary assessment, vital signs and assigned an acuity (the severity of a patient's illness and the level of service needed) using Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients).

Review of the hospital's document titled, "ED Chest Pain," effective date 04/02/2019, showed the protocol for procedures, and orders for ED personnel to follow when patients presented with a complaint of chest pain included:
- Initiation of an intravenous catheter (IVC or IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream);
- ED telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen);
- Oxygen to maintain an oxygen saturation (measure of how much oxygen is in blood) of greater than 90 percent;
- Stat (immediately) priority laboratory orders which included troponin (a type of blood test that measures whether or not a person is experiencing a heart attack);
- Chest x-ray (test that creates pictures of the structures inside the body-particularly bones);
- Electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) and;
- If appropriate, consult with the ST-Elevation Myocardial Infarction (STEMI, heart attack) coordinator.

Review of the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report from 10/12/22, showed the following:
- Patient #15 called 911 for an ambulance on 10/12/22 at 4:34 PM, and the ambulance arrived on-scene at 4:56 PM.
- The ambulance picked up Patient #15 at a gas station located between the patient's home and the hospital.
- Patient #15 was alert, oriented, breathing normally and pressing her hand to her chest. Patient #15 reported that she had sharp pain in the middle of her chest and rated the pain as a ten on a pain severity scale of zero to ten (zero means "no pain" and ten means "the worst possible pain"). Patient #15 reported the pain in her chest was always present, worsened when she took a breath, and that she could feel it between her shoulders in her back and also in her left jaw.
- Patient #15's vital signs and an EKG were completed before the ambulance left the gas station for the hospital. An EKG tracing timed at 5:04 PM with preliminary interpretation as "Borderline EKG **Unconfirmed** Sinus Rhythm, Prolonged QT (an irregular heart rhythm that can be seen on an EKG) interval".
- Patient #15 received medications of aspirin, two doses of nitroglycerin (medication to prevent chest pain caused by heart disease) and a narcotic pain medication through an IV started by the ambulance's paramedic during transport to the hospital. Patient #15 reported no improvement in her pain despite the medications administered and that Patient #15 moved from the ambulance stretcher to a wheelchair and was taken to the ED triage area where she was registered and the paramedic reported the patient's condition to a Registered Nurse (RN).

Review of Patient #15's ED record from 10/12/22 showed:
- She was a 59-year-old female who was transported to the ED by ambulance with a complaint of chest pain and was registered at 5:40 PM.
- She was seen in triage (process of determining the priority of a patient's treatment based on the severity of their condition) at 5:40 PM by Staff T, RN, where a chief complaint of chest pain and shortness of breath was documented. Past medical history was reviewed, vital signs were assessed, and she was assigned an ESI acuity level of 3-Urgent. No pain score was documented.
- An EKG was performed at 5:47 PM and was reviewed by Staff Z, MD, at 5:51 PM, with no documentation of his preliminary interpretation, recommendations, or new orders.
- Stat orders were entered by Staff AA, Physician Assistant (PA), at 5:52 PM and included a chest x-ray, iStat Troponin (cardiac troponin point of care), a High Sensitivity Troponin, complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions).
- At 6:16 PM, Staff AA, PA, documented the patient's skin was pink, warm and dry, respirations were non-labored; and her Glasgow Coma Scale/Score (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 15.
- At 9:15 PM, the iStat Troponin lab was drawn.
- Two separate nurses' notes entered by Staff BB, RN, described that Patient #15's family member presented to the registration/triage desk with concern of wait time and that the family member expressed anger about the wait and requested that Patient #15's IV be removed and that they would be seeking care at Hospital C.
- A Refusal of Services form in which the section titled, "Leaving Against Medical Advice," was completed, dated 10/12/22, timed 2200, signed by the patient and witnessed by Staff AA, PA.
- No additional assessment of her pain, breathing or vital signs were documented after triage at 5:40 PM.

During an interview on 01/30/23 at 1:25 PM, Staff F, RN, ED Assistant Director, stated that when a patient presented to the ED complaining of chest pain, an iStat Troponin and EKG were completed by the triage nurse. The EKG was taken to a physician provider by the technician who performed it. The provider performed an immediate, preliminary review to determine if the STEMI protocol needed to be activated with the Cardiac Catheterization (a procedure used to diagnose and treat some heart conditions) Lab (CCL).

During an interview on 01/30/23 at 1:25 PM, Staff E, RN, Emergency Services Director, stated that an EKG and iStat troponin test could be completed while a patient was in triage.

During an interview on 01/30/23 at 1:35 PM, Staff H, RN, ED Communications Nurse, stated that patients who arrived via ambulance did not always go directly to an ED treatment room. She stated that if the patient was stable enough, they would go through registration and triage and then a determination would be made based on the triage assessment of acuity.

During an interview on 02/02/23 at 11:20 AM, Staff Q, ED Medical Director, stated that the protocol for patients who presented to the ED with chest pain would involve an EKG in the triage area and a troponin blood test as soon as possible. Staff Q stated that a "stat" order placed at 5:50 PM for blood, and not drawn until 9:30 PM would not be ideal. Staff Q stated that when a patient with chest pain had an EKG in the ED, the technician brought the EKG tracing to any available physician for review. The physician told the technician if the EKG was indicative of a STEMI. Staff Q stated that if a patient or their family member expressed concern regarding a change in the patient's condition while waiting, the patient should be reassessed by a nurse and a provider notified of concerns. He stated that the availability of a nurse to reassess was, at times, limited when the volume of patients in the ED was high.

During a telephone interview on 02/03/23 at 9:05 AM, Staff T, RN, stated that she was the triage nurse for Patient #15 on 10/12/22. She stated that Patient #15 presented with complaints of chest pain in the center of the chest and shortness of breath and reported no history of any cardiac disease. Staff T stated that the patient had an EKG within minutes after her arrival, the EKG was taken to a physician to be reviewed and was reported as negative for STEMI or immediate rooming of the patient. She stated that she did take Patient #15's vital signs in triage at 5:45 PM, and they were within normal limits. Staff T stated that she never checked Patient #15's vital signs again and was not aware if anyone else in the ED had done so. Staff T stated that a mid-level provider came to see the patient and placed "stat" orders including a troponin and a chest x-ray. She stated that these labs were usually drawn from a chest pain patient while they were still sitting in triage, but she was not sure why Patient #15's labs were not drawn in triage. She stated that if the lab was ordered as "stat" at 5:51 PM, she would have expected that it would have been drawn before 9:15 PM.

During an interview on 02/08/23 at 1:30 PM, Staff Z, ED physician, stated that he reviewed the EKG for Patient #15's 10/12/22 visit to the ED. He stated that he could not remember exactly what his interpretation was, but that it was not indicative of a STEMI because he did not tell the technician to initiate the STEMI protocol. He stated that the physician's role in the review of the EKG was to identify if there was anything in the EKG tracing that represented a need to activate the CCL for intervention. He stated that when the technician brought an EKG for a preliminary quick read, the physicians did not document any type of interpretation or recommendation in the patient's ED record. He stated that the technician would document the name of the physician and the time that the EKG was reviewed. He stated that the physicians who did the quick EKG read for a chest pain patient may not have any other involvement with that patient during their ED course and were not notified of any changes in condition for that patient.

During an interview on 02/08/23 at 5:00 PM, Staff AA, Physician Assistant (PA) stated that she worked in the ED the evening of 10/12/22 and remembered some of her involvement in Patient #15's care. She stated that the patient presented with chest pain, had a history of cigarette smoking but no history of cardiac issues. Staff AA stated that she remembered that Patient #15 had an EKG, which it was reviewed by a physician, and no immediate cardiac intervention was recommended. She saw Patient #15 briefly in triage and she did not exhibit signs of distressed breathing, was not sweaty and had good color in her skin. Staff AA stated that she could not recall if she did a more extensive examination of Patient #15; but she confirmed that she did not document any examination, such as listening to heart or lungs with a stethoscope. She stated that an ED patient's pain level was documented with a pain scale by the triage nurse. Staff AA stated that she ordered a chest x-ray and stat labs; did not see the patient again during the course of her shift and was not informed of any changes in Patient #15's condition.

During an interview on 02/09/22 at 10:30 AM, Staff BB, RN, stated that she began her shift at 6:30 PM on 10/12/22, and she was assigned to the triage area. Staff BB stated that she remembered that Patient 15's family member approached the desk and told her that she worked for Cox Medical Center and knew that there could sometimes be a wait in the ED, but wanted an approximate time that Patient #15 would be seen. She stated that she explained the triage process to the family member and reassured her that they would get a room for Patient #15 as soon as possible. She stated that she did not remember how many times that Patient #15's family member came to the triage desk that evening, but did remember that at one time the family member said "It's weird that she is having these problems, because she does not have any history of heart problems" and expressed concern that Patient #15 was having to wait. She stated that she again reassured the family member about the process and knew that Patient #15 had her EKG reviewed, but she did not know the status of Patient #15's labs. She did not remember if she ever went to the waiting area to assess or talk to Patient #15. She stated that the last time Patient #15's family member approached the triage desk, they were upset and said they were concerned about Patient #15. The family member told Staff BB that they wanted Patient #15's IV removed so they could leave and go to another hospital for care. She stated that another nurse (Staff U) was standing near the triage desk and she asked that nurse to remove Patient #15's IV and review the leaving against medical advice (AMA) paperwork with her. She stated that she did not review the risks and benefits of leaving AMA with Patient #15. She stated that Staff U brought back the AMA paperwork signed by the patient; but the form was not witnessed or completed, so she filled out the risks and benefits and signed it herself. She stated that she documented in the medical record that the patient left AMA and that she was alert and oriented. She stated that she did not assess Patient #15 when she left, but documented this based on the report of Staff U.

During an interview on 02/03/23 at 6:30 PM, Staff U, RN, stated that he worked on 10/12/22 in the ED, but was not assigned to the triage area. He stated that Staff BB asked him to "Take out the IV. They want to leave AMA," and gave him an AMA form. He stated he went to Patient #15 in the waiting room and found her lying on the sofa. He could tell she was in a lot of discomfort and he asked her if she would stay and they would try to get her a room. He stated that the relative of Patient #15 was insistent that they were going to leave and go to another hospital. He stated that he explained to the patient that there were risks if she left and her condition could worsen, while he removed her IV. He stated that the patient signed the AMA form.

Video review dated 10/12/22, showed the following: Hospital provided video was incomplete as only the sections of video tape used by the hospital's quality department to create a timeline related to their RCA investigation were preserved.
- At 5:37:49 PM, Patient #15 was pushed in wheelchair by EMS personnel to registration/triage desk.
- At 5:39:04 PM, Patient #15 shifted in wheelchair and placed hand on mid-chest and appeared in pain while waiting in line for registration.
- At 5:40:36 PM, Patient #15 continued to sit in wheelchair, shifting her body and postured in appearance to improve breathing.
- At 5:50:37 PM, Patient #15 continued to shift in wheelchair, positioned her body as appearing to improve breathing and placed hand on mid-chest.
- Patient #15 placed hand on mid-chest and shifted her body in an appeared response to pain on multiple occasions from 5:52:00 through 5:57:35.
- At 10:24:04 PM, Patient #15 was seen laying on the sofa.
- At 10:29:08 PM, Staff U, RN, and Patient #15's family member assisted Patient #15 from the sofa to the wheelchair. Patient #15 appeared very weak and gripped at her mid-chest region repeatedly.

Review of Patient #15's medical record from Hospital C on 10/12/22, showed the patient arrived at the ED at 11:07 PM, by private vehicle. Staff CC, ED physician, entered a note 10/12/22 at 11:07 PM, that Patient #15 presented to the ED complaining of chest pain that radiated in her jaw and middle back. Patient #15 reported that the pain in her chest and jaw began at about 12:00 PM on 10/12/22, and she went to Cox Medical Center ED by ambulance. Patient #15 waited for a few hours and was not seen by a physician, so she left and came to Hospital C. The ED provider note showed that Patient #15 reported she had been sweaty and had vomited about three times and was concerned that she was having a heart attack. The ED provider note showed a physical examination with elevated blood pressure of 229/100, normal heart and lung evaluation and an anxious mood. An EKG was performed at 11:14 PM and labs were collected at 11:15 PM. The EKG was reviewed by Staff CC with abnormal findings of ST elevation; and the labs showed a troponin result of 11, elevated white blood cells and some minor electrolyte abnormalities. Staff CC's note showed he contacted Cox Medical Center to transfer the patient for further evaluation and treatment by cardiology specialists. EMS arrived at Hospital C to transfer the patient to Cox Medical Center on 10/13/22 at 00:00. The ED provider note on 10/13/22 at 00:00, showed an elevated blood pressure of 236/106 and the clinical impression was listed as Acute STEMI of inferior wall, probably primary and uncontrolled hypertension. The medical record showed an ED disposition of Transfer in stable condition.

During a telephone interview on 02/10/23 at 3:00 PM, Staff CC, Hospital C ED Physician, stated that when Patient #15 presented to Hospital C's ED she was complaining of chest pain and shortness of breath. He stated that Patient #15's physical presentation was that of a patient suffering a heart attack and he would have assigned her an ESI acuity level of two. He stated that an EKG was performed on Patient #15 and it was indicative of a STEMI and he felt she needed evaluation by a cardiologist. He stated that Hospital C did not have a cardiologist on staff and when a patient presented in need of evaluation by a cardiology specialist, he called larger hospitals in the immediate area to discuss transfer. He stated that he talked with an ED physician at Cox Medical Center and arranged for Patient #15's transfer for evaluation with a cardiologist. He stated that he then spoke to Patient #15 and her family and they informed him that they had been at Cox Medical Center earlier that evening and left their ED and came to Hospital C because Patient #15's condition worsened and she was not evaluated after several hours; but that they were agreeable to returning to that hospital to see the cardiologist. He stated that he reviewed Patient #15's medical record and read that he was aware of a troponin level of 16 from her visit earlier in the evening at Cox Medical Center; but did not recall where he obtained that information. He stated that when a patient presented to the ED complaining of chest pain, the protocol was to perform an EKG and get a troponin drawn as soon as possible. He stated that four hours after presentation would be too long to draw a troponin, as a baseline result was needed and then it was repeated in two hours.

During an interview on 02/06/23 at 2:00 PM, Staff Y, Hospital C Emergency Medical Technician (EMT), stated that he was on the crew that transported Patient #15 to Cox Medical Center from Hospital C. He stated that Patient #15 appeared in distress and presented with symptoms of a heart attack. He stated that he documented that the patient was seen at Cox Medical Center the previous day and left without being seen. He stated that Patient #15's EKG at Hospital C was indicative of a heart attack and that she experienced changes in her EKG during the transport that showed worsening of her condition. The EKG changes were relayed to Cox Medical Center's ED and they were instructed that Patient #15 would go through the ED and directly to the CCL.

During an interview on 2/3/23 at 9:28 AM, Patient #15's sister, stated that she arrived at the ED on 10/12/22, and found her sister sitting in the waiting room about 6:25 PM. She stated that at approximately 8:00 PM, she went to the registration desk and asked the nurse to check her sister's blood pressure because she was concerned that her condition was worse. She stated that the nurse responded to her in a hateful tone that the ED was very busy and there was about a five hour wait. She stated that she even asked about calling a rapid response, because she worked in a different department of Cox Medical Center and was told that a rapid response could be done if something just didn't seem "right". She stated that they took her sister to draw blood and brought her back to the waiting area after she checked with the nurse at 8:00 PM, but she was unsure as to what time that was. She stated that she went back to the desk at about 10:15 PM, because Patient #15 was now sweaty, gray and had begun to vomit. She reported Patient #15's symptoms to the same nurse she spoke with previously and asked if they were closer to being seen. She stated that the nurse spoke curtly to her that there was a triage process and patients had to wait. She stated that she then asked the nurse to remove Patient #15's IV because they were going to go to another hospital. She stated that she feared that her sister was going to die while waiting to be seen by a physician. She stated that the nurse turned to a male co-worker and said "Go take her IV out". She reported that she was not present when any paperwork was signed for Patient #15 to leave the hospital. She stated that she drove Patient #15 to Hospital C and they arrived shortly after 11:00 PM. She said that the ED physician there immediately identified a heart attack on the EKG. The ED physician asked Patient #15 and the complainant if they would like to return to Cox Medical Center to be evaluated by a cardiologist and after discussing it as their best option, they agreed. She stated that Patient #15 was returned to Cox Medical Center by ambulance and when the complainant got there she was informed that they had taken Patient #15 to the CCL. She stated that at some point, Staff R, Interventional Cardiologist, came out to the room where she was waiting and told her that Patient #15's condition had declined rapidly, she was now intubated and the staff was doing CPR. He told her that Patient #15 was "very sick with 99% blockage. Do you want us to continue with CPR?" She stated that she saw a lot of blood on Staff R's clothes, was in shock and never really answered. She stated that Staff R left the room and came back, but she was not sure how much time had elapsed. She stated that he said again "She is very sick. Do you want us to continue with CPR?" She remembered that she asked Staff R if Patient #15 was "gone" and he did not really respond and left the room again. She stated that Staff R returned again and said "She is very sick. She will never be the same. Do you want to continue CPR?" She stated that she shook her head "No".

The hospital failed to provide a timely and an appropriate MSE for Patient #15 on 10/12/22. The patient left the hospital to seek treatment at Hospital C (a nearby hospital), was transferred back to Cox Medical Center for cardiology intervention, taken immediately to the cardiac catheterization lab, suffered a cardiac arrest and was pronounced dead.

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COMPLIANCE WITH 489.24

MEDICAL SCREENING EXAM