HospitalInspections.org

Based on interview and record review, the facility failed to provide a timely Medical Screening Examination (MSE, the process a hospital emergency department must use to determine if an individual has an emergency medical condition [EMC, a medical condition that has acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part]) for one (1) of 22 sampled patients (Patient 1) who presented to the emergency department (ED - a specialized medical facility that provides acute care for patients with serious injuries or illnesses who arrive without a prior appointment, equipped for immediate life-threatening conditions) with chest pain rated as 7/10 on the pain scale. Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity [the severity, complexity, and urgency of a patient's medical condition] and resources needs) of 3 on arrival instead of an ESI of 2. In addition, the facility did not reassess the patient's (Patient 1) elevated blood pressure nor performed timely ongoing monitoring as required by Federal EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires Medicare-participating hospitals to provide a medical screening examination to anyone requesting it, regardless of their insurance status or ability to pay. If an emergency medical condition is found, the hospital must stabilize the patient before they can be discharged or transferred to another facility) and the facility's policies and procedures.

This deficient practice had the potential to result in patient harm and/or death due to inaccurate triaging (the process in an emergency room where a nurse quickly assesses a patient's condition to determine the severity of their illness or injury and prioritize their treatment) and monitoring leading to a delay in MSE.

Findings:

During a concurrent interview and record review on 11/19/2025 at 12:06 p.m. with the Emergency Department Nurse Manager (ED NM) 2, Patient 1's "Patient Care Timeline" record, dated 5/19/2025, was reviewed. ED NM 2 stated that the facility received Patient 1 in the emergency department (ED) via ambulance at 2:37 a.m. The Patient Care timeline also indicated the following:

-At 2:39 a.m., Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity and resources needs) of 3.
-At 2:41 a.m., Patient 1's chief complaint indicated "not feeling well" after taking recreational drugs (substance used primarily for enjoyment). The note also indicated Patient 1 complained of chest pain.
-At 2:41 a.m., Patient 1's vital signs (VS-measurements of the body's most basic functions) were documented as temperature (T- 98.3F), Heart rate (HR) 102, Blood Pressure (BP) 183/113, and oxygen saturation (O2 saturation - a measurement of how much oxygen the blood is carrying as a percentage) 100% on room air (RA).
-At 2:41 a.m., Patient 1's chest pain had a pain score of 7 out of 10 (severe pain), in the left chest that was a continuous ache.
-At 5:41 a.m., Patient 1 was placed in an ED room.
-At 6:04 a.m., Patient 1's VS were documented as T- 98.4, HR-98, BP- 181/100, O2 sat-100%
-At 6:24 a.m., Patient 1 was seen by medical doctor (MD)
-At 6:46 a.m., Patient 1 had orders placed and was administered aspirin (improves blood flow to the heart and potentially reduce heart damage) 162 mg (milligram, a unit of measurement).
-At 6:54 a.m., Patient 1 had labs (laboratory blood draws) collected
-At 7:30 a.m., Patient 1's Troponin (a protein found in the heart muscle and a test helps rule out heart attack) level was 57 (high).

During an interview on 11/19/2025 at 11:50 a.m. with the ED Nurse Manager 2 (EDNM 2), EDNM 2 stated "If I were the triage nurse I would have assigned Patient 1 an ESI level 2 and rechecked the BP more frequently."

During an interview on 11/20/2025 between 8:10 a.m. and 8:45 a.m. with ED Charge Nurse 1 (EDCN 1), the EDCN 1 stated the following:

-the triage nurse does the ESI assessment and determines what level (ESI level) the patient will be.
-the triage nurse registers patients, for example if a chest pain patient walks in, patient may get upgraded to an ESI level 2 based on vital signs.
-when patients arrive by ambulance, the Emergency Medical Technician (EMT) will register patient with the Patient Facility Coordinator (PFC), the PFC will take report, takes VS and assign an ESI 2 if vitals were abnormal and get patient in a room right away.
-the expectations for the nurses when patients with chest pain arrived, would be that VS were taken and if the BP was high, then patient was placed in a room right away.
-the clinical impression of seeing a BP of 183/113 would warrant an ESI level 2 to be assigned.
-A BP of 183/113 was abnormal.
-the standard practice for how often vital signs were checked for patients with chest pain, should be every two hours or more if BP and troponin were elevated.
-the practice for monitoring patients whose initial BP was severely elevated was to notify the MD and ask for medications to administer and recheck the BP 15-30 minutes after administration.
-Patient 1 did not receive appropriate care, and the triage nurse should have assigned Patient 1 an ESI level 2 after the initial VS.
-it was not acceptable for Patient 1 to have a BP of 183/113 and go 3 hours and 23 minutes without a repeat BP check. EDCN 1 stated that as a charge nurse "we track patients waiting for re-assessments or monitoring through our track board, the track board lets us know when BPs are abnormal."
-charge nurses are always looking at track board and always have access to the track board.
-the consequences of leaving a BP unmonitored for so long especially if patients have taken recreational drugs, was "they (referring to the patients) can have a stroke (occurs when blood flow to part of the brain is interrupted) or bleed which is a very common thing we see especially in the ED when the patient has an elevated troponin."

During an interview on 11/20/2025 between 12 p.m. and 12:45 p.m. with the Chief of Emergency Medicine (CEM), the CEM stated the following:

-stabilizing interventions that were expected for a chest pain patient included Electrocardiogram (EKG-a test that checks your heart's electrical activity), VS, and reassessment of VS if they were abnormal.
-the expectations for nurses and qualified EMTs were to take a complete set of VS every two hours at minimum, which included Temperature, HR, BP, and O2 sat.
-a 3-hour and 23-minute delay in VS reassessment was not appropriate for Patient 1.
-there was a delay in the VS re-assessment and a lack of monitoring for Patient 1.
-CEM stated that VS monitoring were very important, and MDs rely on the VS documentation for review
-the risks associated with delaying reassessment for Patient 1 could be Myocardial Infarction (MI- blood flow to heart stops).

During a review of the facility's policy and procedure (P&P) titled, "Triage and Patient Flow in the ED", dated 11/2024, the P&P indicated:

B. Patients who present to the ED by Paramedics/BLS/ALS Ambulance: ...
b) Assign the patient to a treatment bed and notify the primary nurse and physician of the patient's arrival, chief complaint, condition, and immediate needs.
ESI 3- Vital Signs Including Pain Score, every 2 hours or more often if the condition warrants.

During a review of the facility's policy and procedure (P&P) titled, Triage and Patient Flow in the Emergency Department (ED), dated 11/2024, the P&P indicated the following:

1. Patients arriving by way of emergency medical services (EMS - paramedics or transport ambulance services) shall be triaged in the main ED by the Triage registered nurse (RN) and assigned an Emergency Severity Index (ESI - a 5-level triage algorithm used in the ED to sort patients based on the acuity of their condition and the resources they will need) level using the ESI algorithm version 4.
2. The Triage RN will enter the chief complaint, assigned ESI level, place the patient in the treatment area.
3. Patients with ESI level 2 will have vital signs with pain score evaluated every two (2) hours or more often and assessments every 2 hours or more often.

During a review of the facility's policy and procedure (P&P) titled, Standing Order - ED Nurse Initiated Condition-Based Orders, dated 12/2024, the P&P indicated the following:

1. Patients with an ESI 2 (emergent, high-risk situation) will require physician notification of ESI priority, saline lock by way of a vein (IV - a type of access that keeps a vein open for fluids including medications and blood products), cardiac monitor (medical device that tracks the heart's electrical activity, including heart rate), 12-lead electrocardiogram (EKG - a medical test that measures the electrical activity of the heart), and laboratory tests (samples of body fluids, including blood, to provide information about the health of a person).
2. Patients with chest pain will require a patient to be placed in a bed with cardiac monitoring as soon as possible, will need an EKG with results provided to any ED physician, for review, laboratory tests, and chest x-ray, and medication for chest pain.
3. Patients with an ESI 3 (urgent situation) will require a saline lock, cardiac monitor and/or EKG, laboratory tests.

During a review of the facility's policy and procedure (P&P) titled, "Standing Order: ED Nurse Initiated Condition-Based Orders," dated 11/2024, the P&P indicated:
D. Chest Pain .... (Rule Out Myocardial-Infarction) ....
1) If the nurse suspects that the pain is cardiac in origin .... (has history of cardiac disease, or recreational drug use) place the patient in a monitored bed as soon as possible.

During a review of the facility's guidelines titled, "Emergency Severity Index Handbook Fifth Edition," dated 2023, the guidelines indicated:

Unrecognized or unmanaged abnormalities of these vital signs (i.e. .... blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates, highlighting the importance of monitoring a wide range of vital signs to identify deterioration in the patient's health status.

Based on interview and record review, the facility failed to provide a timely Medical Screening Examination (MSE, the process a hospital emergency department must use to determine if an individual has an emergency medical condition [EMC, a medical condition that has acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part]) for one (1) of 22 sampled patients (Patient 1) who presented to the emergency department (ED - a specialized medical facility that provides acute care for patients with serious injuries or illnesses who arrive without a prior appointment, equipped for immediate life-threatening conditions) with chest pain rated as 7/10 on the pain scale. Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity [the severity, complexity, and urgency of a patient's medical condition] and resources needs) of 3 on arrival instead of an ESI of 2. In addition, the facility did not reassess the patient's (Patient 1) elevated blood pressure nor performed timely ongoing monitoring as required by Federal EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires Medicare-participating hospitals to provide a medical screening examination to anyone requesting it, regardless of their insurance status or ability to pay. If an emergency medical condition is found, the hospital must stabilize the patient before they can be discharged or transferred to another facility) and the facility's policies and procedures.

This deficient practice had the potential to result in patient harm and/or death due to inaccurate triaging (the process in an emergency room where a nurse quickly assesses a patient's condition to determine the severity of their illness or injury and prioritize their treatment) and monitoring leading to a delay in MSE.

Findings:

During a concurrent interview and record review on 11/19/2025 at 12:06 p.m. with the Emergency Department Nurse Manager (ED NM) 2, Patient 1's "Patient Care Timeline" record, dated 5/19/2025, was reviewed. ED NM 2 stated that the facility received Patient 1 in the emergency department (ED) via ambulance at 2:37 a.m. The Patient Care timeline also indicated the following:

-At 2:39 a.m., Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity and resources needs) of 3.
-At 2:41 a.m., Patient 1's chief complaint indicated "not feeling well" after taking recreational drugs (substance used primarily for enjoyment). The note also indicated Patient 1 complained of chest pain.
-At 2:41 a.m., Patient 1's vital signs (VS-measurements of the body's most basic functions) were documented as temperature (T- 98.3F), Heart rate (HR) 102, Blood Pressure (BP) 183/113, and oxygen saturation (O2 saturation - a measurement of how much oxygen the blood is carrying as a percentage) 100% on room air (RA).
-At 2:41 a.m., Patient 1's chest pain had a pain score of 7 out of 10 (severe pain), in the left chest that was a continuous ache.
-At 5:41 a.m., Patient 1 was placed in an ED room.
-At 6:04 a.m., Patient 1's VS were documented as T- 98.4, HR-98, BP- 181/100, O2 sat-100%
-At 6:24 a.m., Patient 1 was seen by medical doctor (MD)
-At 6:46 a.m., Patient 1 had orders placed and was administered aspirin (improves blood flow to the heart and potentially reduce heart damage) 162 mg (milligram, a unit of measurement).
-At 6:54 a.m., Patient 1 had labs (laboratory blood draws) collected
-At 7:30 a.m., Patient 1's Troponin (a protein found in the heart muscle and a test helps rule out heart attack) level was 57 (high).

During an interview on 11/19/2025 at 11:50 a.m. with the ED Nurse Manager 2 (EDNM 2), EDNM 2 stated "If I were the triage nurse I would have assigned Patient 1 an ESI level 2, and rechecked BP more frequently."

During an interview on 11/20/2025 between 8:10 a.m. and 8:45 a.m. with ED Charge Nurse 1 (EDCN 1), the EDCN 1 stated the following:

-the triage nurse does the ESI assessment and determines what level (ESI level) the patient will be.
-the triage nurse registers patients, for example if a chest pain patient walks in, patient may get upgraded to an ESI level 2 based on vital signs.
-when patients arrive by ambulance, the Emergency Medical Technician (EMT) will register patient with the Patient Facility Coordinator (PFC), the PFC will take report, takes VS and assigns an ESI 2 if vitals were abnormal and get patient in a room right away.
-the expectations for the nurses when patients with chest pain arrived, would be that VS were taken and if the BP was high, then patient was placed in a room right away.
-the clinical impression of seeing a BP of 183/113 would warrant an ESI level 2 to be assigned.
-A BP of 183/113 was abnormal.
-the standard practice for how often vital signs were checked for patient with chest pain, should be every two hours or more if BP and troponin were elevated.
-the practice for monitoring patients whose initial BP was severely elevated was to notify the MD and ask for medications to administer and recheck the BP 15-30 minutes after administration.
-Patient 1 did not receive appropriate care, and the triage nurse should have assigned Patient 1 an ESI level 2 after the initial VS.
-it was not acceptable for Patient 1 to have a BP of 183/113 and go 3 hours and 23 minutes without a repeat BP check. EDCN 1 stated that as a charge nurse "we track patients waiting for re-assessments or monitoring through our track board, the track board lets us know when BPs are abnormal."
-charge nurses are always looking at track board and always have access to the track board.
-the consequences of leaving a BP unmonitored for so long especially if patients have taken recreational drugs, was "they can have a stroke (occurs when blood flow to part of the brain is interrupted) or bleed which is a very common thing we see especially in the ED when the patient has an elevated troponin."

During an interview on 11/20/2025 between 12 p.m. and 12:45 p.m. with the Chief of Emergency Medicine (CEM), the CEM stated the following:

-stabilizing interventions that were expected for a chest pain patient included Electrocardiogram (EKG-a test that checks your heart's electrical activity), VS, and reassessment of VS if they were abnormal.
-the expectations for nurses and qualified EMTs were to take a complete set of VS every two hours at minimum, which included Temperature, HR, BP, and O2 sat.
-a 3-hour and 23-minute delay in VS reassessment was not appropriate for Patient 1.
-there was a delay in the VS re-assessment and a lack of monitoring for Patient 1.
-CEM stated that VS monitoring was very important, and MDs rely on the VS documentation for review
-the risks associated with delaying reassessment for Patient 1 could be Myocardial Infarction (MI- blood flow to heart stops).

During a review of the facility's policy and procedure (P&P) titled, "Triage and Patient Flow in the ED," dated 11/2024, the P&P indicated:
B. Patients who present to the ED by Paramedics/BLS/ALS Ambulance: ...
b) Assign the patient to a treatment bed and notify the primary nurse and physician of the patient's arrival, chief complaint, condition, and immediate needs.
ESI 3- Vital Signs Including Pain Score, every 2 hours or more often if the condition warrants.

During a review of the facility's policy and procedure (P&P) titled, Triage and Patient Flow in the Emergency Department (ED), dated 11/2024, the P&P indicated the following:

-Patients arriving by way of emergency medical services (EMS - paramedics or transport ambulance services) shall be triaged in the main ED by the Triage registered nurse (RN) and assigned an Emergency Severity Index (ESI - a 5-level triage algorithm used in the ED to sort patients based on the acuity of their condition and the resources they will need) level using the ESI algorithm version 4.
-The Triage RN will enter the chief complaint, assigned ESI level, place the patient in the treatment area.
-Patients with ESI level 2 will have vital signs with pain score evaluated every two (2) hours or more often and assessments every 2 hours or more often.

During a review of the facility's policy and procedure (P&P) titled, Standing Order - ED Nurse Initiated Condition-Based Orders, dated 12/2024, the P&P indicated the following:

-Patients with an ESI 2 (emergent, high-risk situation) will require physician notification of ESI priority, saline lock by way of a vein (IV - a type of access that keeps a vein open for fluids including medications and blood products), cardiac monitor (medical device that tracks the heart's electrical activity, including heart rate), 12-lead electrocardiogram (EKG - a medical test that measures the electrical activity of the heart), and laboratory tests (samples of body fluids, including blood, to provide information about the health of a person).
-Patients with chest pain will require a patient to be placed in a bed with cardiac monitoring as soon as possible, will need an EKG with results provided to any ED physician, for review, laboratory tests, and chest x-ray, and medication for chest pain.
-Patients with an ESI 3 (urgent situation) will require a saline lock, cardiac monitor and/or EKG, laboratory tests.

During a review of the facility's policy and procedure (P&P) titled, "Standing Order: ED Nurse Initiated Condition-Based Orders," dated 11/2024, the P&P indicated:
D. Chest Pain .... (Rule Out Myocardial-Infarction) ....
1) If the nurse suspects that the pain is cardiac in origin .... (has history of cardiac disease, or recreational drug use) place the patient in a monitored bed as soon as possible.

During a review of the facility's guidelines titled, "Emergency Severity Index Handbook Fifth Edition," dated 2023, the guidelines indicated:

Unrecognized or unmanaged abnormalities of these vital signs (i.e. .... blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates, highlighting the importance of monitoring a wide range of vital signs to identify deterioration in the patient's health status.