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Based on clinical record review, policy review, observation and interview, it was determined the facility failed follow established policies and procedure in that:

1) the facility failed to ensure one (#1) of 25 (#1-#25) patient received an appropriate and timely medical screening exam (MSE).
2) the facility failed to ensure one (#1) of 25 (#1-#25) patient was triaged according to the established policy.

Failure to provide an appropriate and timely MSE and triaging the patient according to established policies did not ensure the facility was aware of whether or not Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department. See A-1104 for details.

Based on clinical record review, policy review, observation and interview, it was determined the facility failed follow established policies and procedure in that:

1) the facility failed to ensure one (#1) of 25 (#1-#25) patient received an appropriate and timely medical screening exam (MSE).
2) the facility failed to ensure one (#1) of 25 (#1-#25) patient was triaged according to the established policy.

Failure to provide an appropriate and timely MSE and triaging the patient according to established policies did not ensure the facility was aware of whether or not Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department. Findings follow:

A. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)," with a date of July 2022, provided on 11/08/22 at 10:30 AM showed the following:
1) If an individual "comes to the emergency department" and a request is made for examination or treatment of a medical condition, a medical screening examination, including ancillary services routinely available to the Emergency Department, will be provided to determine whether or not an Emergency Medical Condition exists.
2) All emergency patients and obstetrical patients of less than twenty (20) weeks gestation shall be evaluated and assessed by the Emergency Department and the Emergency Department physician on duty or the physician Practitioner of the patients' choice. This assessment shall be completely and adequately documented.

B. Review of the facility's policy titled, "Triage," with a date of July 2016, provided on 11/08/22 at 10:30 AM showed the following:
1) The triage nurse function under protocols developed by the Emergency Department (ED) Medical Director, ED nurse manager and approved by the Medical Committee.
2) The triage nurses work under the direct supervision of the ED Charge Nurse, nursing director or designees in cooperation with the ED physician who is readily available for consultation.
3) A triage nurse sees all patient presenting to the ED to elicit the chief complaint; conduct and document a brief patient assessment.
4) If a patient waits 20 minutes or more form the time of initial triage to the time of the Formal triage, the charge nurse will be notified and the second triage room and a second triage nurse will be implemented.
5) Responsibilities:
a) Assess all incoming patients and document findings.
b) Determine the priority need for care.
c) Initiate diagnostic and/or therapeutic measures as indicated by protocols, (i.e., order x-ray, splint, ice, elevate).
d) Keep charge nurse informed at reasonable intervals of the number and priority (category) rating of patients to be seen.
e) Monitor all patients in the waiting area. Patient's status is documented as necessary.
f) Maintain an awareness of activity in the treatment area (i.e., codes, delays in care).
6) Triage Procedure:
a) Patients present to the Emergency Department admission desk.
b) The triage nurse sees the patient. The nurse performs the triage interview collecting data sufficiently to determine priority of care.
c) Triage assessment takes place in the triage room.
d) Vital signs are measured unless reason for deferment is noted.
e) Documentation of all above data is done on the triage template in PulseCheck.
f) The triage nurse determines priority of care.
g) The ED staff and physician are kept informed of patients and their acuity in the waiting area. The triage nurse initiates any treatment or diagnostic work up ordered by the physician or included in the Triage Interventions/Protocols.
h) As rooms and staff become available the waiting area patients are called back in the order assigned by the triage nurse.
i) Patients in the waiting room are re-checked periodically based upon their condition.
7) Triage Categories: Category II: Emergent. Listed among the categories was "Chest Pain of Cardiac origin."

D. In an interview with the Assistant Vice President (AVP) of Medical/Surgical and the ED on 11/08/22 at 1:40 PM, when asked what time frame "re-checked periodically" meant, she confirmed the time frame was not defined in the Triage policy.

E. Review of the "Triage Cheat Sheet" provided on 11/08/22 at 10:45 AM showed the following:
1) Chest pain or shortness of breath: EKG (electrocardiogram), CBC (complete blood count), BMP (basic metabolic profile), CPK (creatine phosphokinase)/Troponin, 1 (one) view chest x-ray, COVID antigen.
2) Get an EKG on anyone (excluding small children) with symptoms between their belly button and their chin when there is any possibility the heart could be involved.

F. In an interview with the Assistant Vice President (AVP) of Medical/Surgical and the ED on 11/08/22 at 1:40 PM, she stated the Triage Cheat Sheet was placed in the triage area on 02/23/22. The AVP of Medical/Surgical and the ED stated the triage nurse could order the items on the Triage Cheat Sheet based upon the patients' presentation.

G. Review of Patient #1's clinical record on 11/08/22 showed the following:
1) Triage Notes on 10/24/22 at 7:20 PM showed the patient presented to the ED for evaluation of chest pain that began at approximately 8:15 AM while sitting at work with worsening of pain this PM, reported left arm numbness, nad (no acute distress) noted at this time. Respirations unlabored. Skin warm, skin color was normal, skin was dry.
2) Admission on 10/24/22 at 7:27 PM, the patient's urgency was assigned as "3 Urgent."
3) Pain on 10/24/22 at 7:27 PM: Patient complained of pain described as, on a 0-10, patient rated pain as 10, location: chest.
4) ESI (Emergency Severity Index) Level Tool on 10/24/22 at 7:27 PM: Two or more resources needed, no danger zone vital signs - suggested Emergency Severity Index Level 3 assigned.
5) Vitals signs on 10/24/22 at 7:21 PM showed blood pressure 148/77, pulse 84, respiration 20, temperature 97.6 (degrees Fahrenheit), Pain 10, Oxygen saturation 100% on room air.
6) The patient was transferred from Triage to the Emergency Waiting at 7:27 PM.
7) Nursing Procedure: EKG Chart dated 10/24/22 at 7:27 PM showed, "1925 (7:25 PM), EKG indicated for complaint of chest pain, 12 lead EKG performed on the left chest, done by Dr. (Named), first EKG. Follow-up: after procedure, EKG for interpretation given to Dr. (Named)."
8) Physician In Triage Note dated 10/24/22 at 9:41 PM showed, "67 F (female) c/o (complaints of) cp (chest pain) that began this morning but then resolved, states came back worse tonight w (with) sob (shortness of breath) and left arm numbness/tingling. Alert, nontoxic, slow to answer questions appropriately. VSS (vital signs stable). The patient had a brief encounter by me as the Physician in Triage and understands that the goal of this brief encounter is to facilitate their care. A complete evaluation will be performed once they are brought to a treatment area. I have reviewed the Chief Complaint, vital signs and obtained a brief history. I have ordered appropriate initial diagnostic studies and treatments based upon the abbreviated history and exam performed above. Additional diagnostic, treatment and disposition decisions will be made once the patient is brought to a treatment area. The patient has been informed of the potential for delays and I have asked that they notify me or the Triage Nurse if they desire to leave so that we may review the labs and/or imag (imaging)."
9) Nursing Assessment dated 10/25/22 at 1:19 AM showed, "Complex assessment performed, patient arrives via hospital wheelchair, no steady gait, lift to cart, history obtained from, no history available, patient unresponsive, skin abnormal, skin temperature is cold, skin dusky in color, patient complaints of chest pain, pt (patient) to ED for eval of chest pain since yesterday morning. Pt to room via wheelchair from triage accompanied by Dr. (Named) and (Named) RN (Registered Nurse). Pt lifted to stretcher, pt unresponsive, pulseless and apneic at this time. CPR (cardiopulmonary resuscitation) started."
10) EKG Interpretation on 10/25/22 at 1:36 AM showed, "12 Lead EKG interpreted by Emergency Department Physician, 12 Lead EKG shows sinus tachycardia, rate 122 with no ectopics; Interpretation: Normal EKG, Conduction normal, ST segments normal, T waves inverted."
11) Nurses Note on 10/25/22 at 1:50 AM showed, "Notes: at approx. 0115 (1:15 AM) pt was brought into triage room to reassess vital signs and draw delta troponin. After wheeling pt into triage room, this nurse attempted to arouse pt. Pt would not respond at that time. This nurse checked for pulse and performed sternal rub while sending lab tech to get MD. This nurse was unable to palpate pulse, pt was taken directly into ED room 1 and CPR was initiated."
12) HPI (History of Present Illness) dated 10/25/22 at 1:49 AM showed, "Chief complaint: patient presents for evaluation of cardiac arrest, patient present for evaluation of respiratory arrest. Upon patient re-evaluation by triage nurse patient was found to be without a pulse. Patient was immediately taken back to a room where CPR was started. Patient's initial rhythm was asystole. Patient was given 1 mg (milligram) of Epinephrine. Intubation was attempted however patient's jaw was severely clenched. Patient was given Etomidate and Recuronium which did not improve patient's clinched jaw. This was concerning that patient was likely in rigor mortis. Re-evaluation of rhythm showed the patient was still in asystole. It was decided that further efforts to continue CPR were unlikely to be successful and time of death was called at 0125 (1:25 AM)."
13) Nursing Procedure: Expiration Chart dated 10/25/22 at 6:40 AM showed, "Patient pronounced dead at 0125 (1:25 AM), patient pronounced by Dr. (Named), Patient pronounced dead in emergency department, post-mortem care completed, body identified by daughter, family notified, primary care physician notified, nursing director notified, nursing supervisor notified, coroner/medical examiner notified, funeral home notified, organ procurement agency notified, no autopsy requested."

H. In an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:50 PM, when asked about the Physician in Triage note dated 10/24/22 at 9:41 PM, the Director of Quality, Risk Management and Regulatory Compliance stated the assessment actually occurred during the triage process on 10/24/22 at 7:27 PM. The Director of Quality, Risk Management and Regulatory Compliance stated the time was not changed to reflect the actual time the physician triaged the patient.

I. Observation of video recording for Patient #1 from 10/24/22 at 7:25 PM to 10/25/22 at 1:15 AM on 11/09/22 showed the following:
1) At 7:27 PM the patient was transported to the waiting room from the triage area in a wheelchair. Patient was holding her head. There appeared to be no family or significant others present with the patient. Respirations were visualized.
2) From 7:36 PM to 7:57 PM the patient's position varied from sitting upright to having her head in her lap.
3) At 7:59 PM the patient waved her hand while looking at the receptionist area.
4) At 8:02 PM the patient waved her hand while looking at the receptionist area.
5) At 8:06 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN communicated with the patient. There was no evidence vital signs were obtained. There was no evidence of documentation of the communication with the patient. The RN then leaves the patient.
6) From 8:07 PM to 8:27 PM the patient's position varied from sitting upright to having her head in her lap. Respirations and/or movement were visualized.
7) At 8:28 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as a Radiology Technician communicated with the patient. The Radiology Technician completed their communication with the patient, then communicated with another patient and then transported the other patient out of the waiting room. Patient #1 then placed her head back in her lap.
8) From 8:28 PM to 8:42 PM the patient's position varied from sitting upright to having her head in her lap.
9) At 8:43 PM the patient waved her hand while looking at the receptionist area.
10) At 8:45 PM the patient waved her hand while looking at the receptionist area.
11) At 8:45 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN communicated with the patient. There was no evidence vital signs were obtained. There was no evidence of documentation of the communication with the patient. The RN then leaves the patient.
12) At 8:48 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN placed an arm band on the patient.
13) At 8:50 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as a Laboratory Technician takes the patient to a room off the waiting room and drew blood from the patient.
14) At 8:53 the Laboratory Technician transported the patient back to the waiting room.
15) From 8:59 PM to 9:19 PM the patient's position varied from sitting upright to having her head in her lap. Respirations and/or movement were visualized.
16) At 9:20 PM the patient placed her head in her lap.
17) From 9:20 PM on 10/24/22 until 1:14 AM on 10/25/22, the patient's head was in her lap. There was no evidence the patient changed positions after 9:20 PM on 10/24/22.
18) At 9:35 PM on 10/24/22, respiration by the patient were no longer visualized. The Director of Quality, Risk Management and Regulatory Compliance confirmed the observation.
19) At 10:17 PM a staff member transported another patient into the waiting room and sat the patient next to Patient #1. There was no observation the staff member assessed Patient #1.
20) On 10/25/22 at 1:14 AM two staff members identified by the Director of Quality, Risk Management and Regulatory Compliance as RNs attempted to arouse Patient #1. Patient #1 was then transported into the Emergency Department.
21) During observation of the video from 10/24/22 at 7:25 PM to 10/25/22 at 1:15 AM on 11/09/22, there was no evidence the patients in the waiting room were reassessed or vital signs were obtained.

J. The findings of the video observation were confirmed in an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:00 PM.

K. In an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:50 PM, the Director of Quality, Risk Management and Regulatory Compliance stated Patient #1 was under-triaged as an ESI (Emergency Severity Index) Level 3 Urgent and should have been assigned as an ESI Level 2 Emergent.

L. In an interview with RN #3, who was conducting triage assessments, on 11/09/22 from 9:40 AM to 10:00 AM, RN #3 stated the following:
1) When asked what the process was for triaging a patient presenting to the emergency department, she stated the Registrar registers the patient. The Registrar then notifies the Triage Nurse of a patient needing to be triaged. RN #3 stated she had two minutes to get the patient triaged once notified.
2) When asked if the patient was transported back to the waiting room, how often the patient was reassessed, RN #3 stated every 30 minutes to an hour. RN #3 stated she rounds every 30 minutes on patients. RN #3 stated vital signs were reassessed at a maximum of every two hours but would try to re-evaluate vital signs every hour. RN #3 stated the computer could be set to flag the staff for frequent vital signs. RN #3 stated she was not aware of a policy or a protocol directing the frequency of reassessing the patients.
3) When asked how the ESI Level was assigned to a patient, RN #3 stated the computer assigns the level based on information entered into the electronic health record. RN #3 stated the ESI assigned by the computer could be overridden and changed by the staff. When asked if there was a policy or guidance on how to assign the ESI Level, RN #3 stated she wasn't aware of any policy or guidance.

M. Review of the Corrective Action Plan provided on 11/10/22 at 2:40 PM showed the following:
1) Patients in the waiting room will have hourly vital signs and assessment of pain levels by ED staff. Implemented on November 9th.
2) Policy updated and triage nurses given a copy to review and initial. Implemented on November 9th. This will also be reviewed with a full signature and date at Triage Class.
3) Triage Nurse refresher course will be given and completed on 11/19/22: Monday 11/14/22 4:30 PM to 6:30 PM; Wednesday 11/16/22 4:30 PM to 6:30 PM; Thursday 11/17/22 4:30 PM to 6:30 PM; Saturday 11/19/22 10:00 AM to 12:00 PM.
4) Direct bedding by triage nurse was implemented November 1st.
5) Positions have been posted for paramedics and techs to cover the 10 AM to 10 PM shifts and the 7 PM to 7 AM shifts.
6) Discrepancy in documentation of the time of MD (physician) medical exam and EKG interpretation will be addressed by the ED Medical Director.
7) QA (Quality Assurance) coordinating a Root Cause Analysis involving ED implemented 10/27/22.

N. In an interview with the AVP of Med/Surg and the ED on 11/09/22 at 1:10 PM, she stated "direct bedding" meant the triage nurse can directly assign an ED room to a patient until the ED was full.

O. Review of the policy, "Triage," provided on 11/10/22 at 2:40 PM showed, "Patients in the waiting room will have vital signs and pain scale taken hourly by an ED tech, Paramedic, triage nurse, or licensed personnel."

Based on clinical record review, policy review, observation and interview, it was determined the facility failed to ensure one (#1) of 25 (#1-#25) patient received an appropriate and timely medical screening exam (MSE). Failure to provide an appropriate and timely MSE did not ensure the facility was aware of whether or not Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department. Findings follow:

A. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)," with a date of July 2022, provided on 11/08/22 at 10:30 AM showed the following:
1) If an individual "comes to the emergency department" and a request is made for examination or treatment of a medical condition, a medical screening examination, including ancillary services routinely available to the Emergency Department, will be provided to determine whether or not an Emergency Medical Condition exists.
2) All emergency patients and obstetrical patients of less than twenty (20) weeks gestation shall be evaluated and assessed by the Emergency Department and the Emergency Department physician on duty or the physician Practitioner of the patients' choice. This assessment shall be completely and adequately documented.

B. Review of the facility's policy titled, "Triage," with a date of July 2016, provided on 11/08/22 at 10:30 AM showed the following:
1) The triage nurse function under protocols developed by the Emergency Department (ED) Medical Director, ED nurse manager and approved by the Medical Committee.
2) The triage nurses work under the direct supervision of the ED Charge Nurse, nursing director or designees in cooperation with the ED physician who is readily available for consultation.
3) A triage nurse sees all patient presenting to the ED to elicit the chief complaint; conduct and document a brief patient assessment.
4) If a patient waits 20 minutes or more form the time of initial triage to the time of the Formal triage, the charge nurse will be notified and the second triage room and a second triage nurse will be implemented.
5) Responsibilities:
a) Assess all incoming patients and document findings.
b) Determine the priority need for care.
c) Initiate diagnostic and/or therapeutic measures as indicated by protocols, (i.e., order x-ray, splint, ice, elevate).
d) Keep charge nurse informed at reasonable intervals of the number and priority (category) rating of patients to be seen.
e) Monitor all patients in the waiting area. Patient's status is documented as necessary.
f) Maintain an awareness of activity in the treatment area (i.e., codes, delays in care).
6) Triage Procedure:
a) Patients present to the Emergency Department admission desk.
b) The triage nurse sees the patient. The nurse performs the triage interview collecting data sufficiently to determine priority of care.
c) Triage assessment takes place in the triage room.
d) Vital signs are measured unless reason for deferment is noted.
e) Documentation of all above data is done on the triage template in PulseCheck.
f) The triage nurse determines priority of care.
g) The ED staff and physician are kept informed of patients and their acuity in the waiting area. The triage nurse initiates any treatment or diagnostic work up ordered by the physician or included in the Triage Interventions/Protocols.
h) As rooms and staff become available the waiting area patients are called back in the order assigned by the triage nurse.
i) Patients in the waiting room are re-checked periodically based upon their condition.
7) Triage Categories: Category II: Emergent. Listed among the categories was "Chest Pain of Cardiac origin."

D. In an interview with the Assistant Vice President (AVP) of Medical/Surgical and the ED on 11/08/22 at 1:40 PM, when asked what time frame "re-checked periodically" meant, she confirmed the time frame was not defined in the Triage policy.

E. Review of the "Triage Cheat Sheet" provided on 11/08/22 at 10:45 AM showed the following:
1) Chest pain or shortness of breath: EKG (electrocardiogram), CBC (complete blood count), BMP (basic metabolic profile), CPK (creatine phosphokinase)/Troponin, 1 (one) view chest x-ray, COVID antigen.
2) Get an EKG on anyone (excluding small children) with symptoms between their belly button and their chin when there is any possibility the heart could be involved.

F. In an interview with the Assistant Vice President (AVP) of Medical/Surgical and the ED on 11/08/22 at 1:40 PM, she stated the Triage Cheat Sheet was placed in the triage area on 02/23/22. The AVP of Medical/Surgical and the ED stated the triage nurse could order the items on the Triage Cheat Sheet based upon the patients' presentation.

G. Review of Patient #1's clinical record on 11/08/22 showed the following:
1) Triage Notes on 10/24/22 at 7:20 PM showed the patient presented to the ED for evaluation of chest pain that began at approximately 8:15 AM while sitting at work with worsening of pain this PM, reported left arm numbness, nad (no acute distress) noted at this time. Respirations unlabored. Skin warm, skin color was normal, skin was dry.
2) Admission on 10/24/22 at 7:27 PM, the patient's urgency was assigned as "3 Urgent."
3) Pain on 10/24/22 at 7:27 PM: Patient complained of pain described as, on a 0-10, patient rated pain as 10, location: chest.
4) ESI (Emergency Severity Index) Level Tool on 10/24/22 at 7:27 PM: Two or more resources needed, no danger zone vital signs - suggested Emergency Severity Index Level 3 assigned.
5) Vitals signs on 10/24/22 at 7:21 PM showed blood pressure 148/77, pulse 84, respiration 20, temperature 97.6 (degrees Fahrenheit), Pain 10, Oxygen saturation 100% on room air.
6) The patient was transferred from Triage to the Emergency Waiting at 7:27 PM.
7) Nursing Procedure: EKG Chart dated 10/24/22 at 7:27 PM showed, "1925 (7:25 PM), EKG indicated for complaint of chest pain, 12 lead EKG performed on the left chest, done by Dr. (Named), first EKG. Follow-up: after procedure, EKG for interpretation given to Dr. (Named)."
8) Physician In Triage Note dated 10/24/22 at 9:41 PM showed, "67 F (female) c/o (complaints of) cp (chest pain) that began this morning but then resolved, states came back worse tonight w (with) sob (shortness of breath) and left arm numbness/tingling. Alert, nontoxic, slow to answer questions appropriately. VSS (vital signs stable). The patient had a brief encounter by me as the Physician in Triage and understands that the goal of this brief encounter is to facilitate their care. A complete evaluation will be performed once they are brought to a treatment area. I have reviewed the Chief Complaint, vital signs and obtained a brief history. I have ordered appropriate initial diagnostic studies and treatments based upon the abbreviated history and exam performed above. Additional diagnostic, treatment and disposition decisions will be made once the patient is brought to a treatment area. The patient has been informed of the potential for delays and I have asked that they notify me or the Triage Nurse if they desire to leave so that we may review the labs and/or imag (imaging)."
9) Nursing Assessment dated 10/25/22 at 1:19 AM showed, "Complex assessment performed, patient arrives via hospital wheelchair, no steady gait, lift to cart, history obtained from, no history available, patient unresponsive, skin abnormal, skin temperature is cold, skin dusky in color, patient complaints of chest pain, pt (patient) to ED for eval of chest pain since yesterday morning. Pt to room via wheelchair from triage accompanied by Dr. (Named) and (Named) RN (Registered Nurse). Pt lifted to stretcher, pt unresponsive, pulseless and apneic at this time. CPR (cardiopulmonary resuscitation) started."
10) EKG Interpretation on 10/25/22 at 1:36 AM showed, "12 Lead EKG interpreted by Emergency Department Physician, 12 Lead EKG shows sinus tachycardia, rate 122 with no ectopics; Interpretation: Normal EKG, Conduction normal, ST segments normal, T waves inverted."
11) Nurses Note on 10/25/22 at 1:50 AM showed, "Notes: at approx. 0115 (1:15 AM) pt was brought into triage room to reassess vital signs and draw delta troponin. After wheeling pt into triage room, this nurse attempted to arouse pt. Pt would not respond at that time. This nurse checked for pulse and performed sternal rub while sending lab tech to get MD. This nurse was unable to palpate pulse, pt was taken directly into ED room 1 and CPR was initiated."
12) HPI (History of Present Illness) dated 10/25/22 at 1:49 AM showed, "Chief complaint: patient presents for evaluation of cardiac arrest, patient present for evaluation of respiratory arrest. Upon patient re-evaluation by triage nurse patient was found to be without a pulse. Patient was immediately taken back to a room where CPR was started. Patient's initial rhythm was asystole. Patient was given 1 mg (milligram) of Epinephrine. Intubation was attempted however patient's jaw was severely clenched. Patient was given Etomidate and Recuronium which did not improve patient's clinched jaw. This was concerning that patient was likely in rigor mortis. Re-evaluation of rhythm showed the patient was still in asystole. It was decided that further efforts to continue CPR were unlikely to be successful and time of death was called at 0125 (1:25 AM)."
13) Nursing Procedure: Expiration Chart dated 10/25/22 at 6:40 AM showed, "Patient pronounced dead at 0125 (1:25 AM), patient pronounced by Dr. (Named), Patient pronounced dead in emergency department, post-mortem care completed, body identified by daughter, family notified, primary care physician notified, nursing director notified, nursing supervisor notified, coroner/medical examiner notified, funeral home notified, organ procurement agency notified, no autopsy requested."

H. In an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:50 PM, when asked about the Physician in Triage note dated 10/24/22 at 9:41 PM, the Director of Quality, Risk Management and Regulatory Compliance stated the assessment actually occurred during the triage process on 10/24/22 at 7:27 PM. The Director of Quality, Risk Management and Regulatory Compliance stated the time was not changed to reflect the actual time the physician triaged the patient.

I. Observation of video recording for Patient #1 from 10/24/22 at 7:25 PM to 10/25/22 at 1:15 AM on 11/09/22 showed the following:
1) At 7:27 PM the patient was transported to the waiting room from the triage area in a wheelchair. Patient was holding her head. There appeared to be no family or significant others present with the patient. Respirations were visualized.
2) From 7:36 PM to 7:57 PM the patient's position varied from sitting upright to having her head in her lap.
3) At 7:59 PM the patient waved her hand while looking at the receptionist area.
4) At 8:02 PM the patient waved her hand while looking at the receptionist area.
5) At 8:06 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN communicated with the patient. There was no evidence vital signs were obtained. There was no evidence of documentation of the communication with the patient. The RN then leaves the patient.
6) From 8:07 PM to 8:27 PM the patient's position varied from sitting upright to having her head in her lap. Respirations and/or movement were visualized.
7) At 8:28 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as a Radiology Technician communicated with the patient. The Radiology Technician completed their communication with the patient, then communicated with another patient and then transported the other patient out of the waiting room. Patient #1 then placed her head back in her lap.
8) From 8:28 PM to 8:42 PM the patient's position varied from sitting upright to having her head in her lap.
9) At 8:43 PM the patient waved her hand while looking at the receptionist area.
10) At 8:45 PM the patient waved her hand while looking at the receptionist area.
11) At 8:45 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN communicated with the patient. There was no evidence vital signs were obtained. There was no evidence of documentation of the communication with the patient. The RN then leaves the patient.
12) At 8:48 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as an RN placed an arm band on the patient.
13) At 8:50 PM a staff member identified by the Director of Quality, Risk Management and Regulatory Compliance as a Laboratory Technician takes the patient to a room off the waiting room and drew blood from the patient.
14) At 8:53 the Laboratory Technician transported the patient back to the waiting room.
15) From 8:59 PM to 9:19 PM the patient's position varied from sitting upright to having her head in her lap. Respirations and/or movement were visualized.
16) At 9:20 PM the patient placed her head in her lap.
17) From 9:20 PM on 10/24/22 until 1:14 AM on 10/25/22, the patient's head was in her lap. There was no evidence the patient changed positions after 9:20 PM on 10/24/22.
18) At 9:35 PM on 10/24/22, respiration by the patient were no longer visualized. The Director of Quality, Risk Management and Regulatory Compliance confirmed the observation.
19) At 10:17 PM a staff member transported another patient into the waiting room and sat the patient next to Patient #1. There was no observation the staff member assessed Patient #1.
20) On 10/25/22 at 1:14 AM two staff members identified by the Director of Quality, Risk Management and Regulatory Compliance as RNs attempted to arouse Patient #1. Patient #1 was then transported into the Emergency Department.
21) During observation of the video from 10/24/22 at 7:25 PM to 10/25/22 at 1:15 AM on 11/09/22, there was no evidence the patients in the waiting room were reassessed or vital signs were obtained.

J. The findings of the video observation were confirmed in an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:00 PM.

K. In an interview with the Director of Quality, Risk Management and Regulatory Compliance on 11/09/22 at 12:50 PM, the Director of Quality, Risk Management and Regulatory Compliance stated Patient #1 was under-triaged as an ESI (Emergency Severity Index) Level 3 Urgent and should have been assigned as an ESI Level 2 Emergent.

L. In an interview with RN #3, who was conducting triage assessments, on 11/09/22 from 9:40 AM to 10:00 AM, RN #3 stated the following:
1) When asked what the process was for triaging a patient presenting to the emergency department, she stated the Registrar registers the patient. The Registrar then notifies the Triage Nurse of a patient needing to be triaged. RN #3 stated she had two minutes to get the patient triaged once notified.
2) When asked if the patient was transported back to the waiting room, how often the patient was reassessed, RN #3 stated every 30 minutes to an hour. RN #3 stated she rounds every 30 minutes on patients. RN #3 stated vital signs were reassessed at a maximum of every two hours but would try to re-evaluate vital signs every hour. RN #3 stated the computer could be set to flag the staff for frequent vital signs. RN #3 stated she was not aware of a policy or a protocol directing the frequency of reassessing the patients.
3) When asked how the ESI Level was assigned to a patient, RN #3 stated the computer assigns the level based on information entered into the electronic health record. RN #3 stated the ESI assigned by the computer could be overridden and changed by the staff. When asked if there was a policy or guidance on how to assign the ESI Level, RN #3 stated she wasn't aware of any policy or guidance.

M. Review of the Corrective Action Plan provided on 11/10/22 at 2:40 PM showed the following:
1) Patients in the waiting room will have hourly vital signs and assessment of pain levels by ED staff. Implemented on November 9th.
2) Policy updated and triage nurses given a copy to review and initial. Implemented on November 9th. This will also be reviewed with a full signature and date at Triage Class.
3) Triage Nurse refresher course will be given and completed on 11/19/22: Monday 11/14/22 4:30 PM to 6:30 PM; Wednesday 11/16/22 4:30 PM to 6:30 PM; Thursday 11/17/22 4:30 PM to 6:30 PM; Saturday 11/19/22 10:00 AM to 12:00 PM.
4) Direct bedding by triage nurse was implemented November 1st.
5) Positions have been posted for paramedics and techs to cover the 10 AM to 10 PM shifts and the 7 PM to 7 AM shifts.
6) Discrepancy in documentation of the time of MD (physician) medical exam and EKG interpretation will be addressed by the ED Medical Director.
7) QA (Quality Assurance) coordinating a Root Cause Analysis involving ED implemented 10/27/22.

N. In an interview with the AVP of Med/Surg and the ED on 11/09/22 at 1:10 PM, she stated "direct bedding" meant the triage nurse can directly assign an ED room to a patient until the ED was full.

O. Review of the policy, "Triage," provided on 11/10/22 at 2:40 PM showed, "Patients in the waiting room will have vital signs and pain scale taken hourly by an ED tech, Paramedic, triage nurse, or licensed personnel."