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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that a medical screening examination was completed to determine if a medical emergency existed. See deficiency at A-2406 (A).

2. The Hospital failed to ensure the Medical Staff Bylaws and/or Rules and Regulation included the individual(s) determined to be qualified to conduct Medical Screening Examinations (MSE). . Refer to A-2406 (B).

The immediate jeopardy (IJ) began on 4/9/2023, due to the Hospital's failure to follow their chest pain protocol to ensure an medical screening exam was completed to determine if a medical condition existed. Subsequently, the patient went to Hospital B and was diagnosed with an acute myocardial infarction (heart attack). The IJ was announced on 6/14/2023 at 2:15 PM during a meeting with the Hospital President, Chief Financial Officer, Chief Medical Officer, Chief Nursing Officer, Quality Director and Regional Director of Regulatory and was not removed by the survey exit date of 6/14/2023.

A. Based on document review and interview, it was determined that for 1 of 17 (Pt #1) patients presenting to the emergency department (ED) with chest pain, the Hospital [Hospital A] failed to ensure that a medical screening examination was completed to determine if a medical emergency existed. Subsequently, Pt #1 left Hospital A without being seen and went to Hospital B, where Pt #1 was diagnosed with an acute myocardial infarction (heart attack).

Findings include:

1. The Hospital's policy titled, "Cardiac Emergency: Management of (9/19/2022)" was reviewed on 6/12/2023 and required, "RN collect comprehensive data pertinent to the patient' health situation. Identify patient's chief complaint. ... History of present illness. Assess patient's level of pain, utilizing 0-10 pain scale. ... Past medical history. Obtain and document relevant historical background data. Past medical history, past surgical history. ... Physical assessment ... Interventions: Patients presenting, either ambulatory or via ambulance, will have an EKG (electrocardiogram) done within 5-10 minutes of presentation. EKG will be given immediately to ED attending who will sign and time EEC and document interpretation in electronic Medical Record."

2. The clinical record of Pt. #1 was reviewed on 6/12/2023 and included:
-Pt. #1 presented to the emergency department (ED), via family car, on 4/9/2023 at 10:14 AM with an arrival complaint of chest pain for one week and nausea/vomiting beginning 4/8/2023, PM. The acuity level assigned to Pt. #1 upon arrival was a 3 (urgent).
-Triage start time was 10:14 AM (E#3 - Nurse), immediately upon arrival. Vital signs were stable, as follows: Blood pressure - 155/87, temperature - 97.6, pulse - 87, respirations - 20 and oxygen level - 97%. Pain assessment included, "Currently in pain: Yes." Triage interventions: "ED protocol initiated." Triage was completed at 10:18 AM. The triage note did not include Pt #1's medical history; a physical assessment of Pt #1; or level of Pt #1's pain. No interventions, including an EKG, were completed.
-Nursing note (E#4), dated 4/9/2023 at 11:20 AM, included, "Patient [Pt. #1] left without being seen."
-The record did not indicate what time Pt #1 left the ED.

3. The clinical record of Pt. #1 from Hospital B was reviewed on 6/13/2023 and included:
-Pt. #1 presented to the ED at Hospital B on 4/9/2023 at 11:30 AM with a chief complaint of chest pain.
-The history of present illness included chest pain for over 24 hours and a history of coronary artery bypass surgery (creates a new path for blood to flow around the heart). Chest pain was an 8 out of 10 in severity. The triage note included, "stabbing sternal chest pain radiating to left side of chest, that began two days ago. Pain has been increasing. Complains of n/v [nausea/vomiting]. History of triple bypass 15 years ago and dementia." An initial EKG was performed during triage that was inconclusive.
-ED triage vital signs on 4/9/2023 at 11:36 AM were stable, as follows: blood pressure - 138/78, temperature - 97.3, pulse - 74, respirations - 18 and oxygen level 93%.
-The ED physician's physical exam included MDM (medical decision making): "Patient [Pt. #1] with complaints of chest pain possibly concerning for acute ischemia [lack of blood flow]. Initial EKG demonstrates ST depression diffusely, no obvious ST elevation therefore will obtain stat [immediate] cardiology consultation and will repeat EKG with right sided posterior leads."
-ED course was documented as:
- 11:50 AM - Cardiology at bedside evaluating Pt. #1
- 11:52 AM - Based on posterior leads there is evidence of ST elevation, a Cardiac Cath lab alert called.
- 11:56 AM - Heparin (blood thinner) IV (intravenous - into the vein) initiated
- 12:00 PM - Cardiology at bedside obtaining bedside echocardiogram
- 12:22 PM - X-ray (chest) at bedside
-The final ED diagnosis was ST elevation myocardial infarction (STEMI - occlusion of one or more coronary arteries that supply the heart with blood). Pt. #1 was taken for a cardiac catheterization on 4/9/2023, treated with DES (drug-eluding stents) and was admitted and monitored in the cardiac ICU with medical treatment. Pt. #1 was discharged from Hospital B on 4/12/2023.

4. The triage nurse (E#3), who triaged Pt. #1 on 4/9/2023, was interviewed via telephone on 6/13/2023 at 11:30 AM. E#3 stated, "When a patient presents to the hospital, they come directly to the triage nurse or security if the nurse is busy. An initial assessment is completed to include demographics, presentation reason, vital signs and a level of triage is assigned. [Pt. #1] had chest pain upon presentation and should have had an EKG within 10 minutes. I don't know why [Pt. #1] didn't. There should have been a pain score assigned to evaluate the level of pain the patient was experiencing; I don't know why I didn't document a pain scale. Once the EKG is complete, it is shown to the doctor to determine further care."

5. The Charge Nurse (E#6), who was on duty on 4/9/2023, was interviewed on 6/13/2023 at 10:45 AM. E#6 stated, "For any chest pain patient who presents to the ED, the expectation is to have an EKG completed within 10 minutes to ensure the proper treatment can begin."

6. The Director of Nursing Critical Care (E#1) was interviewed on 6/13/2023 at 9:35 AM. E#1 stated that the Hospital has a cardiac catheter lab and a full cardiac surgery team available around the clock to treat chest pain and any other heart concern. E#1 stated, "We have a cardiac team available for any intervention required. When a patient presents to the ED with chest pain, an EKG is to be completed within 10 minutes and the ED physician reads it right away."

7. An ED physician (MD#1) was interviewed on 6/13/2023 at 1:00 PM. MD#1 stated that any patient who presents to the ED with chest pain requires a quick assessment and depending on bed availability should be taken directly to the main ED. When a bed is not readily available, the patient should have an EKG within 10 minutes of arrival and have an ED physician evaluate it (identified by signature, date, and time). MD#1 stated, "If the EKG is abnormal or shows a concern, the charge nurse is notified and a bed needs to be found, either by moving someone out of the ED or a hall bed. Treatment needs to begin immediately. We are a full cardiac hospital and have acute cardiologist available around the clock." MD#1 stated, "The EKG is essential for decisions on treatment."

B. Based on document review and interview, it was determined that the Hospital failed to ensure the Medical Staff Bylaws and/or Rules and Regulation indicated the individual(s) determined to be qualified to conduct Medical Screening Examinations (MSE).

Findings include:

1. On 6/13/2023, the Medial Staff Bylaws and Rules and Regulations (dated 6/23/21), were reviewed. The Medical Staff Bylaws and Rules and Regulations did not include the individual(s)/medical practitioner(s) who were determined to be qualified to conduct a medical screening examination.

2. On 6/13/2023, 17 ED clinical records were reviewed. Each record had a MSE completed by an attending physician or resident.

3. On 6/13/2023 at 1:30 PM, an interview was conducted with the Chief Medical Officer (MD #2). MD #2 stated the Hospital Bylaws and Rules and Regulations do not include who is qualified to conduct Medical Screening Examinations. MD #2 stated that the Hospital Bylaws and Rules and Regulations should include who is qualified to do a MSE.

4. The ED Medical Director (MD#3) was interviewed via telephone on 6/14/2023 at 9:05 AM. MD#3 stated that the ED is staffed with Attending physicians and senior emergency residents, and all can perform MSEs. The ED does not use any other level of provider (i.e.: Physician assistants or nurse practitioners).