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Based on interview, record review, policy review and video review, the hospital delayed treatment for one patient (#1) out of 30 Emergency Department (ED) records reviewed which resulted in death. The hospital's ED average monthly census over the past six months was 1,014; and the six months from July 2021 through December 2021 was 1,105.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 10/14/19 showed:
- It is the policy of Parkland Health Center to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and requests examination or treatment will receive an appropriate medical screening examination (MSE) beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) provided by qualified medical personnel as determined by the hospital's board of directors.
- "Emergency Medical Condition (EMC)," means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.

Review of the hospital's policy titled, "Assessment of the Emergency Department Patient" undated showed:
- All patients admitted to the ED will be assessed by a Registered Nurse (RN) in a prompt manner dependent on the patients' chief complaint, clinical status, initial findings, and patient volume.
- Triage will be based on the 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).
- This will be based on the patient's chief complaint, number of resources that will need to be utilized as well as vital signs, and will be determined in triage.

Review of the untitled and undated hospital document, posted at the ED desk of the Patient Access staff directed staff to immediately notify nursing of presentation of a patient with cardiac complaints such as chest pain; neck, jaw or arm pain; or shortness of breath

Review of the medical record of Patient #1 showed:
- He was a 51-year-old male who presented by personal vehicle to the ED on 09/10/21 at 1:32 PM with chest pain.
- He was sent to the waiting room.
- At 1:46 PM, another patient in the waiting room alerted the Patient Access staff that the man was having a "seizure".
- At 1.50 PM, the physician came to the waiting room.
- At 2:35 PM, the patient was declared deceased.

Based on interview, record review, policy review and video review, the hospital delayed treatment to one patient (#1) out of 30 patient records reviewed which resulted in death. The hospital's Emergency Department (ED) average monthly census over the past six months was 1,014. The hospital's ED average monthly census for the six months from July 2021 through December 2021 was 1,105.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 10/14/19 showed:
- It is the policy of Parkland Health Center to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and requests examination or treatment will receive an appropriate medical screening examination (MSE) beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) provided by qualified medical personnel as determined by the hospital's board of directors.
- "Emergency Medical Condition (EMC)," means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.

Review of the hospital's policy titled, "Assessment of the Emergency Department Patient" undated showed:
- All patients admitted to the ED will be assessed by a Registered Nurse (RN) in a prompt manner dependent on the patients' chief complaint, clinical status, initial findings, and patient volume.
- Triage will be based on the 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).
- This will be based on the patient's chief complaint, number of resources that will need to be utilized as well as vital signs, and will be determined in triage.

Review of the untitled and undated hospital document, posted at the ED desk of the Patient Access staff, directed staff to immediately notify nursing of presentation of a patient with cardiac complaints such as chest pain; neck, jaw or arm pain; or shortness of breath.

Review of the hospital document titled, "Treatment/Care Event" dated 09/10/21, showed:
- The specific event type was delay/lack of response to patient condition.
- Initial severity level - death.
- Brief factual Description - Patient signed in with chest pain and registration did not inform staff that he had arrived. Another patient that had signed in and was sitting in the waiting room alerted staff that the patient was not responsive. That was when registration called staff. An RN and Physician went to the waiting room. Three nurses were caring for another patient that had arrived by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and was aggressive. We were attempting to triage him and keep him safe. The DON (Director of Nursing) called for an AMBU bag (a hand-held device used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) and a stretcher. Upon arriving to the waiting room, I found the patient with agonal respirations (gasping, labored breathing). The patient was placed on a stretcher and taken to room two where he went into cardiopulmonary arrest (when the heart suddenly and unexpectedly stops pumping). The patient was pronounced at 2:35 PM.
- Follow up actions - Discussed with charge nurse on 09/13/21, who stated that the DON was present during the situation and discussed with Staff V and Staff I, Director of Clinical Excellence, immediately after the situation occurred on 09/10/21. Two of the three core nurses were tied up with an autistic child (a developmental disorder that impairs communication and social interaction) who was vomiting post Ketamine (short-acting anesthetic) administration by EMS and they were attempting to protect his airway. The third nurse was in another room. They were unaware this patient had arrived. The registrar registered patient with complaint of chest pain and failed to follow established process of calling a nurse. Registrars have a list of complaints that they are to call the nurse with immediately. First call to nursing staff was that the patient was unresponsive. A nurse and physician immediately responded to waiting room and the patient was found unresponsive with a pulse but respirations agonal. The patient was placed on a stretcher and resuscitative measures initiated. Patient arrived at 1:32 PM. Code (emergency situation where a person's heart or breathing has stopped and staff quickly respond to attempt to restore the heartbeat or breathing) documentation started at 1:50 PM.
- Nurses note at 2:41 PM read - registrar called stating patient lethargic (weak/sluggish) and possible seizure (a sudden, uncontrolled electrical disturbance in the brain which causes changes in behavior, movements and/or levels of consciousness). Patient found with agonal respirations, unresponsive and skin diaphoretic (excessive, abnormal sweating). Obtained stretcher and moved patient to room two. Patient vomited and respiration ceased en route to room two. Patient pronounced dead at 2:35 PM.
- Resolutions and Outcomes - Facility Risk Management Notes
Registrar disclosed she failed to notify the triage nurse when the patient arrived with chest pain. "Patient did not appear to be in distress and there was a rowdy patient on the ambulance stretcher they just brought in." Nurse stated that when she went to check on patient he had agonal breathing. Placed on stretcher and monitor and was in V-fib (a type of irregular heart rhythm in which the heart will no longer pump blood. V-Fib is a medical emergency that will lead to death if not treated promptly.) Stated she and another nurse stated need to shock and physician was preoccupied with an airway. Nurse again stated V-fib and he needed shocked, Physician again attempted to intubate (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own). Nurse stated patient was in V-fib more than nine minutes before shock was administered. Nurse stated physician did not follow Advanced Cardiac Life Support, (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) protocol.
- Registrar stated she didn't follow protocol and alert staff that a person with chest pain arrived. Patient sat in the waiting room fourteen minutes before cardiac arrest. RN at the code stated Physician did not follow ACLS protocol, focused on airway (describes the organs of the respiratory tract that allow airflow during ventilation) versus acknowledgement of V-Fib and waited nine minutes before the first defibrillation (administering a controlled electric shock in order to allow restoration of the normal rhythm) even though - the Physician that the patient needed shocked.
Sprint management - latent failure
- The event possibly contributed to the patient's death
- Communication breakdown
- Environment
- Lack of or failure to follow policy/procedure/process

Review of Patient #1's medical record showed:
- He was a 51-year-old male who presented by personal vehicle to the ED on 09/10/21 at 1:32 PM with chest pain.
- He was sent to the waiting room.
- At 1:46 PM, another patient in the waiting room alerted the Patient Access staff that the man was having a "seizure".
- At 1.50 PM, the physician came to the waiting room.
- At 2:35 PM, the patient was declared deceased.

Review of the hospital video dated 09/10/21 showed:
- At 1:33.24 PM, Patient #1 drove into and parked his vehicle in the parking lot.
- At 1:34.07 PM, he opened the door into the hospital with his hand on his chest.
- At 1:34.18 PM, he presented to the registrars window.
- At 1:34.43 PM, he walked into the waiting room and sat down.
- At 1:35.41 PM, he placed his right hand to his chest.
- At 1:40.12 PM, he repositioned his upper body.
- At 1:40.56 PM, he placed his hand on his chest.
- At 1:42 PM, he placed his left hand on his chest.
- At 1:45.21 PM, he looked to his left.
- At 1:45.45 PM, both hands fall to his side.
- At 1:46 PM, his legs move and he slumps back into his chair.
- At 1:46.36 PM, another patient in the waiting room is seen going to the registrar's window.
- At 1:47.12 PM, he slumped to the right in his chair.
- At 1:47.32 PM, the physician touched shoulder of patient.
- At 1:47.40 PM, the physician removed the patient's mask.
- At 1:47.43 PM, a nurse brought a wheelchair.
- At 1:47.58 PM, the nurse and physician unsuccessfully tried to put the patient in the wheelchair.
- At 1:48.09 PM, the physician is seen putting a stethoscope to the patient's chest.
- At 1:49.36 PM, a gurney is brought to the waiting room for the patient.
- At 1:49.49 PM, the patient is taken into the ED.

During an interview on 03/08/23, Staff K, DON, stated that sometimes ED would call her to help if they were busy. She stated that she walked out to the ED desk to see where she could start helping. The other patient in the waiting room came to the (registrar's) window and said he thought Patient #1 was having a seizure. She stated that she looked at the waiting room camera and got a wheelchair. He had agonal respirations and was gasping for air. He was pale and incontinent of urine. She stated that she went into the ED and said there was a code. Staff T, Physician, went to the waiting room.

During an interview on 03/08/23 at 10:31 AM, Staff L, ED Medical Director, stated that chest pain was either given a 1 or 2 ESI triage. He stated that he would expect the ED staff to be notified immediately of a patient with chest pain.

During an interview on 03/08/23, Staff M, Patient Access, stated that Patient #1 came in and said his chest "kind of hurt". She sent him to the waiting room. She stated that she had been directed in her education to immediately notify nursing if a patient with chest pain presented to the ED but all nursing staff were with a combative patient and all the beds were occupied. She stated that there was no nurse in the triage room to call. She stated that she could have notified them by an overhead page or by the hospital provided portable phone (a wearable device for users who communicate primarily with voice and need to receive basic text messages and alarm notifications.)

During a telephone interview on 03/09/23 at 9:25 AM, Staff T, Physician, stated that this event was a long time ago. He was now retired and does not have access to the medical record. He stated that he was busy with something. He stated that he did not think the patient presented with chest pain. He had a pulse and a code was initiated. He stated that the patient was not in a shockable rhythm. He stated that a shockable rhythm would be Ventricular Fibrillation, or V-Fib and Pulseless ventricular tachycardia, or V-tach.