HospitalInspections.org

Based on interview and document review, the hospital failed to maintain compliance with 42 CFR 489.24 with respect to the Emergency Medical Treatment and Labor Act (EMTALA). The lack of compliance constitutes an immediate jeopardy to patient health and safety.

See findings at C-2406: Based on interview and document review, the hospital failed to ensure a timely comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed when the patient who presented to the emergency department (ED) with complaints of shoulder, neck and chest pain was not assessed timely or acted upon to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen.

Based on interview and document review, the hospital failed to post in places likely to be noticed by all individuals a sign specifying the rights of individuals under section 1867 treatment for individuals for examination and treatment for emergency medical conditions and women in labor (EMTALA).

Findings include:

On 1/3/22, at 9:02 a.m. a tour of the emergency department (ED) was conducted with the ED Manager and Chief Nursing Officer (CNO). During the ED tour there was an EMTALA sign in the ED waiting room, however the hospital failed to have an EMTALA sign in the ambulance bay or inside the entrance into the ED visible from the ambulance bay specifying the rights of individuals under section 1867 of the Social Security Act with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA). Additionally, there were no individual EMTALA signs in individual ED rooms for individuals to view while waiting for an examination. The ED manager acknowledged there was no sign posted in the ambulance bay entrance going into the ED, nor was there individual EMTALA signage posted in any ED rooms. The ED manager acknowledged patients often times would use the ambulance bay entrance and would then be brought directly back into an ED room for triage.

The policy EMTALA review/revised date 9/8/2022, lacked direction for posting of signs.

Based on interview and document review, the hospital failed to ensure a timely comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed when the patient who presented to the emergency department (ED) with complaints of shoulder, neck and chest pain was not assessed timely or acted upon to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen.

Findings Include:

P1's emergency department (ED) medical record from hospital A dated 10/14/22, indicated P1, a 37-year-old male, arrived at the hospital's ED on 10/14/22, by self, at 3:49 p.m. and was triaged by a nurse at 3:51 p.m. P1's chief complaints that included left shoulder, neck, and chest pain for the past three days. The record indicated P1 informed the triage nurse, "I haven't even gotten out of my truck for three days" he works for a pipeline. P1 has been coughing. P1 had vomiting and diarrhea taking aspirin (ASA) and TUMS (antacid) for the pain without relief, and just had the flu. Blood pressure 144/93, pulse 93, respirations 16, oxygen saturations at 98% on room air, and temperature 98.2 Fahrenheit. P1 was experiencing pain on intensity scale of 1-10, P1's pain intensity was an 8. P1 was triaged by nursing staff at an acuity level 3, meaning he required urgent treatment and required at least two of the hospital's resources (i.e., x-ray, laboratory). The record revealed P1 was not re-evaluated when he reported increased chest pain on three occasions while in the ED waiting room. P1 did not receive a medical screening exam (MSE) until 5:10 p.m., approximately 1 hour and 20 minutes after arriving to the hospital with complaints of left shoulder, neck, and chest pain. At the time of the MSE, P1's medical record revealed a critical Troponin I High Sensitivity (4.0-76.2) of 19178.4 ng/L and electrocardiograph (EKG) results indicated ST-T Waves: ST elevation -V3, V4, V5 both diagnostics indicating a significant cardiac event. On 10/14/22, at 7:20 p.m. P1's signed Transfer Certification Record indicated P1 required transfer to a higher level of care with the diagnosis of ST-Elevation Myocardial Infarction (STEMI), a severe type of heart attack. P1's discharge condition was critical.

A review of P1's ED record dated 10/14/22 from hospital B, where P1 had been transferred to for a higher level of care indicated hospital A provided P1's initial history and physical (H&P) report indicating P1 reported he had been experiencing chest pain off and on over the previous 3 days. P1 reported the pain was progressively worse and more frequent, eventually starting to radiate down his arms and up into his jaw associated with shortness of breath. He presented to hospital A's ED where initially was felt that his chest pain may be musculoskeletal, however, testing which included Troponin and EKG revealed P1 had experienced a cardiac event. At hospital B P1 was emergently taken to the catheter lab where P1 was found to have an ulcerated plaque in the proximal left anterior descending artery (LAD) (largest coronary artery of the heart) which was successfully stented with synergy drug-eluting stent.

During an interview with P1 1/3/23, at 9:22 a.m. P1 stated he had arrived at hospital A's ED around 5:00 p.m. on 10/14/22 with complaints of having chest pain at an 8 out of 10; however, he was told to go wait in the waiting room. P1 stated he had gone to the reception desk numerous times telling the reception staff he needed to be seen right away and that he was having a heart attack. P1 stated he was in tears in the waiting room because the pain had been so bad. P1 stated the reception staff behind the desk had gone back to report that he was pacing and crying in pain but when she came back from the ED, she reported to him they would get to him when they could. P1 stated once he was finally brought back to the ED, he was seen by the physician who then ordered an EKG, chest x-ray and labs. P1 stated he had reported his pain again at a 10 to the nurse assigned to him, however, the nurse stated to him "pain will not kill you". P1 stated it was not until after the labs and EKG results were back that they started providing care for him which included starting an IV and administering medications to treat both the heart attack and pain. P1 stated his labs and EKG revealed P1 had experienced a cardiac event. P1 stated he was taken immediately to hospital B where he was brought into surgery for a stent placement. P1 was discharged 2 days later 10/16/22.

During an interview with registered nurse (RN)-A on 1/3/23, at 2:17 p.m. RN-A stated that she had worked 3:00 p.m. to 11:30 p.m. on 10/14/22, at hospital A as the triage nurse. RN-A stated she triaged P1 when he came to hospital A's ED. RN-A verified her nursing note indicated P1 arrived at hospital A's ED with chief complaints which included left shoulder, neck, and chest pain for the past three days which was unrelieved by taking ASA and TUMS. RN-A stated she did not triage P1 at a higher level of needing to be seen by the medical provider because P1 was presenting with cold symptoms and the ED was full. RN-A stated staff did inform her multiple times P1 was asking to be seen and she told staff she would get him back to the ED as soon as she could. RN-A stated she did not reassess P1 when he presented back to the staff to be seen or consult with a physician regarding P1's signs and symptoms. RN-A stated cardiac events per hospital triage protocol are to be triaged at a level two that indicates a patient would need to be brought back immediately to the ED to have a MSE completed by the ED physician or medical provider. RN-A stated if a patient presents to the ED and has a change in condition while being in the ED waiting area that a patient is required to be re-evaluated and re-triaged due to having a change in condition. RN-A further stated P1 had presented to hospital A's ED classic signs of a cardiac event which included chest pain, arm, and neck pain.

During an interview with RN-B on 1/3/22, at 3:35 p.m. RN-B stated she worked on 10/14/22 at hospital A in the ED. RN-B stated she did not recall the patient or registration telling triage that P1 was crying and in the waiting room making comments of chest pain. RN-B acknowledged in an effort to calm the patient she would respond to a patient by saying "I understand you hurt, we are going to get your pain down, it's not going to kill you." RN-B stated when patients come into the ED patients are triaged and that prioritizes when the medical provider will see them. RN-B stated patients who present to the ED with cardiac complaints and chest pain are to be triaged at a level 2 and brought back immediately to receive the MSE and start treatment which included EKG, labs, and cardiac monitoring. At the end of the interview RN-B stated she recalled P1 in the room saying he was cold, getting him a blanket, but P1 never told RN-B he had crushing chest pain and felt run down. And, when the lab results came back there was no question of his condition.

During an interview with the medical doctor (MD)-A on 1/3/22, at 2:39 pm. MD-A stated he was not aware P1 was not brought back to a room at the time of triage and assumed that possibly it was a busy time and there was not a room available right away. MD-A stated once P1's lab and EKG results were received P1 was determined to be critical and required a transfer to a higher-level hospital, hospital B for treatment. MD-A stated patients who present with cardiac concerns are to be immediately brought back to the ED for a MSE and to start treatment which included EKG, labs, and cardiac monitoring. MD-A verified this did not happen on 10/14/22, when P1 arrived in the ED with complaints of shoulder, neck, and chest pain. MD-A stated he would not have wanted to receive the care P1 initially received when he presented to hospital A's ED for himself. MD-A further stated he depended on the nursing staff to appropriately triage and would have expected P1 to have been brought back for immediate care and treatment.

During an interview with registration staff (R)-A on 1/3/22, at 3:50 p.m. R-A stated she had been working on 10/14/22, the afternoon P1 came into the ED with complaints which included chest pain. R-A stated she remembered P1 because P1 was in the waiting room pacing and crying. R-A stated she had gone back to the ED to let RN-A know at least three times P1 was crying and saying he was having a heart attack; however, RN-A did not come out to re-triage P1. R-A stated RN-A told her they would get him back to the ED when they had open rooms. R-A stated registration can see tracker that identifies what ED rooms are available and rooms had been open at the times she went back to report to RN-A that P1 was crying out saying he was having a heart attack. R-A stated you could see that P1 had been in so much pain and she could not understand why he was not taken immediately back to the ED for treatment. R-A stated when patients come to the ED with chest pain they are always brought right back. R-A further stated when she was told P1 had to be transferred to a higher level of care because he had a heart attack it was very upsetting because she had told RN-A numerous times that P1 needed to be brought back and was not.

During an interview with emergency department manager (EDM)-A on 1/5/22, at 8:33 a.m. EDM-A confirmed P1 had presented to hospital A's ED with reports of shoulder, neck, and chest pain on 10/14/22, at approximately 5:49 p.m.; however, P1 had not been immediately brought back into the ED for a MSE. EDM-A verified P1 had not received a MSE until 7:10 p.m. EDM-A verified through review of facility ED logs that at the time P1 presented to the ED rooms had been available and open. EDM-A stated her expectation is that nursing staff are following proper triage procedure and protocol which included cardiac concerns to be triaged at a level 2 and be brought back immediately into the ED for a MSE and to begin treatment. EDM-A stated her expectation was for nursing staff to re-triage and see any patient who is in the waiting room when registration staff is reporting a change in condition. EDM-A stated neither of these were done when P1 presented to hospital A's ED on 10/14/22. EDM-A verified once P1 was brought back into the ED for his MSE tests were ordered which revealed P1 was critical and needed immediate transfer to a higher level of care for further treatment. EDM-A stated RN-A made an incorrect judgment call when P1 presented to the ED on 10/14/22.

During an interview with chief nursing officer (CNO) on 1/5/22, at 9:06 a.m. CNO stated it was her expectation that patients are triaged appropriately. CNO stated an initial triage determines patient acuity and which initiates the MSE. CNO stated her expectation is that patients are re-assessed with any changes they are experiencing and would be brought back into the ED. CNO stated it was concerning that P1 had not received his MSE for over an hour upon arrival to the hospital ED with complaints of shoulder, neck, and chest pain. CNO further stated when P1 had increased chest pain and crying out in pain while in the waiting room he should have been reassessed and brought back immediately to the ED. CNO stated it was her expectation that all policies and procedures are being followed for patient safety and proper patient care.

The facility's policy EMTALA review/revision date 9/8/2022, directed that the facility is compliant with federal, state and locally mandated rules and regulations whenever individuals present themselves to the Emergency Department requesting care. The policy purpose is to determine if an emergency medical condition exists for individuals presenting and requesting the services of the Emergency Department; to assure a transfer of care occurs when required services are beyond the scope of the facility; to ensure quality care and compliance with the provisions of EMTALA. The act requires a medical screening exam (MSE) for any individual who presents themselves to the Emergency Department requesting care. Any person requesting emergency services, who presents to a facility that provides emergency services, must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency medical condition (EMC) exists. The medical screening exam (MSE) is performed by an MD and/or a NP/PA. If the MSE reveals an emergency medical condition it must be stabilized.

The facility policy Emergency Department Triage Protocol reviewed/revision date 4/21/2022, directed All patients who present to the Emergency Room will be triaged and provided a medical screening exam (MSE) to provide a method of evaluating and prioritizing care to Urgent Care and Emergency Department patients; to assure presenting patients receive a timely medical screening exam (MSE). The five-tier triage model will be utilized.
5 = Needs little or no treatment. None of the hospital ' s resources are necessary (i.e., simple rash).
4 = Minor treatment. No more than one of the hospital ' s resources are necessary (i.e., prescription).
3 = Urgent. At least two of the hospital ' s resources are required (i.e., xray, laboratory).
2 = Emergent. Unstable/compromised. If left untreated they will quickly deteriorate.
1 = Needs resuscitation. The most serious, life threatening situations requiring immediate assistance.