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Based on staff interview and record review, the hospital failed to comply with 42 CFR 489.24 Special Responsibilities of Medicare Hospitals in Emergency Services, by not fulfilling the requirements for an appropriate screening for one (Patient 1) of 30 patients reviewed. This failure has the potential to adversely affect patient safety and quality healthcare for this patient and for other patients who require a medical screening exam.

Findings:

During the EMTALA survey conducted from 8/8/12 to 8/9/12, the survey team determined Patient 1 was not appropriately screened for an emergency medical condition. (Refer to A-2406)

Based on interview, medical record and document review, the hospital failed to perform an appropriate medical screening examination (MSE) to determine whether an emergency situation existed for one (Patient 1) of 30 patients reviewed as evidenced by failing to:

a. Implement policies and procedures to provide initial additional diagnostic interventions for a patient presenting with chest pain.

b. Implement policies and procedures to re-assess and escalate evaluation by a qualified medical professional for a patient with continuing chest pain and was observed on the floor in the ED waiting room in pain.

c. Implement policies and procedures to notify the emergency department physician and charge nurse to intervene when a patient has communicated intent to leave without being seen.

These failures had the potential to adversely affect patient safety and quality healthcare for Patient 1 and other patients requiring a medical screening exam by a qualified medical professional to determine if an emergency medical condition existed and provide subsequent stabilizing treatment for an emergency medical condition.

Findings:

Record review on 8/8/12 indicated Patient 1, a 66 year old male, arrived in the Emergency Department (ED) of Hospital A by private vehicle on 3/6/12 at 4:06 p.m., complaining of a sudden onset of chest pain. Registered Nurse 2 (RN 2), the on-duty triage nurse documented in Patient 1's ED record on 3/6/12, Triage time 1607 (4:07 p.m.). Acuity: LEVEL 3 (stable condition that requires intervention and/or ongoing assessment required by hospital policy and procedure). Chief complaint: CHEST PAIN and sudden onset, pain in both sides of front part of neck down to epigastric area, 'not sure if it muscular spent most of the morning climbing in the gym'. PAST MEDICAL HX (history): Hypertension: 16:11 (4:11 p.m.) with BP (blood pressure): 143/80 (normal is 120/80). History Onset 1500 (3:00 p.m.). Pain level now: 5/10 (moderate pain on a 1 to 10 pain scale).

RN 2 documented on 3/6/12 at 4:14 p.m. "Blood samples drawn....". Emergency Medical Technician 1 (EMT 1) documented on 3/6/12 at 4:20 p.m. "12-lead EKG was performed by a tech and shown to the ED physician." A full review of the ED record showed no documentation by an ED physician.

RN 1, the relief triage nurse, documented the following under "Disposition/Discharge" 17:15 (5:15 p.m.). "Pt. [patient's] daughter who is MD is in waiting room, asks why her father has not been taken to a monitored bed if he is having 'active' chest pain. Informed daughter that there are no monitored beds at this time, there are several CP [chest pain] patients in the department; that her father's EKG showed no changes from his previous EKG and his Troponin [a cardiac marker that can indicate heart muscle damage] labs had been drawn and sent. Daughter opts to take father to another hospital. The patient left the Emergency Department without being seen by a physician; patient was accompanied by a family member. The patient appears to be alert, oriented X 3, coherent and in no acute distress. The patient notified the ED staff prior to leaving the department and stated is leaving the ED due to the long waiting time."

Patient 1's daughter stated in a telephone interview on 7/16/12 at 10:00 a.m. that her father went to the emergency department of Hospital A on 3/6/12 seeking medical attention for sudden onset of chest pain. She stated she received a call from her father at approximately 5:00 p.m. asking for help as he had been there over an hour, had not been seen by the doctor and the pain was so bad that he had to lie down on the ED waiting room floor.

Patient 1's daughter said that she arrived in the ED approximately 10 minutes later, finding Patient 1 on the floor of the waiting room looking ashen and clutching his chest. She looked immediately for help and identified herself as a physician.

RN 1, the relief triage nurse, appeared at the front of the waiting room. The daughter said she identified herself as a physician and asked why Patient 1 was on the floor with active chest pain and not being treated. According to the daughter, RN 1 stated, " I don't know why he chose to lie on the floor" and continued to tell her that the EKG was normal and his blood work was in the lab and he could "wait out here". A short time later, RN 1 returned with the EKG, saying, "...see, his EKG is normal, he can wait".

The daughter stated she insisted Patient 1 required immediate medical attention for his ongoing symptoms, even if he were not having a heart attack "...he still needed evaluation and treatment for other life-threatening causes of the chest pain, he was clearly in distress and having ongoing active pain." According to the daughter, RN 1 said, "...there were 4-5 patients in back with chest pain and they had no available monitored beds in the ED". The daughter said she asked one more time if they were going to expedite taking Patient 1 to an ED room for evaluation and treatment and was told "No" by RN 1.

Patient 1's daughter stated she became quite concerned that critical time was being lost and she had to do something immediately. She told RN 1 that she and Patient 1 were leaving and assisted Patient 1 from the floor and take by private vehicle to the next closest hospital (Hospital B). She stated she realized while driving, the best course was to call 911 and have the ambulance meet them in route and take him the rest of the way to Hospital B. After arrival to the ED of Hospital B, at 6:20 p.m., Patient 1 went into cardiac arrest and died at 8:08 p.m. on 3/6/12.

On 8/9/12, review of the ambulance report dated 3/6/12 at 5:43 p.m. indicated "66 YO [year old] male, GCS 15 [Glasgow Coma Scale of 15 means fully conscious, no neurological deficits], found seated in car in severe distress, c/o CP [complaining of chest pain]...Patient describes 10/10 [10 on a pain scale from one to 10 is the worst pain imaginable] 'Sharp/intense' pain to anter CX [anterior chest] wall bilaterally, from clavicles [collarbones] to base of ribcage...Pt further c/o SOB (shortness of breath) & nausea....Pt very pale/cool/dry. 12-lead shows 1st deg HB [first degree heart block, the heart's internal pace-maker shows a delay in conduction]..NTG [nitroglycerin] X[times] 2 given, 4 mg MS [morphine] given w/o [without] relief. Pt. very anxious, continuously writhing & unable to find pos of comfort......"

On 8/9/12 review of Hospital B's ED record dated showed Patient 1 arrived and was immediately triaged at the ED on 3/6/12 at 6:20 p.m. with a diagnosis of "Chest Pain" and was assigned triage acuity LEVEL 2 (unstable condition that requires immediate intervention and continued assessment).

On 3/6/12 at 6:22 p.m. the ED physician documented "Chief Complaint: CHEST PAIN. This started just prior to arrival and is still present." The ED physician notes the Patient 1's pain quality as sharp and location as in the right and left chest area. Notes his "...pain level as 10/10 on arrival and 10/10 at maximum... has had difficulty breathing and nausea and some sweating episodes...described as radiating to the neck."

At 6:51 p.m. the ED physician documented "Pt [patient] has severe CP [chest pain] and I am concerned for Disect [aortic dissection]. BP [blood pressure] in both arms same, pain radiates to neck not back. ECG [EKG] NSR [normal sinus rhythm no ischemic changes]. Have ordered CT angio [diagnostic radiological exam]. 1900 [7:00 p.m.] called to room 'pt having a seizure', arrived to find pt post ictal [after a seizure] and unresponsive labored agonal respirations HR [heart rate] in low 40's [normal 60-80] sys [systolic] BP in 80's [normal 120]. Opened up fluids, gave atropine and Narcan [resuscitation medications] no response. ECG repeated and showed clear change and massive inferior MI [heart attack]. Had staff call in cath lab and cardiologist. Pt continued to have agonal respiration while being bagged [bag device used to push oxygen into the lungs]. Moved to Room C [cardiac room] for intubation [insertion of breathing tube inserted] CPR in progress and began multiple rounds of Atropine/Epi... Pt never regained pulse or spontaneous respirations. Patient 1 was declared dead at 8:08 p.m. on 3/6/12.

Review of the autopsy report dated 3/7/12 indicated "Cause of death: Cardiac insufficiency due to dissecting aneurysm of the ascending aorta." (The ascending aorta is the first section of aorta out of the heart; coronary arteries supplying blood to the heart muscle itself branch off the ascending aorta)."

On 8/9/12 at 10:40 a.m.,during an interview with Hospital A's Director of Risk Management (RM) the actions of RN 1 were reviewed regarding Patient 1's intention to leave while in the ED waiting room on 3/6/12. The RM stated "What he [RN 1] should have done is take the patient back [out of the waiting room and to an ED exam room], told the charge nurse and had the physician explain the risk of leaving without a medical evaluation."

Regarding RN 2's actions during the initial triage, RM stated triage nurses were to follow standardized procedures and "...for chest pain, you're supposed to bring the patient back for an EKG and labs. If over 29 you're supposed to put them on the monitor [cardiac] and get a chest x-ray. We talked to the nurse [RN 2, the first triage nurse] and she doesn't know why she didn't put him on the monitor and get the x-ray."

Hospital A staff interviewed on 8/9/12 at 1:10 p.m. included the Quality Manager (QM), RM, an ED physician (EDP), and the current ED manager (EDM). RM stated "security (staff) was the one who notified (RN 1) that a patient was on the floor and a physician wanted to talk to him."

The EDM stated triage nurses would not change the triage level of a patient who showed signs of deterioration in the waiting room but should notify the physician that the patient needed to be seen earlier. EDP agreed that there should be a communication between the nurse and the physician, and for patients presenting with chest pain with worsening symptoms, physicians relied on "well-trained triage nurses to give us the information."

EDM confirmed the ED was full at the time of Patient 1's visit. When asked how a patient with worsening symptoms could be accommodated if all the beds in the ED were full, the EDM stated the charge nurse should quickly check to see which patient currently roomed could be moved to a chair, then communicate with the physician of the need to bring another patient back. The EDM stated 21 of the 22 rooms in the ED already had cardiac monitoring capability and if all the monitored and the unmonitored rooms were full, the expectation was that staff would still be able to bring the patient back into the ED, place the patient on a gurney, using a portable monitor from the crash cart to provide cardiac monitoring.

EDM confirmed the need for an "...immediate assessment and to bring the patient [Patient 1] back to the exam room. We need to find the reason patient is on the floor." EDM was asked how the hospital determined staff competency for the role of triage nurse. EDM stated staff annually had to show proficiency by assigning triage levels to test scenarios depicting ED clinical situations. Also, nurses were to annually review and attest they understood the nursing standardized procedures, or orders approved by the physicians that were based on a patient's presenting symptoms.

During a telephone interview on 3/9/12 at 2:45 p.m. RN 3, the charge nurse on duty for Hospital A, stated "He [RN 1] came to see me a couple of times". He said the patient's daughter was there and wanted to see his EKG. The second time he checked, about one and a half minutes later, he said he found the patient [Patient 1] was on the floor." At that point, RN 3 stated "I looked to free up a bed, triage a patient from a room to either a chair or a gurney".

RN 3 stated, "...there was no indication there was an re-assessment done [by RN 1] and I rely on my triage nurses for their critical thinking skills. The impression was the patient was okay. I hadn't questioned his [RN 1] practice. Then no more than five minutes later he [RN 1] told me the patient [Patient 1] had left". RN 3 stated it was the "...responsibility of the triage nurse to notify us if the patient is going to leave without being seen. The next conversation I had with him [RN 1] was not that the patient was going to leave and then I was told the patient had left."

During an interview on 8/9/12 at 3:30 p.m. RM stated after the 3/6/12 incident involving Patient 1, the hospital immediately re-examined triage policies and nursing practice standard procedures and assessed nursing staff knowledge of the policies and procedures. The hospital discovered the nurses were not consistent in their knowledge and implementation of the policies and procedures.

RM stated the hospital immediately re-inserviced nursing staff on the standardized procedures, particularly regarding chest pain, and the responsibility of the triage nurses that included communicating to the charge nurse and the physician of changes in patient condition or intention to leave the ED. According to RM, RNs 1, 2, and 3 were suspended pending the completion of the investigation. RN 1 was terminated because of his refusal to cooperate with the investigation.

Review of the hospital policy "Emergency Department Practice Guidelines, Implementation by RN" indicated: " Physician consultation is to be obtained whenever situations arise beyond the intent of the standardized procedure or the competence or scope of practice/experience of the Registered Nurse." The policy and directed the RN to "Implement and follow the guideline(s) related to the chief complaint(s)."

The ED Standardized Procedure for "CHEST PAIN (not related to trauma or cough)" indicated:
1. Order 12 lead EKG and pulse oximetry as soon as possible."
2. Patients over 29 years old: Place on cardiac monitor; Order portable chest-x-ray."

Review of the hospital policy "Emergency Departments -Triage Policies and Assessment of Acuity Levels" indicated:
(6) Triage Nurses are responsible for communicating information between Triage, the ED Charge Nurse, the waiting area and the treatment areas. The Triage RN's will instruct all patient who are sent to the Waiting Room, at the time of the patient's initial triage assessment, to notify the Triage RN if the patient's condition worsens or changes or if the patient experiences increased pain.
(9) If a patient who has been triaged and placed in the Waiting Room complains of change of condition, increased pain, or has abnormal test results return, the Triage RN or Charge RN will document in the nursing notes and intervene as appropriate."

Review of the hospital policy "Emergency Department-Against Medical Advice (AMA): Emergency Department Specific" indicated the purpose was to:
1) To assure documentation of the advisement to patients of risks and consequences of departure from the Emergency Department prior to completion of evaluation, treatment, and disposition by the ED Physician (EDMD) or ED Physician's Assistant (EDPA).
2) To discourage a patient from leaving the Emergency Department without an EDMD's or EDPA's order.
3) To establish criteria for the proper documentation of patients leave 'AMA, LWBS or Elopement' and to document appropriately in the event that the patient leaves."

The Policy required:
1. The EDMD or EDPA will be notified of the patient's intention to leave the hospital as soon as it becomes known and as soon as the EDMD or EDPA is available."

The procedure/practice included:
1. ED staff shall notify the EDMD or EDPA of the patient's intent to leave and location of patient awaiting advisement as soon as it is known and the EDMD or EDPA is available.
2. The EDMD or EDPA must discuss with the patient (and/or the patient's family as appropriate) the potential risks and consequences which may occur if the patient leaves prior to the completion of the exam."