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Based on interview, record review, policy review, and review of video surveillance, the hospital failed to ensure staff followed its policies and procedures, and did not provide a Medical Screening Exam (MSE) within the hospital's capabilities and capacity in a timely manner to prevent a delay in care, when one patient (#24) presented on hospital property within 100 feet of the emergency department (ED) doors with an Emergency Medical Condition (EMC) that met the prudent layperson observer standard. Thirty-one Emergency Department (ED) medical records were reviewed of patients who presented to the hospital's ED seeking medical care/treatment, out of a sample selected from April 2020 to October 2020. The hospital's ED had an average of 3,364 emergency visits per month over the past 6 months.

This failure by the hospital had the potential to delay care and treatment for all patients that presented to the hospital's ED seeking medical care/treatment.

Findings Included:

Review of the hospital's policy titled, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA), GA-063," dated 07/23/20, showed the following:

"Comes to the Emergency Department: means the individual (not yet a patient) - presents at the Hospital's ED or on Hospital Property and examination or treatment for a medical condition
is requested or it can reasonable be inferred that the individual needs examination or treatment for a medical condition."

"MSE: Means "medical screening examination" and refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in Labor." "Such screening must be done within the facility's capability and available personnel, including on-call physicians and other QMPs." "The medical screening examination is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs and must continue until the patient is either Stabilized or appropriately transferred."

Review of hospital videos and interviews with hospital staff stationed outside and inside the hospital ED showed that staff failed to follow this policy and did not provide patient # 24 with an appropriate (timely) medical screening examination within the hospital's capabilities and capacity on 8/24/20 when notified "approximately 10" times of a "situation" in the parking lot.

Review of the hospital's video recording titled, "ED & Main Entrance," dated 08/24/20, showed a southeast camera view of the parking lot outside the hospital's ED and Diagnostic Center entrances. The review showed that a male (later identified as patient # 24's son) assisted patient # 24 from a car in the hospital parking lot at 9:45:16 AM. As the video continued, the male struggled to carry patient # 24 to the ED entrance but had to stop and lay her down on the side walk. At 9:47:23 AM the video showed the male began to perform chest compressions and at 9:47:30 AM, bystander # 2 (a male in a black shirt and tan shorts), entered camera view and upon seeing the situation, began running toward the ED entrance.

Review of a second video camera recording titled, "ED Main Entry" dated 08/24/20, showed the view from inside of the main ED entrance. At 9:46:46 AM, the video showed bystander #4 (a male with a white mask), entered the ED, got the Screener's attention and began pointing and looking toward the parking lot. At 9:47:52 AM, bystander #2 (a male in a dark shirt), entered the ED, pointed to the parking lot, and appeared to be speaking to the Screener. At 9:48:20 AM, bystander #5 (a female with dark sunglasses), entered the ED, turned several times to look out toward the parking lot, and appeared to be speaking to the Screener while pointing to the parking lot. At 9:49:22 AM, Staff M, Hospitalist RN (sitting outside the ED on break), opened the door at the ED entrance and appeared to be speaking with the Screener, the Screener walked toward the ED door and then exited camera view toward the admitting/waiting room area. At 9:51:30 AM, bystander #2 re-entered the ED and appeared to be speaking to the Screener, waving his hands and pacing the entrance area while the Screener was on the phone. At 9:52:19 AM, bystander #6 (a female in a white shirt), entered the ED, pointed to the parking lot, and appeared to be speaking to the Screener.

Review of the City's Fire Department Emergency Medical Services (EMS) report showed that hospital staff contacted the 911 operator on 8/24/2020 at 9:51:02 AM and a second call from a "probable citizen" was recorded at 9:51:04 AM.

Review of the hospital's undated and untitled document showed a "Code Blue" (hospital code for an emergency) was initiated on 08/24/20 at 9:54:22 AM, approximately 3 minutes after staff called 911.

During an interview on 10/08/20 at 8:25 AM, Staff I, Screener, (non-clinical staff assigned to screen individuals entering the ED for signs and symptoms of COVID-19 on 8/24/2020) stated that:
- On the day of the event a hospital vendor was the first person that notified her of a "fall" in the parking lot.
- She notified the admitting desk, Staff J, Admitting/Registration Clerk, that someone reported a fall in the parking lot and Staff J placed a phone call, she assumed to the ED Charge Nurse.
- Approximately 10 times someone came to tell her there was a situation in the parking lot.
- She continued to inform the bystanders that the situation was being handled.
- After Staff M told her that assistance was needed in the parking lot for a patient receiving CPR, she went back to admitting, where Staff J, Admitting/Registration Clerk, called the operator and she was told to call 911.
- While on the phone with 911, she walked over to the ED entrance and looked toward the parking lot where saw a nurse doing chest compressions.
- She was unaware that if a patient needed assistance she was to call a Rapid Response.
- She was unaware that if there was an emergency in the parking lot that the hospital policy stated 911 was to be called.

During an interview on 11/17/20 at 12:00 PM, Staff F, ED charge nurse stated that:
- She was working as the ED charge nurse that shift.
- She received a call on her phone from Staff I, Screener, stating that there had been a fall in the parking lot.
- Staff I stated she had received direction to tell the patient to call 911 for assistance and wanted to ensure this direction was correct.
- She told Staff I that calling 911 was the correct action.
- Approximately five minutes later she heard the Code Blue page.

Review of a second hospital policy titled "Rapid Response, PC-355" with an effective date of 11/12/2018 showed the following:
"Procedure: III. Non-Patient Rapid Response Calls"
"A Rapid Response may be called to assist non-patients (visitors, outpatients on hospital campus or employees)." "However, it must be noted assistance will be limited to those actions any reasonable and prudent health-care professional would offer in an out of hospital emergency/first aid situation as Rapid Response order sets are not in effect for the non-patient."

Review of a third hospital policy titled "Code Blue, PC-354", dated 12/19/18 showed the following: "4. Stand-alone automatic external defibrillators (AEDs) should be utilized where available." "All healthcare workers with a current BLS/AED card are expected to use the AED on any victim found down, be it patient, visitor or employee."
"5. The Emergency Medical System (EMS) will be activated for all areas not covered by the Code Blue team, as well as all arrests occurring outside the building." "If the Code Blue team is not able to transport the Code Blue cart to the scene, the team will provide BLS until EMS arrives."

During an interview on 10/07/20 at 2:50 PM, Staff E, RN, ED Manager, stated that:
- On 8/24/20, there were seven nurses, two nursing assistants, two physicians, and one nurse practitioner on duty in the ED.
- There was not a designated Code Blue Team, the team would be determined on staff availability, but would always include a physician and the Charge Nurse.
- Whenever a Screener or admitting staff identified a patient that needed assistance, they should escalate it and call for a Rapid Response, "the Screener that day (8/24/20) did not know to do that."
- The Code Blue policy stated that EMS (emergency medical services, 911) would be called for any situation that arose in the parking lot.
- The rationale for that policy was that when the size of the campus was taken into consideration, EMS would be able to respond faster than ED staff.
- EMS calls from the parking lot occurred "quite frequently" due to falls or spinal concerns.

Please refer to 2406 for further details.

Based on observation, interview, record review, policy review, and review of video surveillance, the hospital failed to ensure a Medical Screening Exam (MSE) within the hospital's capabilities and capacity was performed in a timely manner to prevent a delay in care, when one patient (#24) presented on hospital property within 100 feet of the emergency department (ED) doors with an Emergency Medical Condition (EMC) that met the prudent layperson observer standard. Thirty-one Emergency Department (ED) medical records were reviewed of patients who presented to the hospital's ED seeking medical care/treatment, out of a sample selected from April 2020 to October 2020. The hospital's ED had an average of 3,364 emergency visits per month over the past 6 months.

As a result of the delay in treatment, patient # 24 was not breathing and did not have a pulse from approximately 9:46 AM until approximately 10:03 AM when she was brought inside the ED. The patient died less than 24 hours later. The hospital's failure had the potential to affect all individuals who presented on hospital property seeking care for an emergency medical condition.

Findings Included:

During an interview on 10/07/20 at 4:00 PM, Staff G, Security Director, stated that:
- The hospital's security monitors covered over 200 camera views across five screens.
- There was no dedicated staff that monitored every camera view due to various calls and activity around the campus daily.

Review of the hospital's video recording titled, "ED & Main Entrance," dated 08/24/20, showed a southeast camera view of the parking lot outside the hospital's ED and Diagnostic Center entrances. The review showed:

- 9:45:00 AM, a white car drove into camera view and parked between the Diagnostic Center and ED entrances.
- 9:45:16 AM, a male (later identified as Patient #24's son) exited the car, walked around to the passenger's side and removed Patient #24 from the car.
- 9:46:08 AM, Patient #24 appeared to be unresponsive as her son struggled to carry her.
- 9:46:24 AM, Patient #24's son stopped on the sidewalk, placed his hands under her arms and attempted to drag her toward the ED entrance.
- 9:46:27 AM, Patient #24's son turned, and appeared to be speaking to a car that had stopped, while he attempted to hold the patient upright.
- 9:46:38 AM, the car drove away, Patient #24's son laid her down on the sidewalk.
- 9:46:54 AM, Bystander #1, female in dark dress, walked over to Patient #24, appeared to speak to her son, and reached down and touched the patient.
- 9:47:23 AM Patient #24's son began chest compressions.
- 9:47:30 AM, Bystander #2 (a male in a black shirt and tan shorts), entered camera view and upon seeing the situation, began running toward the ED entrance.
- 9:48:15 AM, Bystander #3 (a male in a black shirt), exited the car, ran over to Patient #24 and took over performing chest compressions.
- 9:49:00-9:53:26 AM, no video footage, the video feed was blurred and skipped several minutes.
- 9:53:26 AM, video resumed with Bystanders #1, #2, and #3, one unidentified bystander, and Staff M, Hospitalist Registered Nurse (RN), who was performing CPR.
- 9:53:28 AM, the Fire Department appeared in camera view.
- 9:54:44 AM, a firefighter took over chest compressions from Staff M.
- 9:54:59 AM, an unidentified hospital staff member arrived in camera view.
- 9:55:05 AM, additional hospital staff from the ED responded.
- 9:55:13 AM, one hospital staff member ran back toward the ED entrance.
- 9:55:16-10:03:48 AM, no video footage, the video was blurred and skipped several minutes.
- 10:03:48 AM, an ambulance was observed on the scene.

Review of a second video camera recording titled, "ED Main Entry" dated 08/24/20, showed the view inside of the main ED entrance. The video showed:

9:46:46 AM, Bystander #4 (a male with a white mask), entered the ED, got the Screener's attention and began pointing and looking toward the parking lot.
- 9:46:50 AM, the Screener exited camera view toward the admitting/waiting room area.
- 9:46:57 AM, Bystander #4 exited the ED.
- 9:47:19 AM, Bystander #4 returned to the ED entrance and appeared to be looking for the Screener.
- 9:47:24 AM, the Screener returned to camera view with a wheelchair. Bystander #4 held open the ED door. The Screener appeared to briefly glance outside, parked the wheelchair near the doorway, and returned to the screening desk.
- 9:47:36 AM, Bystander #4 exited the ED door and walked away from the entrance.
- 9:47:52 AM, Bystander #2 (a male in a dark shirt), entered the ED, pointed to the parking lot, and appeared to be speaking to the Screener. The Screener did not look out into the parking lot and continued to perform COVID-19 screenings on other patients, but did appear to acknowledge the bystander.
- 9:48:03 AM, Bystander #2 exited the ED.
- 9:48:20 AM, Bystander #5 (a female with dark sunglasses), entered the ED, turned several times to look out toward the parking lot, and appeared to be speaking to the Screener while pointing to the parking lot.
- 9:49:22 AM, Staff M, Hospitalist RN, opened the ED entrance and appeared to be speaking with the Screener, the Screener walked toward the ED door and then exited camera view toward the admitting/waiting room area.
- 9:49:52 AM, the Screener returned to camera view, exited the ED, and appeared to be observing the parking lot.
- 9:50:10 AM, the Screener re-entered the ED entrance, picked up the telephone, and placed a call.
- 9:51:30 AM, Bystander #2 entered the ED again and he appeared to be speaking to the Screener, waving his hands and pacing the entrance area while the Screener was on the phone.
- 9:52:19 AM, Bystander #6 (a female in a white shirt), entered the ED, pointed to the parking lot, and appeared to be speaking to the Screener. The Screener was still on the telephone.
- 9:52:25 AM, Bystander #2 and Bystander #6 exited the ED.
- 9:53:01 AM, the Screener ended the telephone call, and continued with the COVID-19 screenings of waiting patients.

Review of the City's Fire Department Emergency Medical Services (EMS) 8/24/20 report showed that hospital staff contacted the 911 operator at 9:51:02 AM and a second call from a "probable citizen" was recorded at 9:51:04 AM.

Review of the hospital's undated and untitled document showed a "Code Blue" (hospital code for an emergency) was initiated on 08/24/20 at 9:54:22 AM, approximately 3 minutes after staff called 911.

Attempts to contact patient # 24's son for an interviewed were unsuccessful.

Review of a news media article titled, "Woman Lies Pulseless Outside Hospital ER, Family Told to Call 911", dated 10/05/20 showed the patient's son stated:
- "9:27 AM was her last breath".
- "She had stomach pain and vomiting, by the hour, the vomiting kept increasing".
- "I parked in the emergency parking lot and tried to carry her".
- "I just had to kind of flay her down on the sidewalk".
- "When you get there, you expect to get help immediately, not sit there and hope to God someone comes out and helps her".
- "If I had to call 911 just to get a stretcher to the car, I should've just stayed home at that point".

Review of the Fire Department's document titled, "Prehospital Care Report," dated 08/24/20, showed the following:
- 9:51 AM, they were dispatched for a cardiac arrest in the hospital parking lot with CPR in progress.
- 9:53 AM, upon arrival there was a female lying on the concrete in the parking lot with CPR being performed by a family member and one hospital nurse.
- The family member stated as he was walking the patient into the hospital she collapsed to the ground.
- 9:54 AM, the patient's physical assessment was performed and the first responder noted the patient did not have breath sounds or a pulse, continuous chest compressions were initiated, and electrocardiogram (EKG, test that checks for problems with the electrical activity within the heart) pads were placed on the patient.
- The patient had a brownish-colored liquid in her mouth and around her nose that was suctioned out. Documentation showed the first responder assessed the patient and calculated her Glasgow Coma Score (numerical assessment of a patient's level of consciousness) was "3" (maximum score is 15 which means the patient is fully awake, the minimum score is 3 which equates to a deep coma or brain dead state).
- 9:55 AM the patient remained in "asystole" (no heart beat present).
- 9:56 AM, an IV (intravenous catheter) was established.
- 9:57 AM, the patient was given the first round of epinephrine intravenously (IV, in the vein).
- A mechanical chest compression device (delivers external chest compressions in place of a human rescuer) was applied to the patient and continuous chest compressions continued.
- A physician from the hospital was on the scene.
- 10:01 AM, the patient was found to have Pulseless Electrical Activity (PEA, where the electrocardiogram shows a heart rhythm that should produce a pulse, but does not) and the physician asked that the patient be given one ampule (a sealed glass capsule containing a measured liquid ready for injecting) of Sodium Bicarbonate.
- 10:03 AM, the patient was lifted from the ground to the hospital stretcher and moved inside the hospital to the ED.
- Once inside the ED the patient was turned over to the hospital's care.

During an interview on 10/08/20 at 8:25 AM, Staff I, Screener, (non-clinical staff assigned to screen individuals entering the ED for signs and symptoms of COVID-19 on 8/24/2020) stated that:
- She had been employed as a Screener for two months.
- She had online orientation, shadowed another Screener for one shift, and was then "on her own."
- On the day of the event, a hospital vendor was the first person that notified her of a "fall" in the parking lot.
- She notified the admitting desk, Staff J, Admitting/Registration Clerk, that someone reported a fall in the parking lot and Staff J placed a phone call, she assumed to the ED Charge Nurse.
- Approximately 10 times someone came to tell her there was a situation in the parking lot.
- She continued to inform the bystanders that the situation was being handled.
- After Staff M told her that assistance was needed in the parking lot for a patient receiving CPR, she went back to admitting, where Staff J, Admitting/Registration Clerk, called the operator and she was told to call 911.
- While on the phone with 911, she walked over to the ED entrance and looked toward the parking lot where saw a nurse doing chest compressions.
- She was unaware that if a patient needed assistance she was to call a Rapid Response.
- She was unaware that if there was an emergency in the parking lot that the hospital policy stated 911 was to be called.

During an interview on 10/08/20 at 9:00 AM, Staff J, Admitting/Registration Clerk, stated that:
- A bystander came in the ED entrance and spoke with Staff I, Screener, who then came to the admitting desk and reported that someone had fallen.
- She placed a call to the ED "IA desk" and was told the patient in the parking lot would need to call 911, she conveyed this information to Staff I, Screener.
- Staff I returned to the admitting desk five to seven minutes later and stated that chest compressions had been happening for five minutes.
- She called the hospital Operator who then called a Code Blue.
- In past situations, nurses had directed admitting staff to let people in the parking lot know they would need to call 911 for assistance if they were not yet inside the building.

During an interview on 11/17/20 at 12:00 PM, Staff F, ED RN stated that:
- She was working as the ED charge nurse that shift.
- She received a call on her phone from Staff I, Screener, stating that there had been a fall in the parking lot.
- Staff I stated she had received direction to tell the patient to call 911 for assistance and wanted to ensure this direction was correct.
- She told Staff I that calling 911 was the correct action.
- Approximately five minutes later she heard the Code Blue page.

During an interview on 10/07/20 at 2:50 PM, Staff E, RN, ED Manager, stated that:
- On 8/24/20, there were seven nurses, two nursing assistants, two physicians, and one nurse practitioner on duty.
- There was not a designated Code Blue Team, the team would be determined on staff availability, but would always include a physician and the Charge Nurse.
- Whenever a Screener or admitting staff identified a patient that needed assistance, they should escalate it and call for a Rapid Response, "the Screener that day did not know to do that."
- The Code Blue policy stated that EMS would be called for any situation that arose in the parking lot.
- The rationale for that policy was that when the size of the campus was taken into consideration, EMS would be able to respond faster than ED staff.
- EMS calls from the parking lot occurred "quite frequently" due to falls or spinal concerns.

During an interview on 10/08/20 at 1:45 PM, Staff A, Chief Nursing Officer stated that:
- Screeners were originally nurses, however those positions changed to more permanent ones in mid-July when the hospital resumed elective surgeries, and the Screeners hired were non-clinical.
- "A seven-minute delay in a code blue situation is huge."

During an interview on 10/07/20 at 1:30 PM, Staff D, Risk Management Vice President, stated that the hospital's September 2, 2020 Root Cause Analysis determined that initially Screeners were clinical staff, but as the Screener position became permanent, those clinical staff were replaced and Staff I, Screener was not clinical nor aware of how to clinically respond.

Review of Patient #24's medical record dated 08/24/20-08/25/20 showed the following:
- She was a 43-year-old female.
- She arrived in the ED at 10:03 AM.
- Her diagnoses included cardiac arrest, respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), severe sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) with septic shock (widespread infection causing organ failure and dangerously low blood pressure), anoxic brain injury (harm to the brain due to lack of oxygen).
- She was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) at 5:42 PM.
- Imaging results suggested anoxic brain injury.
- She was transitioned to comfort care and passed away at 9:31 AM on 08/25/20.

Review of the hospital's document titled, "Parking Lot Code Blue, Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause), dated 09/02/20, stated the following:
- A timeline of the events from 08/24/20 was completed.
- On 08/24/20, Patient #24's son drove the patient in, he reported she had been without a pulse for about 10 minutes.
- 9:45 AM, the son parked the car in the parking spot in front of the Diagnostic Center entrance approximately 100 yards away from ED entrance.
- 9:46 AM, the son carried the patient to the sidewalk, the patient was unable to stand so he laid her down.
- 9:47 AM, CPR was started by a bystander; a visitor alerted the ED Screener that a patient "passed out in parking lot,". The screener is stationed in an area between two double doors, one set of doors that exits to the parking lot, and one set of doors that enters into the ED waiting area.
- 9:47 AM The Screener entered the ED waiting area and notified admitting staff of a reported fall. Admitting staff called the Information Assistant (IA) (an ED dedicated area near the nurse's station, staffed by a Nursing Assistant (NA), where either staff or patients can call or present to and receive information), of a reported fall and the IA stated the patient was to call 911 if assistance was needed.
- 9:48 AM, a male in a black top/tan shorts ran into the ED entrance and asked the Screener what was being done about the patients, the Screener assured, "We are handling it."
- 9:48 AM, CPR continued and a Hospitalist Registered Nurse (RN) joined the bystander. A female visitor in a grey shirt entered the ED, notified the Screener, and pointed to the parking lot, the Screener assured her, "We are handling it."
- 9:49 AM, a male in a black top/tan shorts left the ED entrance and returned to the scene. The Screener, on the phone with admitting staff, asked what else could be done. Admitting staff stated to call 911, the Screener notified admitting staff of chest compressions, admitting staff called the Operator for a Code Blue.
- 9:51 AM, the Screener called 911. At that time, the Screener looked out the ED entrance door and noted compressions being done on the patient. A male in a black shirt ran to the ED entrance, the Screener let him know that EMS was one minute away (per the Fire Department, there were multiple phone calls at that time on this event).
- 9:52 AM, a male in a black shirt walked quickly back to the scene.
- 9:53 AM, the Fire Department arrived.
- 9:54 AM, a Code Blue was paged overhead; Hospital staff ran outside, including security.
- 10:01 AM, an ambulance arrived.
- 10:02 AM, the patient was brought to the back of the ED on a hospital ED stretcher.
- 8/25/20, the decision was made for comfort care (medical care at the end of life) due to an anoxic brain injury (harm to the brain due to a lack of oxygen) and then the patient passed away.
- Other details of the event: the ED Staff RN was called and told the Screener/Admitting to call EMS for a fall in the parking lot.
- The ED Charge Nurse was not notified until a Code Blue was called.
- Between 9:00 AM-10:00 AM there were 13 arrivals, six were via EMS; one was a psychiatric patient that pulled a NA for a one-to-one (1:1, continuous visual contact with close physical proximity) observation.
- 9:20 AM, nine patients were in the waiting room; four Level 2's, three Level 3's, and 2 Level 4's; 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).
- Screening and admitting locations were appropriately staffed during that time.

During an interview on 10/07/20 at 12:45 PM, Staff A, Chief Nursing Officer (CNO), stated that:
- She was aware the event was a problem and it was "looked at very closely."
- An RCA was initiated as soon as the event happened.
- All staff that could be identified through video review were interviewed.

During an interview on 10/08/20 at 1:45 PM, Staff D, Risk Management Vice President, stated that:
- She was made aware of the incident on 08/24/20.
- Interventions were immediately put into place.
- The investigation into the incident began on 08/24/20.
- The Root Cause Analysis (RCA) was dated for 09/02/20, because that was the day team members from different departments came together to finalize it.
- If an emergent situation would arise within 250 yards of the hospital, a Code Blue would be responded to.
- Staff would respond to any situation on campus; however, EMS could be necessary in the interim or as an adjunct to their staff.
- There was a miscommunication between the bystander and the Screener that caused a delay in Patient #24's treatment; however, as soon as staff recognized the emergent situation they responded immediately.