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Based on observations, review of records, policy and procedures, facility license, and interviews, the hospital failed to ensure that an appropriate medical screening examination was conducted, that was within the capability of the hospital's emergency department, including ancillary services for 1 (#2) of 20 sampled patients, who presented to the hospital's emergency department complaining of chest pain. Refer to findings in Tag 2406


Based on review of medical records and policies and procedures, it was determined, the facility failed to ensure that the hospital offered and informed an individual of the risks and benefits a medical screeing examination and/or further medical examination and treatment. The hospital failed to ensure that the medical record contained a description of the examination, treatment or both that was refused by the individual, this failure affected 1 (#2) of 20 sampled patients. Refer to findings in Tag A- 2407.

Based on observations, review of records, policy and procedures, facility license, and interviews, the hospital failed to ensure that an appropriate medical screening examination was conducted, that was within the capability of the hospital's emergency department, including ancillary services for 1 (#2) of 20 sampled patients, who presented to the hospital's emergency department complaining of chest pain.


The findings included:

Review of the registration record of Patient #2 reveals that she presented to the Emergency Department (ED) of Hospital A, on 12/28/18 at 12:30 PM. The patient informed the clerk that she was having chest pain as evidenced by the documentation on the registration form, "Chest pain/numbness of left side, SOB (shortness of breath)". In addition, the patient was provided and signed the following documents at the same time: Notice Acknowledgement of Privacy Rights and Practices, Interpreter services available, Consent for Communications, Advance Directives, Leaving Against Medical Advice and General Consent for Treatment. A copy of the patient driver's license was also obtained as evidenced by the dated and signed forms on 12/28/18 at 12:34 PM.

Further review of the record indicates at 1:34 PM, the Triage Nurse documented, "went to call patient out of lobby and she did not answer". Registration states, "She had family issue and needed to leave." Patient #2 was never seen or triaged by RN (Registered Nurse) trained in triage to determine the urgency of the patient's complaints of chest pain, SOB, and numbness to her left side. Patient #2 was not taken immediately to the treatment area to be assessed and the ED physician was not notified so that immediate interventions were started such as an EKG, vital signs and blood work, as per the facility policies and procedures. The patient did not receive a Medical Screening Examination (MSE) by the ED Physician although her presenting complaint was of chest pain. The facility failed to ensure that that their policies and procedures were followed, related to chest pain as evidenced by failing to ensure that an appropriate MSE was provided for Patient #2 on 12/28/18. Instead, Patient #2 waited in the ED waiting room for over an hour after going to the desk several times and wanted to be seen and evaluated by a physician for the stated complaints.


During an observation of the ED on 02/05/19 at 9:30 AM, Charge Nurse A provided the following information:
1. "Upon arrival to the ED, a walk in patient presents to the desk where a clerical staff person asks the reason for the visit, takes their name and complaint and informs the Nursing staff of the patient's arrival.
2. When a room becomes available, an ED nurse will go to the waiting room and escort the patient to the room. If a room is not available at that time, the patient remains in the waiting area.
3. Triage assessments are not conducted until the patient is brought back to the treatment area. If a patient presents to the ED and complains of chest pain, the clerical staff person has been instructed to notify the Charge Nurse and she will come to get the patient to take them back immediately.
4. If no room is available, the Charge Nurse will move existing patients back into the waiting room in order to accommodate the patient who presented with complaints of chest pain."
The Charge Nurse stated the patients are instructed to sit down in the waiting area. The facility uses a "Pull and Fill" procedure where patients who present to the ED are brought back to the treatment area and put into available rooms by the nursing staff. If a room is not available at that time, the patient waits in the waiting area until a treatment room is available. Regardless of how long the patient waits, a triage assessment including an acuity determination is not conducted until the patient is brought back in the treatment room. The Charge Nurse stated that if patient with an emergency condition presents, they are brought back immediately and patients moved out of rooms to accommodate them. He stated that this is a problem because you have patients in a room; you have to move them out of the room, and place them in the hall or back in the waiting room, which can be chaotic.
The Charge Nurse was asked and stated that the "Pull and Fill" procedure has been used for the past 3 or 4 years as the facility no longer uses a dedicated Triage Nurse. Prior to last week, the facility had a Security Guard at the front and he was the first person that a patient saw. He made the determination of whether they should go back immediately or not. The Security Guard does not have a clinical background. The Charge Nurse said, "We have had a lot of patients' complains about the delay in getting back to a room before a triage assessment is done. Now we have a Paramedic at the front."

Interview with The CNO (Chief Nursing Officer), who was in attendance during the observation, stated that he was in the ED last week when an urgent patient arrived and the only person present was a Registration Clerk. He took the patient back, as the Registration Clerk did not have the clinical expertise to determine the acuity of the patient's condition. Since this past Friday, he has now assigned a Paramedic to greet the patients when they arrive. The Paramedic is clinically trained to determine if they need to go back immediately or not. He confirmed that the Paramedic does not conduct a Triage Assessment, just uses his/her knowledge to decide if the patient needs to go back or not.


An interview with the Paramedic on duty, on 02/05/19 at 9:00 AM, was asked what information she requests from the presenting patient. She stated, that she asks their name and why they came to the Emergency Department (ED). She does not perform a triage assessment or take their vital signs. Her only responsibility is to ask why they come to the ED. If for example, a patient tells her that they have chest pain, she will call back to the ED and an ED Nurse will come and take the patient back. She confirmed that the facility does not utilize a Triage Nurse to assess patients upon arrival. If a patient does not inform her of an emergency condition, the patient is instructed to move to the Patient Access registrar to take such information as needed to verify their identity. This could be a driver's license or other document.


An interview was conducted with the CNO on 02/05/19 at 12:22 PM. He stated the Security Guard is not clinically trained. An example was last Friday, when a female patient came in and told the guard she had passed out twice in one hour. I was present, got her in the wheelchair, and took her back. At peak times, we want to have a clinical body to see the patients when they arrive. Currently, a Paramedic inquires about the issue and she determines if they need to go back immediately. Previously this did not happen. This is a new procedure, less than a week old."
The CNO continued, "In January, we had a patient speak to the Patient Advocate to complaint of timeliness of being seen. She came in the end of December (2018). I spoke to her in January (2019). She thought she was having a heart attack, but she did not present to non-clinical staff (registration clerk) that she was having chest pain. They (security guard or registration clerk) made the judgement, not a nurse. She told them her left arm was numb and she was having jaw pain. Most clinicians know that women often present this way during a heart attack, but a non-clinical person would not. She (registration clerk) did the quick registration and the patient left after about 15 minutes. Our nurse was here. We did a chart review with this nurse, she said it took about 15 or 20 minutes to get her, and she (Patient #2) was already gone. Patient went to a Pharmacy (across the street), who's owner is on our Board of Directors. He told us that he took her blood pressure and told her to go the ED. She said she was going to sit in her car. He said she drove herself to Hospital B. This is one of many such incidents. If no beds, you have to wait for triage, until a bed opens up."
The CNO further said, "Security retains videos, I can check 2 or 3 weeks prior, and then they record over them. It is gone now. I looked at the video and there were two at registration desk, when she (Patient #2) arrived. Quick Registration takes 5 to 7 minutes. She walked up to get in line and then sat down. She came back when it was her turn 8 to 10 minutes later and then sat down. The person before her went to Interventional Radiology. She walked back to registration and then walked out the door. We initiated the change on Friday, February 1 (2019). During slow times, it is still just the security guard at the front. Still not doing immediate triage by RN on arrival."


Another interview was conducted with Charge Nurse #B on 02/06/19 at 12:27 PM. She stated that she has been employed at the facility for a year and came from another facility where she was charge nurse in the ED. She stated that she voiced her concern that a failure to conduct a Triage Assessment upon arrival was a violation of EMTALA regulations. Patients are brought back and placed in a room as soon as a room becomes available. An assessment / determination of acuity does not occur until a patient is brought back. The ED Nurse then makes the assessment and acuity determination. If a patient arrives with a true emergency condition, she must scramble to move patients out of rooms to make accommodation for the newly arrived true emergency patient. She was concerned that a non-clinical person is making the determination of whether a presenting patient has an emergency medical condition and not a clinical professional. She asked the other nursing staff how long this "Pull and Fill" procedure has been going on and was informed that it was 3 or 4 years. She stated that sometimes while waiting for a room to open up, she would take a patient into the empty triage room and do an assessment if she thinks they require an immediate assessment. She will then move patients out of rooms in order to accommodate a patient with a true emergency condition.


A side by side, review of the electronic record of Patient #2 was conducted with the Charge Nurse and the Chief Nursing Officer (CNO) on 2/5/19. He opened the demographic record, which was completed by the Registration Clerk and documented the reason for the visit was "chest pain, radiating down left arm". The Charge Nurse stated that clinical personnel do not have access to this form. They document in the electronic record in different fields. He confirmed that the patient must have informed the Registration Clerk that she had chest pain, radiating down her left arm as that is what the clerk documented. He confirmed that the clerk did not inform the Charge Nurse and the patient left one-hour later without being assessed by any clinical personnel. He confirmed that unless the Registration Clerk notifies the Charge Nurse that a patient needs to be brought back immediately, the clinical staff are completely unaware that an emergent condition exists. The Triage nurse went to the waiting room to bring Patient #2 back as documented at 1:35 PM. She documented that the patient had left without being seen. The CNO and the Charge Nurse both confirmed that Patient #2 should have been brought back immediately, as she was presenting with an emergency condition requiring immediate assessment and treatment.



The surveyor obtained a copy of the closed clinical record of Patient #2 who presented to another facility (Hospital B) on 12/28/18 at 2:19 PM. The patient informed Hospital B that she had been experiencing crushing chest pain since 10:00 AM that morning, radiating down her left arm to her left neck and jaw and had diaphoresis. Based on the results of the physical examination, laboratory (elevated troponins) and diagnostic testing, the patient was admitted to the Cardiac Step Down Unit of Hospital B. The patient was discharged on 1/1/19 with the diagnosis of coronary artery vasospasm, chest pain, electrocardiogram (EKG) suggestive of ischemia.


Facility License Review revealed "State of Florida, Agency for Health Care Administration, Division of Quality Assurance, Effective Date: 05/01/2017; Expiration Date: 04/30/2019 was reviewed. The License revealed in part, " ... Steward Sebastian River Medical Center ...Licensed Programs Level: Adult Cardiovascular Services, Primary Stroke Center ... Emergency Services, ...Cardiology, Cardiovascular Surg (surgery)."



Policy and Procedure Reviews included the following:

Review of the Hospital A's Administrative Policy dated 5/2014 entitled, "Requirements for compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) (COBRA)," included the following:
1. The hospital will provide an appropriate medical screening examination by qualified personnel. Utilizing the expertise of a team composed of a Triage Personnel, Physician, Ancillary Services and Emergency Department Staff, the screening will be initiated and completed within the capabilities of the Emergency Department.


A Review of the facility policy for the Emergency Department Scope of Care and revised 8/13 revealed the following:

1. All patients who present to the Emergency Department will receive care by qualified personnel in a timely manner consistent with the acuity of their illness.
2. All patients presenting to the SRMC (Steward Sebastian River Medical Center) ED (Emergency Department) will be triaged by a qualified healthcare provider and receive a Medical Screening Examination by a Hospital Designated practitioner. A physician trained in Emergency Medicine will be available in the Department.




Review of the Triage Policy dated 8/13 revealed:
1. Each Patient upon entering the Emergency Department will be assessed by an Emergency Department Registered Nurse trained in triage to determine the urgency of the patient complaint.

2. The patient will be assigned to the appropriate area of the Emergency Department with the appropriate resources to adequately care for the patient.

3. The patients will be triaged utilizing the nursing process of assessment, planning, and intervention per SRMC protocols. Diagnostic procedures contained within the first 10 minutes. Physician to notify of warning potentially lethal arrhythmias or suspicion of myocardial infarction.




Review of the Policy for Initial Management of the Patient Chest Pain revealed:

1. Patients presenting to the Emergency Department with Chest pain will be immediately assessed and the physician notified for immediate interventions to begin.
2. Patient is to be seen as soon as possible upon arrival. Triage Nurse to obtain history and conduct physical assessment including vital signs and cardiac monitoring. EKG should be obtained within the first 10 minutes. Physician to notify of any warning or potentially lethal arrhythmias of suspicion of myocardial infarction.

The facility failed to ensure that an appropriate medical screening examination was conducted, that was within the capability of the hospital's emergency department, including necessary ancillary services for patient #2, who presented to the hospital's emergency department complaining of chest pain.

Based on review of medical records and policies and procedures, it was determined, the facility failed to ensure that the hospital offered and informed an individual of the risks and benefits of further medical examination and treatment. The hospital failed to ensure that the medical record contained a description of the examination, treatment or both that was refused by the individual, this failure affected 1 (#2) of 20 sampled patients.


The findings included:


Policy and Procedure Review revealed the facility's policy titled" Emergency Medical Treatment and Active labor Act (EMTALA); Chapter: Rights and Responsibilities, Policy Number RI 12, Publication Date: July 22, 2016, was reviewed. The policy specified in part, "II. Refusal to consent to Treatment. A. Refusal of Medical Screening Examination (MSE); If a patient refuses to consent to medical screening examination and indicates his/her intention to leave the hospital prior to receiving a MSE, Emergency Department staff should, whenever practicable, inform the patient of the risks and benefits of the examination ... The medical record must contain a description of the attempt to inform the patient of the risks and benefits of the medical screening examination."

Medical Record Reviews including the registration record of Patient #2 reveals the patient presented to the Emergency Department (ED) of Hospital A, on 12/28/18 at 12:30 PM. The patient informed the clerk that she was having chest pain as evidenced by the documentation on the registration form, "Chest pain/numbness of left side, SOB (shortness of breath)". Further review revealed in part, at 1:34 PM, the Triage Nurse documented, "went to call patient out of lobby and she did not answer". Registration states, "She had family issue and needed to leave." The facility failed to ensure that their policy and procedures on informed refusal was followed as evidenced by patient informed the staff of her intentions and why she was leaving the facility prior to a MSE on 12/28/18. There is no documentation in the medical record that an attempt was made to inform Patient #2 of the risks and benefits of the MSE.

The medical record failed to reflect that screening, further examination, and or treatment were offered by the hospital prior to the individual's leaving the premises. There is no evidence the hospital documented in writing the risks/benefits of not completing the examination and/or treatment; the reasons for refusal; if any, a description of the examination or treatment that was refused; and the steps taken to try to secure the written, informed refusal as it was not secured.