HospitalInspections.org

Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings included:

The hospital's Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether an Emergency Medical Condition (EMC) existed for one (1) of 38 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #2).

~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.

Based on policy and procedure reviews, medical record reviews and staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for one (1) of 38 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #2).

The findings included:

Review of the policy "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Stabilization...", last approved 12/13/2021, revealed "...3. Extent of the MSE (Medical Screening Examination) a. Determine if an EMC (Emergency Medical Condition) exists. The hospital must perform an MSE to determine if an EMC exists...b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer....5. No Delay in Medical Screening or Examination .... c. EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation of EMTALA.... Even if the hospital cannot immediately complete an appropriate MSE, the hospital must assess the individual's condition upon arrival of the EMS service to ensure that the individual is appropriately prioritized based on his or her presenting signs and symptoms to be seen for completion of the MSE. ..."

Review of the EMS (Emergency Medical Services) Patient Care Record, on 11/14/2023, revealed EMS was called to Patient #2's home on 10/17/2023. The record noted the patient's medical history was "Cirrhosis of Liver, Diabetes, Infectious disease, Neuropathy, Other-Infection of foot - amputation schedule for 10/21." Review of the Narrative Note revealed "(EMS) DISPATCHED EMERGENCY TRAFFIC.... SYNCOPAL EPISODE (episode of unconsciousness with recovery) WITH CHEST PAIN AND SHORTNESS OF BREATH ...ARRIVED....TO FIND A 66-YEAR-OLD MALE, A&Ox4 (alert and oriented to person, place, time, situation), SKIN PALE, WARM, AND DRY.... PT ADVISED HE HAD BEEN HAVING CHEST PAIN AND SHORTNESS OF BREATH FOR THE LAST WEEK.... ADVISED THAT HE .... HAD BEEN WORKING AROUND THE HOUSE AND ALL OF A SUDDEN HE DID NOT FEEL GOOD AND PASSED OUT.... PT ADVISED HE RECENTLY HAD SURGERY ON HIS FOOT AND IT....GOT AN INFECTION AND WAS TAKING ANTIBIOTICS FOR SAME. PT ADVISED HE WAS GOING TO NEED ANOTHER SURGERY.... IT WAS NOW NOTED THAT PT'S EKG WAS SHOWING.... ALSO SHORT RUNS OF A WIDE COMPLEX TACHYCARDIA. PT REMAINED COMPLETELY A&Ox4 .... PT WAS PLACED ON SUPPLEMENTAL OXYGEN WITH NOTED IMPROVEMENT IN BREATHING....PT WAS FOUND .... HYPERGLYCEMIC (high blood sugar) .... HAD NOT BEEN ABLE TO TAKE HIS INSULIN YET TODAY....PT WAS ADMINISTERED FLUID AS RECORDED ....PT ADVISED HIS CHEST PAIN WAS A 6/10 (on a scale of 0-10 with 0 being no pain and 10 being the worst pain) AND THAT TAKING A DEEP BREATH HURT....THIS HAS BEEN GOING ON ALL WEEK AND HAS NOT CHANGED.... UPON ARRIVAL AT (Hospital) PT WAS TAKEN TO ER ROOM, WHERE (EMS) WAITED FOR ER PERSONNEL TO COME FOR THE HANDOFF REPORT WHILE BEING CONTINUALLY MONITORED. A FACILITY RN FINALLY ARRIVED AND A FULL REPORT WAS GIVEN AND PT CARE WAS TRANSFERRED TO THE RECEIVING RN. ..."

EMS record review revealed the team arrived at the hospital with Patient #2 at 1748 and care was transferred to hospital staff at 1907 (1 hour, 19 minutes after arrival). Review revealed EMS staff continued monitoring Patient #2 after arrival to the hospital's ED. The last recorded EMS vital signs were at 1858 with BP 104/61, pulse 70, respirations 15, 99% pulse ox and a pain score of 6.

Review of the Dedicated Emergency Department (DED) medical record, on 11/14/2023, revealed Patient #2 arrived by EMS to the hospital on 10/17/2023 at 1753. Review of the "ER Report" by a Physician Assistant (PA), at 1845, revealed "...66-year-old male patient.... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. Patient reports that he has had chest pain and shortness of breath ongoing over the past week and reports that these symptoms are aggravated with exertion.... he states that today he had acute worsening to his symptoms .... had a syncopal episode earlier today. He reports pain and shortness of breath are still present. He states that he also has bilateral lower extremity swelling which has been ongoing over the past couple of weeks .... He states that he has ulcer to the first metatarsal of his left foot and this extends to his bone. He states that he has planned to have amputation of the first digit of his left foot this coming Friday patient currently taking ciprofloxacin (antibiotic), Diflucan (antifungal), and Duricef (antibiotic).... Medical Decision Making.... EMS reports that they gave patient 324 mg aspirin.... blood pressure was approximately 96 mmHg. They gave one L (liter) of normal saline IV blood pressure is 105/66 now. EMS also reports that patient had 7 beat run of V tach on their EKG tracing in route with patient now in sinus rhythm and occasional bigeminy. Ordered EKG and for patient to be on telemetry.... Point-of-care CBG (blood sugar), CMP (comprehensive metabolic panel), CBC (complete blood count), troponin, proBNP, D-dimer, lactic acid, and portable 1 view chest x-ray ordered. EKG obtained and notes sinus rhythm with PVCs and 4 beat run of V tach (ventricular tachycardia - where lower chambers of the heart beat very quickly). ..."

Review of the "ED Triage", performed 10/17/2023 at 1900 (1 hour and 7 minutes after EMS arrival) revealed a pre-hospital blood glucose of 459 and an acuity of "3-urgent". Vital signs were recorded as: Temperature 97.9, Pulse 72, Respirations 20, blood pressure 106/69 and oxygen saturation of 100% on 4 liters oxygen. Patient #2's pain score was noted as seven (7).

Further review of the PA's "ER Report" note revealed "...1953 Dr. (Name) called to patients bedside for cardiac arrest and assumed care of patient. CPR initiated.... 2017....Called lab to request results of chemistries be available as soon as possible. Labs resulted after arrest .... Resuscitation attempt failed. Patient deceased. Suspect etiology to cardiac arrest related to MI (Myocardial infarction- heart attack).

Review of orders revealed a stat order for an EKG at 1841 (48 minutes after Patient #2 arrived to the ED). Review revealed a hospital EKG was completed at 1905 (24 minutes after order and 1 hour 12 minutes after arrival). Review of lab orders revealed the following lab tests were ordered stat at 1841: Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the stat orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The labs resulted later, the CBC at 2002 and the CMP at 2012. The D-Dimer resulted at 2006 as 824 (high). The Pro BNP resulted at 2023 as 9690 (High - reference range 5-125) and the Troponin resulted at 2039 as 0.460 (High - reference range 0.000-0.034). The physician was notified.

Review of the "ER Report", service date/time 10/17/2023 at 2030, revealed a note by a physician that indicated "...I was called to the patient's bedside at 1953 for cardiac arrest. Staff reports that only moments before the patient had been alert and talking. CPR (cardio- pulmonary resuscitation) was initiated. The patient was placed on a monitor and defibrillator. Initial rhythm revealed ventricular tachycardia (fast heart rhythm). He received electrical therapy and CPR was resumed. Patient received high-quality chest compressions. He would briefly show signs consciousness indicating adequate cerebral perfusion (blood to the brain) with chest compressions, but remained without an organized rhythm .... required continuation of CPR. He received multiple doses of electrical therapy.... He received magnesium as well as amiodarone (medication for irregular heart rhythm) for shock refractory ventricular tachycardia. Ventricular tachycardia progressed to ventricular fibrillation (life threatening arrhythmia). He also received multiple doses of epinephrine (emergency medication) per ACLS (advanced cardiac life support) protocol for pulseless arrest. He was intubated.... I called the physician assistant to the bedside to brief me on the details of the initial presentation. During the resuscitation I took the opportunity to review the available work-up. The EKG was brought to me for review at 2002 .... For this patient who presented with chest pain, syncope, and suffered cardiac arrest has either suffered an MI or rhythm disturbance .... I reviewed his medications.... I made attempts to address....reversible causes of cardiac arrest. As resuscitation proceeded the rhythm progressed ....to asystole .... After 30 minutes of resuscitation he remained in asystole. All team members agreed that further resuscitative efforts were futile.... the patient was pronounced dead at 8:24 PM (2024) ....10/17/23 20:38:56 I received a (sic) from the chemistry lab. Troponin is 0.46 .... Diagnosis/Disposition Chest pain Syncope Ventricular tachycardia Cardiopulmonary arrest. ..."

Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS responded to a call for a patient with chest pain and shortness of breath. Interview revealed on EKG the heart was very irritated, throwing PVCs, PACs (arrhythmias) and then short runs of wide complex tachycardia (rapid heart rate). Interview revealed there was potential for things to turn unstable quickly. By the time they got to the hospital there were just a few PVCs. EMS #70 stated at some point the patient started to get hypotensive and the fluids had emptied, so the other EMS staff gathered another bag of fluids. Patient #2, per EMS, was on supplemental oxygen and had no complaints at the time. Interview revealed they got the patient into an ED bed at 1845 but there was no nurse for report. At 1907 (1 hours, 17 minutes after arrival), per interview, EMS was able to give hand-off report to a nurse. Interview revealed waits had gotten more common recently and it seemed like a staffing issue.

Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the patient came into the ED with EMS and there were no rooms available. PA #71 stated he saw the patient while in the hallway and placed orders. Interview revealed the patient had not been triaged, he was still in the hall. Interview revealed prior to arrival the patient had "a few runs, approximately 8 beats", of V tach. PA #71 stated the patient was given a liter of fluids and the rhythm improved. Patient #2 remained on the EMS monitor prior to getting a formal EKG in the ED, the PA stated. Interview revealed there were another 4 beats of V tach but it was not sustained; the patient appeared stable. PA #71 moved on to another patient and did not see Patient #2 after he got in an ED room until the PA heard the code and responded. Interview revealed these type patients should be closely monitored. Interview revealed the goal for the screening evaluation was 20 minutes from arrival.

Telephone interview with RN #66, on 11/16/2023 at 0938, revealed the nurse assigned to Patient #2's room was busy and not able to triage the patient, so RN #66 responded, did the hand-off with EMS and triaged Patient #2. The patient had been placed on a monitor by the Certified Nursing Assistant (CNA). RN #66 then received report from EMS. Interview revealed there was not a bed available when Patient #2 first arrived by EMS. When RN #66 went to triage the patient, Patient #2 had just been put in a room and was stable, alert and talking. RN #66 stated that after Patient #2 was triaged, RN #66 drew blood for labs. The RN stated labs were not drawn until after the patient was accepted and in a room. Until patients were in a room and care handed-off from EMS, interview revealed, they were "counting on EMS to care for (the patients). ..."

Telephone interview on 11/16/2023 at 1100 with MD #72 revealed he heard the overhead page for Patient #2 and immediately responded. Interview revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. Interview revealed there is a chest pain protocol, but the protocol had to be activated by a provider. MD #72 acknowledged there was a delay for Patient #2.

In summary, Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain after a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived). The patient was triaged at 1900 and labs were collected at 1920 by nursing staff. Patient #2 was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (1 hour 12 minutes after arrival). The D-Dimer, Pro BNP and Troponin all resulted after 2000 and all resulted abnormally high. Patient #2 experienced cardiac arrest around 1953 (2 hours after arrival to the DED). CPR was initiated but was not successful and Patient #2 expired. There was a delay in triage, medical screening and interventions, including hospital EKG and labs for a patient who arrived at the hospital via EMS for chest pain and syncope.