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Based on interview and record review. The facility failed to:

1. Complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for one of 22 sampled patients (Patient 8).

This deficient practice resulted in Patient 8 not receiving an MSE and evaluation for EMC (Emergency medical Condition), which had the potential for patient harm. Patient 8 left the facility without being seen (LWBS). (Refer to A-2406)

2. Carry out physician's orders for two of 22 sampled patients (Patients 1 and 9) who presented to the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment.

This deficient practice resulted in the facility failing to provide further medical examination and stabilizing treatment to Patients 1 and 9, and had the potential to result in harm. (Refer to A-2407)

Findings:

1. During a concurrent interview and record review on 3/6/2025 at 3:40 p.m. with the Performance Improvement Coordinator (PIC), Patient 8's Emergency Department Summary, dated 9/1/2024, was reviewed. The Emergency Department Summary indicated Patient 8 arrived in the Emergency Department (ED) on 9/1/2024 at 12:21 a.m. with a chief complaint of "headache, fainted and hit back of head on the floor at concert, swelling and scalp abrasion, had cocktail drink and marijuana at concert." Patient 8 was Triaged (Acuity Level) on 9/1/2024 at 12:32 am, as Emergency Severity Index (ESI) level-3 (Urgent) ("Requires 2 or more resources and VS may or may not be in Danger Zone"). Vital Signs were- Temperature: 98.2 F (normal 97F to 99F); Pulse 94 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure148/93 (normal BP 120/80); Pulse oximetry 99% on room air (RA);1/10 Pain assessment. Electrocardiogram (EKG, measures heart's electrical activity) was ordered at 12:47 a.m. indicating "ST elevation probably normal repolarization pattern." RN (Registered Nurse) attempted first call for Patient 8 at 3:00 a.m., for MSE recorded at 3:05 a.m. Patient 8 left without being seen (LWBS). PIC verified Patient 8 did not have an MSE, no neurologic exam, no head injury exam, or cleansing of Patient 8's head abrasion, no lab and no image orders.

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Exam," dated 10/20/2023, the P&P indicated "to provide a medical screening exam to all the individuals presenting to the emergency department to determine if an emergency medical condition exists and to provide medical screening examination emergency services and care as indicated to stabilize the medical condition."

During a review of the facility's policy and procedure (P&P) titled, "RN standardized procedures Emergency Department," dated 7/20/2024, the P&P under section: presenting symptoms Syncope, indicated implementation of standardized procedures in the emergency department evaluation for Syncope included: lab blood draw for CBC (complete blood count); Basic Metabolic Panel. Nursing orders include cardiac monitor, pulse oximeter Monitor; oxygen to keep saturation above 90%; checking Patient's blood sugar level and EKG.

2.a. During a concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), DED stated the following: Patient 1 presented to the ED on 1/17/2025 at 11:30 p.m. for shortness of breath and throat swelling. Patient 1 was evaluated by the Physician (MD 1) at 11:59 p.m. The DED reviewed Patient 1's medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac (Toradol, a nonsteroidal anti-inflammatory drug, reduces inflammations and relieves moderate to severe pain), Dexamethasone (treats inflammation [swelling]), Diphenhydramine (Benadryl, treats allergies), Normal Saline (a solution of salt and water similar to that found in the body) had been ordered and had not been administered to Patient 1. There was no documentation indicating the reason the medications had not been given.

During the same concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), Patient 1's medical record was reviewed. Patient 1's medical record indicated MD 1 ordered Cardiac (heart) monitoring and Oximetry (a non-invasive method to measure a person's blood oxygen saturation, or the percentage of red blood cells carrying oxygen, providing a quick assessment of how well the lungs are functioning) on 1/18/2025 at 12:09 a.m. for Patient 1. The DED verified there was no documentation indicating as to whether the cardiac monitoring or oximetry orders were carried out and it should have been documented. MD 1 also ordered a CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) scan on 1/18/2025 at 12:19 a.m., which was not completed. DED stated Patient 1 left against medical advice (AMA, a situation where a patient leaves a healthcare facility before their doctor recommends) on 1/18/2025 at 4:15 am. The DED verified that none of the physician's orders were carried out or completed during the time Patient 1 was in the ED, for approximately 4 hours.

During a concurrent interview and record review on 3/6/2025 at 9:59 a.m. with the Manager of Pharmacy (MOP), the MOP stated the following: One-time medications orders in the Emergency Department automatically cancel themselves one minute after the medication is ordered by the physician. The medication then appears as "active" in the medication administration record (MAR) and the medication is highlighted in red until the medication is acknowledged and administered by a nurse. MOP stated that medications ordered in the ED are immediately available to nurses to avoid any delay in administering the medication. Medications ordered in the ED should be given as soon as possible. The MOP reviewed Patient 1's medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac, Diphenhydramine, Dexamethasone, and Normal Saline had been ordered by the physician. The MAR indicated that the medications were not acknowledged by a nurse and the medications were not administered to Patient 1. The MOP stated that the medications for Patient 1 were meant to treat Patient 1 symptoms, including throat swelling.

During a review of Patient 1's "Triage (a preliminary assessment in order to determine the urgency of a patient's need for treatment and nature of treatment required)" note, dated 1/17/2025 at 11:34 p.m., the triage note indicated the following: Patient 1 complained of throat pain and SOB (shortness of breath) one (1) hour ago ... Patient 1 started with hoarse voice and suddenly could not speak ...Priority level: 3 (Urgent, conditions prompt attention but can wait a short period for assessment and treatment)

During a review of Patient 1's "ED Physician Documentation," dated 1/18/2025 at 12:17 a.m., the ED Physician Documentation indicated the following: "Chief complaint: Shortness of breath (SOB). Stated Complaint: Throat swelling. Patient (1) ...with history of asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breath) presents ...for evaluation of throat pain and swelling and difficulty speaking after returning from vacation..."

During a review of Patient 1's "Physician Note," dated 1/18/2025 at 12:09 a.m., the noted indicated "Patient okay to get CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) with contrast (a dye or substance that helps show abnormal areas inside the body) without labs."

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's order indicated the following: Ketorolac 15 milligrams (MG, a unit of measurement) IV (in the vein) Once (one time).

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's Order indicated the following. Dexamethasone 10 mg IV Once.

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m. indicated the following: Diphenhydramine 50 mg IV Once.

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's Order indicated the following: Sodium Chloride (IV fluid) 1000 milliliters (ml, a unit of measurement) one time.

During a review of Patient 1's "Medical Administration Record," dated 1/18/2025, the Medical Administration Record indicated the following:

-Ketorolac (Toradol) 15 milligrams (MG) IV (in the vein) Once (one time). Current status was active (pending administration to patient) and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication was administered by a nurse.
-Dexamethasone 10 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse.
-Diphenhydramine (Benadryl, relieves allergies) 50 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse.
- Sodium Chloride (IV fluid) 1000 milliliters (ml) one time. Current status was active and was highlighted in red. There was no documentation indicating that order was acknowledged or carried out.

During a review of Patient 1's "Orders," dated 1/18/2025 at 12:09 a.m., the Orders indicated for a Rapid Group A Strep Test (a diagnostic test used to detect the presence of Group A streptococcus bacteria [a common bacteria found on the skin or throat]). There was no documentation indicating that the test had been completed, nor were there any test results in the medical record. This was verified by DED in an interview.

During a review of Patient 1's "Orders," dated 1/18/2025, the Orders indicated the following was ordered for Patient 1:

-Oximetry (a medical procedure that measures the oxygen saturation of the blood) Continuous: Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.
- Cardiac Monitor (a device that records the heart's electrical activity): Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.
-IV Saline Lock (a capped-off intravenous [in the vein] catheter that is flushed with saline to prevent blood from clotting and maintain access for further medication or fluid administration), Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.

During a review of Patient 1's "Summary Report," dated 1/18/2025, the report indicated "left ama (against medical advice) without signing paperwork."

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Examination," dated 10/2023, the P&P indicated the following: The hospital will provide a medical screening examination ...to any individual who comes to the Emergency Department seeking an examination or medical treatment ...to determine if the individual has an emergency medical condition ...If is determined that the individual has an emergency medical condition, the Emergency department will provide the individual, within the capacities of the Hospital, with such further medical examination and treatment, as required to stabilize the medical condition.

2.b. During a concurrent interview and record review, on 3/7/2025 at 10:45 a.m. with the Stroke Coordinator (SC), Patient 9's Emergency Department Summary record, dated 9/15/2024, was reviewed. The Emergency Department Summary indicated Patient 9 arrived in ED on 9/15/2024 at 7:28 p.m. with chief complaint "Chest pain, sudden onset, left sided Chest pain, hurts when moves." Patient 9's Triage (Acuity Level) on 9/15/2024 at 7:34 p.m. was Emergency Severity Index (ESI) level-3 (urgent). Vital Signs: Temperature: 98.5 F (normal 97 Fahrenheit- a unit of measurement to 99F); Pulse 69 (normal is 60 to 100); Respiration rate (RR):19 breaths per minute (normal RR 12 to 20); Blood Pressure (BP)1161/97 (normal is BP 120/80) Pulse oximetry 98% on room air (RA), 4/10 Pain assessment.

During a review of Patient 9's physician orders dated 9/15/2024 at 9 p.m., the physician orders indicated STAT (emergent) physician orders :Nitroglycerin (medicine used to treat chest pain), aspirin 81 milligrams (mg, a unit of measurement); IV saline; continuous cardiac monitor; continuous pulse oximetry; oxygen cannula; undress and gown patient; electrocardiogram; notification of admission to telemetry ; complete blood count; basic metabolic panel; D- dimer (a protein that is released when blood clots break down); B type natriuretic peptide (a hormone released by the heart in response to increased stress); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged), Chest X-ray.

During further review of Patient 9's medical record, the Lab (laboratory) results included a Critical Value Troponin (found in heart muscle and usually elevated when heart muscle is damaged) level which was elevated= 54 (normal 3 to 34). At 9:10 p.m., lab attempted twice to notify a registered nurse (RN) of critical Troponin result but with no response. D-Dimer (a protein that is released when blood clots break down) was elevated 18.37 (normal<0.50). B type natriuretic peptide was181 (normal o to 100). Follow-up Troponin level drawn at 10:51 p.m. showed a Troponin level of 51 (normal 3 to 34), reported to RN at 12:22 a.m. on 9/16/2024. The EKG result indicated: incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart).

During a review of Patient 9's physician orders dated 9/16/2024 at 1 a.m., the Stat orders included Enoxaparin (injectable blood thinner that prevents and treats blood clots), Ultrasound (US) Venous lower extremity (US of leg veins for blood clots); Lung perfusion studies (to evaluate for blood clots in the lung).

During a review of Patient 9's physician orders dated 9/16/2024 at 1:49 a.m., the record indicated to Request Admit from ED.

During a review of Patient 9's ED Physician Documentation, dated 9/15/2024, the record indicated Patient 9 had elevated Troponin and D -dimer and Patient 9 needed evaluation and treatment for Pulmonary embolus. Same document indicated Patient 9's EKG included incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart), inverted T wave (could be heart attack) and no ST elevation (elevation indicated heart artery blockage). Patient 9's diagnosis included; acute coronary syndrome (Chest pain that can lead to heart attack); NSTEMI (heart attack with damage to heart without ST elevation); rule out pulmonary embolus (artery in the lung is blocked by a blood clot), and acute kidney injury (AKI, kidneys suddenly lose their ability to function). Plan indicated to admit Patient 9 to telemetry (a specialized ward where patients receive continuous cardiac [heart] monitoring) unit and facility Hospitalist notified.

The same document indicated that findings and plan was explained to Patient 9 and that Patient 9 was provided aftercare instructions and instructions to return for worsening symptoms. The record also indicated that Patient 9 had to follow-up with PMD and indicated Patient 9's condition improved. Patient 9's ED Physician Documentation was signed 9/16/ 2024 at 1:27 p.m.

During a concurrent interview and record review on 3/7/2025 at 11:10 a.m. with the Director of Emergency Department (DED), Patient 9's Emergency Department Summary, dated 9/15/2024, was reviewed. DED was asked if Patient 9 was on continuous cardiac monitor and continuous oximetry, DED stated there was no documentation Patient 9 was on continuous cardiac monitor or continuous pulse oximetry. DED was asked would the continuous Cardiac monitor and continuous oximetry alarm make noise if Patient 9 was disconnected, DED stated yes and verified there was no documentation by RN of Patient 9 being disconnected from the cardiac monitor. DED was also asked if Patient 9 received medications ordered STAT by physician including Aspirin, Morphine Sulphate, Nitroglycerin, and Lovenox. DED stated Aspirin was ordered at 9 p.m. and given at 10:14 p.m. and Nitroglycerin was given by a licensed vocational nurse (LVN) at 10:27 p.m. DED confirmed that Morphine, Lovenox, and Normal Saline IVF were not given as per physician orders.

During the same concurrent interview and record review on 3/7/2025 at 11:25 a.m. with the Director of Emergency Department (DED), the DED stated Patient 9 left sometime after 10 p.m., not sure when Patient 9 left. Patient 9's Emergency Department Summary, documented by an LVN, under section Notes, indicated "Patient (Patient 9) not found in ED common areas" on 9/16/2024 at 12 midnight. DED also confirmed there was no Discharge orders written by MD.

During a review of Patient 9's "ED Physician Documentation," dated 9/16/2024 at 2:38 a.m., the documentation indicated Patient 9 could not be found and might have eloped. Physician tried to telephone Patient 9 twice, left voicemail that cardiac enzymes were elevated and could have blood clot in lungs both of which were life threatening and to return to ED.

During a review of the facility's policy and procedure (P&P) titled, "RN standardized procedures emergency department," dated 7/20/2024, the P&P indicated "RN is responsible for a patient for whom a standardized procedure has been implemented including: showing EKG to the physician notifying the physician of any abnormal lab or radiology result , any change in patient condition abnormal vital signs or any other concern regarding the patient... the RN is responsible to ensure physician orders are received ... and implemented in a timely manner."

During a review of a facility's policy and procedure titled, "Medical Screening Exam," dated 10/20/2023, under section: stabilizing treatment, the P&P indicated "if it is determined that an individual has an emergency medical condition the emergency department will provide the individual with the capabilities of the hospital such further medical examination and treatment as required to stabilize the medical condition."

Based on interview and record review, the facility did not complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for one of 22 sampled patients (Patient 8).

This deficient practice resulted in Patient 8 not receiving an MSE and evaluation for EMC (Emergency medical Condition), which had the potential for patient harm. Patient 8 left the facility without being seen (LWBS).

Findings:

During a concurrent interview and record review, on 3/6/2025 at 3:40 p.m. with the Performance Improvement Coordinator (PIC), Patient 8's Emergency Department Summary, dated 9/1/2024, was reviewed. The Emergency Department Summary indicated Patient 8 arrived in the Emergency Department (ED) on 9/1/2024 at 12:21 a.m. with a chief complaint of "headache, fainted and hit back of head on the floor at concert, swelling and scalp abrasion, had cocktail drink and marijuana at concert." Patient 8 was Triaged (Acuity Level) on 9/1/2024 at 12:32 am, as Emergency Severity Index (ESI) level-3 (Urgent) ("Requires 2 or more resources and VS may or may not be in Danger Zone"). Vital Signs were- Temperature: 98.2 F (normal 97F to 99F); Pulse 94 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure148/93 (normal BP 120/80); Pulse oximetry 99% on room air (RA);1/10 Pain assessment. Electrocardiogram (EKG, measures heart's electrical activity) was ordered at 12:47 a.m. with indication of "ST elevation probably normal repolarization pattern." RN call attempted first call for Patient 8 at 3:00 a.m., for MSE recorded at 3:05 a.m. Patient 8 left without being seen (LWBS). PIC verified Patient 8 did not have an MSE, no neurologic exam, no head injury exam or cleansing of Patient 8's head abrasion, no lab and no image orders.

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Exam," dated 10/20/2023, the P&P indicated "to provide a medical screening exam to all the individuals presenting to the emergency department to determine if an emergency medical condition exists and to provide medical screening examination emergency services and care as indicated to stabilize the medical condition."

During a review of the facility's policy and procedure (P&P) titled, "RN standardized procedures Emergency Department," dated 7/20/2024, the P&P under section: presenting symptoms Syncope, indicated implementation of standardized procedures in the emergency department evaluation for Syncope included: lab blood draw for CBC (complete blood count); Basic Metabolic Panel. Nursing orders include cardiac monitor, pulse oximeter Monitor; oxygen to keep saturation above 90%; checking Patient's blood sugar level and EKG.

Based on interview and record review the facility failed to carry out physician's orders for two of 22 sampled patients (Patients 1 and 9) who presented to the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment.

This deficient practice resulted in the facility failing to provide further medical examination and stabilizing treatment to Patients 1 and 9 and had the potential to result in harm.

Findings:

1. During a concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), DED stated the following: Patient 1 presented to the ED on 1/17/2025 at 11:30 p.m. for shortness of breath and throat swelling. Patient 1 was evaluated by the Physician (MD 1) at 11:59 p.m. The DED reviewed Patient 1's medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac (Toradol, a nonsteroidal anti-inflammatory drug, reduces inflammations and relieves moderate to severe pain), Dexamethasone (treats inflammation [swelling]), Diphenhydramine (Benadryl, treats allergies), Normal Saline (a solution of salt and water similar to that found in the body) had been ordered and had not been administered to Patient 1. There was no documentation indicating the reason the medications had not been given.

During the same concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), Patient 1's medical record was reviewed. Patient 1's medical record indicated MD 1 ordered Cardiac (heart) monitoring and Oximetry (a non-invasive method to measure a person's blood oxygen saturation, or the percentage of red blood cells carrying oxygen, providing a quick assessment of how well the lungs are functioning) on 1/18/2025 at 12:09 a.m. for Patient 1. The DED verified there was no documentation indicating as to whether the cardiac monitoring or oximetry orders were carried out and it should have been documented. MD 1 also ordered a CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) scan on 1/18/2025 at 12:19 a.m., which was not completed. DED stated Patient 1 left against medical advice (AMA, a situation where a patient leaves a healthcare facility before their doctor recommends) on 1/18/2025 at 4:15 am. The DED verified that none of the physician's orders were carried out or completed during the time Patient 1 was in the ED, for approximately 4 hours.

During a concurrent interview and record review on 3/6/2025 at 9:59 a.m. with the Manager of Pharmacy (MOP), the MOP stated the following: One-time medications orders in the Emergency Department automatically cancel themselves one minute after the medication is ordered by the physician. The medication then appears as "active" in the medication administration record (MAR) and the medication is highlighted in red until the medication is acknowledged and administered by a nurse. MOP stated that medications ordered in the ED are immediately available to nurses to avoid any delay in administering the medication. Medications ordered in the ED should be given as soon as possible. The MOP reviewed Patient 1's medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac, Diphenhydramine, Dexamethasone, and Normal Saline had been ordered by the physician. The MAR indicated that the medications were not acknowledged by a nurse and the medications were not administered to Patient 1. The MOP stated that the medications for Patient 1 were meant to treat Patient 1 symptoms, including throat swelling.

During a review of Patient 1's "Triage (a preliminary assessment in order to determine the urgency of a patient's need for treatment and nature of treatment required)" note, dated 1/17/2025 at 11:34 p.m., the triage note indicated the following: Patient 1 complained of throat pain and SOB (shortness of breath) one (1) hour ago ... Patient 1 started with hoarse voice and suddenly could not speak ...Priority level: 3 (Urgent, conditions prompt attention but can wait a short period for assessment and treatment).

During a review of Patient 1's "ED Physician Documentation," dated 1/18/2025 at 12:17 a.m., the ED Physician Documentation indicated the following: "Chief complaint: Shortness of breath (SOB). Stated Complaint: Throat swelling. Patient (1) ...with history of asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breath) presents ...for evaluation of throat pain and swelling and difficulty speaking after returning from vacation..."

During a review of Patient 1's "Physician Note," dated 1/18/2025 at 12:09 a.m., the noted indicated "Patient okay to get CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) with contrast (a dye or substance that helps show abnormal areas inside the body) without labs."

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's order indicated the following: Ketorolac 15 milligrams (MG, a unit of measurement) IV (in the vein) Once (one time) .

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's Order indicated the following. Dexamethasone 10 mg IV Once.

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m. indicated the following: Diphenhydramine 50 mg IV Once.

During a review of Patient 1's "Physician's Order," dated 1/18/2025 at 12:15 a.m., the Physician's Order indicated the following: Sodium Chloride (IV fluid) 1000 milliliters (ml, a unit of measurement) one time.

During a review of Patient 1's "Medical Administration Record," dated 1/18/2025, the Medical Administration Record indicated the following:

-Ketorolac (Toradol) 15 milligrams (MG) IV (in the vein) Once (one time). Current status was active (pending administration to patient) and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication was administered by a nurse.
-Dexamethasone 10 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse.
-Diphenhydramine (Benadryl, relieves allergies) 50 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse.
- Sodium Chloride (IV fluid) 1000 milliliters (ml) one time. Current status was active and was highlighted in red. There was no documentation indicating that order was acknowledged or carried out.

During a review of Patient 1's "Orders," dated 1/18/2025 at 12:09 a.m., the Orders indicated for a Rapid Group A Strep Test (a diagnostic test used to detect the presence of Group A streptococcus bacteria [a common bacteria found on the skin or throat]). There was no documentation indicating that the test had been completed, nor were there any test results in the medical record. This was verified by DED in an interview.

During a review of Patient 1's "Orders," dated 1/18/2025, the Orders indicated the following was ordered for Patient 1:

-Oximetry (a medical procedure that measures the oxygen saturation of the blood) Continuous: Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.
- Cardiac Monitor (a device that records the heart's electrical activity): Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.
-IV Saline Lock (a capped-off intravenous [in the vein] catheter that is flushed with saline to prevent blood from clotting and maintain access for further medication or fluid administration), Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview.

During a review of Patient 1's "Summary Report," dated 1/18/2025, the report indicated "left ama (against medical advice) without signing paperwork."

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Examination," dated 10/2023, the P&P indicated the following: The hospital will provide a medical screening examination ...to any individual who comes to the Emergency Department seeking an examination or medical treatment ...to determine if the individual has an emergency medical condition ...If is determined that the individual has an emergency medical condition, the Emergency department will provide the individual, within the capacities of the Hospital, with such further medical examination and treatment, as required to stabilize the medical condition.

2. During a concurrent interview and record review, on 3/7/2025 at 10:45 a.m. with Stroke Coordinator (SC), Patient 9's Emergency Department Summary record, dated 9/15/2024, was reviewed. The Emergency Department Summary indicated Patient 9 arrived in ED on 9/15/2024 at 7:28 p.m. with chief complaint "Chest pain, sudden onset, left sided Chest pain, hurts when moves." Patient 9's Triage (Acuity Level) on 9/15/2024 at 7:34 p.m. was Emergency Severity Index (ESI) level-3 (urgent). Vital Signs: Temperature: 98.5 F (normal 97 Fahrenheit- a unit of measurement to 99F); Pulse 69 (normal is 60 to 100); Respiration rate (RR):19 breaths per minute (normal RR 12 to 20); Blood Pressure (BP)1161/97 (normal is BP 120/80) Pulse oximetry 98% on room air (RA), 4/10 Pain assessment.

During a review of Patient 9's physician orders dated 9/15/2024 at 9 p.m., the physician orders indicated STAT (emergent) physician orders :Nitroglycerin (medicine used to treat chest pain), aspirin 81 milligrams (mg, a unit of measurement); IV saline; continuous cardiac monitor; continuous pulse oximetry; oxygen cannula; undress and gown patient; electrocardiogram; notification of admission to telemetry ; complete blood count; basic metabolic panel; D- dimer (a protein that is released when blood clots break down); B type natriuretic peptide (a hormone released by the heart in response to increased stress); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged), Chest X-ray.

During further review of Patient 9's medical record, the Lab (laboratory) results included a Critical Value Troponin (found in heart muscle and usually elevated when heart muscle is damaged) level which was elevated= 54 (normal 3 to 34). At 9:10 p.m., lab attempted twice to notify a registered nurse (RN) of critical Troponin result but with no response. D-Dimer (a protein that is released when blood clots break down) was elevated 18.37 (normal<0.50). B type natriuretic peptide was181 (normal o to 100). Follow-up Troponin level drawn at 10:51 p.m. showed a Troponin level of 51 (normal 3 to 34), reported to RN at 12:22 a.m. on 9/16/2024. The EKG result indicated: incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart).

During a review of Patient 9's physician orders dated 9/16/2024 at 1 a.m., the Stat orders included Enoxaparin (injectable blood thinner that prevents and treats blood clots), Ultrasound (US) Venous lower extremity (US of leg veins for blood clots); Lung perfusion studies (to evaluate for blood clots in the lung).

During a review of Patient 9's physician orders dated 9/16/2024 at 1:49 a.m., the record indicated to Request Admit from ED.

During a review of Patient 9's ED Physician Documentation, dated 9/15/2024, the record indicated Patient 9 had elevated Troponin and D -dimer and Patient 9 needed evaluation and treatment for Pulmonary embolus. Same document indicated Patient 9's EKG included incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart), inverted T wave (could be heart attack) and no ST elevation (elevation indicated heart artery blockage). Patient 9's diagnosis included; acute coronary syndrome (Chest pain that can lead to heart attack); NSTEMI (heart attack with damage to heart without ST elevation); rule out pulmonary embolus (artery in the lung is blocked by a blood clot), and acute kidney injury (AKI, kidneys suddenly lose their ability to function). Plan indicated to admit Patient 9 to telemetry (a specialized ward where patients receive continuous cardiac [heart] monitoring) unit and facility Hospitalist notified.

The same document indicated that findings and plan was explained to Patient 9 and that Patient 9 was provided aftercare instructions and instructions to return for worsening symptoms. The record also indicated that Patient 9 had to follow-up with PMD and indicated Patient 9's condition improved. Patient 9's ED Physician Documentation was signed 9/16/ 2024 at 1:27 p.m.

During a concurrent interview and record review on 3/7/2025 at 11:10 a.m. with the Director of Emergency Department (DED), Patient 9's Emergency Department Summary, dated 9/15/2024, was reviewed. DED was asked if Patient 9 was on continuous cardiac monitor and continuous oximetry, DED stated there was no documentation Patient 9 was on continuous cardiac monitor or continuous pulse oximetry. DED was asked would the continuous Cardiac monitor and continuous oximetry alarm make noise if Patient 9 was disconnected, DED stated yes and verified there was no documentation by RN of Patient 9 being disconnected from the cardiac monitor. DED was also asked if Patient 9 received medications ordered STAT by physician including Aspirin, Morphine Sulphate, Nitroglycerin, and Lovenox. DED stated Aspirin was ordered at 9 p.m. and given at 10:14 p.m. and Nitroglycerin was given by a licensed vocational nurse (LVN) at 10:27 p.m.; DED confirmed that Morphine, Lovenox, and Normal Saline IVF were not given as per physician orders.

During the same concurrent interview and record review, on 3/7/2025 at 11:25 a.m. with the Director of Emergency Department (DED), the DED stated Patient 9 left sometime after 10 p.m., not sure when Patient 9 left. Patient 9's Emergency Department Summary, documented by an LVN, under section Notes, indicated "Patient (Patient 9) not found in ED common areas" on 9/16/2024 at 12 midnight. DED also confirmed there was no Discharge orders written by MD.

During a review of Patient 9's "ED Physician Documentation," dated 9/16/2024 at 2:38 a.m., the documentation indicated Patient 9 could not be found and might have eloped. Physician tried to telephone Patient 9 twice, left voicemail that cardiac enzymes were elevated and could have blood clot in lungs both of which were life threatening and to return to ED.

During a review of the facility's policy and procedure (P&P) titled, "RN standardized procedures emergency department," dated 7/20/2024, the P&P indicated "RN is responsible for a patient for whom a standardized procedure has been implemented including: showing EKG to the physician notifying the physician of any abnormal lab or radiology result , any change in patient condition abnormal vital signs or any other concern regarding the patient... the RN is responsible to ensure physician orders are received ... and implemented in a timely manner."

During a review of a facility's policy and procedure titled, "Medical Screening Exam," dated 10/20/2023, under section: stabilizing treatment, the P&P indicated "if it is determined that an individual has an emergency medical condition the emergency department will provide the individual with the capabilities of the hospital such further medical examination and treatment as required to stabilize the medical condition."