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Based on record review and interview, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of thirty sampled patients (Patient 1) on 5/16/2022 emergency room visit.

This deficient practice resulted in Patient 1 not having a medical screening examination (MSE) to determine if Patient 1 had an emergency medical condition, on 5/16/2022 at 8:03 p.m.. Patient 1 was found unresponsive in the waiting room, on 5/16/2022 at 10:52 p.m. (2 hours and 49 minutes after arrival) and subsequently expired at 11:13 p.m.

Findings:
A review of Patient 1's "Patient Care Report with Attachments," by the EMS (Emergency Medical Services, dated 5/16/2022 at 7:39 p.m., indicated Patient 1 was brought to the facility at 8:04 p.m (as indicated on the record), for alcohol intoxication, chest pain, and "cardiac issue."

A review of Patient 1's "In /Out /ER Patient Admission Record," indicated Patient 1 was admitted to the Emergency Department (ED) on 5/16/2022 at 8:03 p.m. (as written on the record).

A review of Patient 1's "Emergency Medical Record," indicated Patient 1 was triaged on 5/16/2022 at 8:07 p.m., Patient 1 was brought by Fire/Rescue ambulance. Patient 1 was assessed as a priority level 3, and expired at 11:17 p.m.
A review of the triage notes titled, "Rapid Initial Assessment", dated 5/16/2022 at 8:07 p.m., indicated Patient 1 was brought in by rescue ambulance (RA) for ETOH (alcohol). Per Emergency Medical Services (EMS), a bystander called 911 due to Patient 1 found laying on the ground by the street, intoxicated. Patient 1 had a strong smell of alcohol. Chief complaint: ingestion and Priority : ESI 3 / Urgent ( Level 1 / Resuscitation: patient presents with a condition that requires immediate , aggressive attention, Level 2 / Emergent: indicates a patient presents with a condition posing a potential threat to life, limb, or function and requires a medical screen within 10 minutes of arrival. Level 3 / Urgent: patient presents with a condition that could progress to a serious problem requiring emergency intervention. Patients should have a medical screen within 30 minutes of arrival. Level 4 / Semi-Urgent: a patient condition is stable. Level 5 / Non-Urgent: patient has a minor illness, injury, or stable chronic condition).

A review of a note titled, "RME (rapid medical evaluation) Attestation", dated 5/16/2022 at 8:20 p.m., indicated Patient 1 was brought in by EMS after running in and out of traffic. He has been cooperative. ETOH. No complaints. Spanish speaking. No orders were placed for Patient 1.

A review of Patient 1's "Emergency Notes", dated 5/16/2022, indicated the following;
a. At 8:20 p.m., per charge nurse (CN 1), Patient 1 to ED lobby. No change in Patient's condition. Alert and oriented times three.
b. At 8:20 p.m., Patient 1 appears in no apparent distress (NAD), awake and alert.
c. At 10:51 p.m., Emergency Department (ED) technician (tech) notified me that she noticed Patient 1 slumped over in chair. ED tech checked for pulses and got me for help. Code Blue initiated. CPR started in lobby. Patient 1 then taken to room 15 for MD care.
d. At 10:55 p.m., CPR in progress.
e. At 11:13 p.m., no pulse, no breathing, unresponsive, no signs of life. CPR stopped and Patient 1 was pronounced dead.

A review of a document titled, "Code Blue Record," dated 5/16/2022 at 10:53 p.m., indicated a Code (a cardiopulmonary arrest happening to a patient) had been activated at 10:52 p.m. for Patient 1. Code team arrived at 10:53 p.m.. Patient 1's condition upon Code Team arrival; unconscious (a person is unable to respond to people or activity), cyanotic (a bluish color to the skin or mucous membranes I usually due to lack of oxygen in the blood), pupils dilated (when the black center of the eyes are larger than normal), not breathing, no pulse, and temperature was cold. CPR (cardiopulmonary resuscitation) was started at 10:53 p.m.. The code was stopped at 11:13 p.m.. Code outcome: Patient 1 expired.

A review of a note titled, "HPI-General Illness', dated 5/16/2022 at 10:53 p.m., indicated Patient 1 brought by EMS after a bystander saw him running in and out of traffic and appeared to be intoxicated. Patient's vital signs upon arrival were: BP (blood pressure) 116/90, HR (heart rate) 100, RR (respiratory rate) 19, SPO2 (percentage of oxygen in the blood) 98 %. Patient was placed in the waiting room when he became unconscious, and CPR was in progress at 10:52 p.m.. Patient 1 was taken into critical care room for further resuscitation ...Time of death was called at 11:13 p.m.. Primary impression: cardiac arrest.
During a concurrent interview and record review of a note titled "RME", on 8/26/2022 at 11:30 a.m., the Director of the Emergency Department (DED) stated the physician assistant (PA 1) initiated a greeting (a polite word or sign of welcome or recognition) at triage, no orders were placed for Patient 1. The DED stated that after triage, the charge nurse (CN 1) instructed the Fire and Rescue ambulance personnel to take Patient 1 to the lobby. The DED stated that neither CN 1 nor the ambulance personnel (EMS, staff) handed off (gave report of patient condition) the patient to the Emergency Medical Technician (EMT) in the lobby. The DED stated there should have been a hand off. The DED stated Patient 1 was seen at the time of triage by PA 1, at 8:20 p.m., who conducted an RME (rapid medical evaluation) and documented a comment only, no orders were placed. The DED stated the RME note was not a medical screening examination (MSE). The DED stated Patient 1 did not receive a MSE during while in the emergency department.
During a concurrent interview and record review of the "RME" note, on 8/26/2022 at 11:50 a.m., PA 1 stated she spoke to Patient 1 on 5/16/2022 at 8:20 p.m. and documented a quick blurb (a short and descriptive account) in the medical record. PA stated she did not take Patient 1 history, nor, did she perform a physical exam. PA 1 stated she performed a rapid medical evaluation (RME), a quick evaluation to determine the severity of the patient.

During an interview, on 8/26/2022 at 11:59 a.m., the Medical Director for the Emergency Department (MDED) stated the RME was a rapid evaluation of the patient, it was only the beginning and only a small portion of the MSE. The MDED stated the RME did not fall under the definition of an MSE. The MDED stated the MSE was required to exclude a life-threatening emergency per EMTALA regulations.

A review of the facility's policy and procedure titled, "Standards of Practice or Care," dated 8/29/2019, indicated the patient was evaluated based on triage levels. Urgent: indicates the patient presents with a condition that could progress to a serious problem requiring emergency intervention. Patient should have a medical screen within sixty (60) minutes of arrival.

A review of the facility's policy and procedure titled, "Screening & Stabilization (EMTALA)", reviewed 3/2021, indicated a hospital must provide an appropriate MSE within the capacity of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an emergency medical condition (EMC) exist; (i) to any individual, including a pregnant woman having contractions, who request such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. The Hospital must perform an MSE to determine if an EMC exist. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an 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. The individual must be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, or if he or she does, until he or she is stabilized or appropriately admitted or transferred. The MSE may vary depending on the individual's signs and symptoms: (i.) Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory test, CT scans, and other diagnostic procedures.