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Based on staff interviews, Emergency Department's (ED) policy and procedures, and ED patient record reviews, the hospital failed to comply with 42 CFR § 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases.
This failure compromised one patient's (Patient 1) medical status and could potentially affect other patients in need of emergency services in the hospital.

Findings:

During an EMTALA Survey on 12/21/23 to 1/8/24, the survey team determined the ED, failed to ensure two Patients (Patient 1 and Patient 2) received safe and timely re-assessments after triage, leading up to no or delayed Medical Screening Exams (MSE). The ED staff failed to re-assess Patient 1, according to hospital policy and procedure, to ensure his medical condition was stable, resulting in Patient 1's cardiac arrest and death in the ED lobby 8-hours after his arrival. The ED staff failed to ensure Patient 2 was re-assessed, according to hospital policy and procedure, to ensure her medical condition was stable, resulting in a decline of Patient 2's mental and physical status, until she received an MSE 11-hours after her arrival. (Cross Reference A-2406).

Based on staff interviews, Emergency Department's (ED) policy and procedures, and ED patient record reviews, the facility failed to re-assess walk-in patients who had been triaged, but awaited room placement in the Emergency Department (ED).

These failures did not comply with facility policy, delayed the provision of medical screening examination (MSE), and potentially caused one Patient's emergency medical condition to worsen without monitoring or detection, resulting in death.

Findings:

During an interview on 12/18/23 at 2:34 p.m., Confidential Complainant (CC) stated a patient (Patient 1) expired in the ED without being seen by a physician. CC stated the ED was understaffed, and there were 30-40 patients waiting in the ED at the time.

During a record review on 12/19/21 on 11:12 a.m., Patient 1's "ED Encounter" dated 12/8/23 was reviewed. Record review revealed the following timeline:
15:44 (3:44 p.m.): Patient 1 arrived (walked-in) to the ED with complaints of chest discomfort.
15:49 (3:49 p.m.): an EKG (or ECG, is a test that checks how the heart is functioning by measuring the electrical activity of the heart) was performed on Patient 1 and yielded a sinus rhythm result (normal).
15: 52 (3:52 p.m.): Patient 1's vital signs were checked: Blood pressure (BP) = 170/85, Heart Rate (HR) = 70, Resp (Respirations) = 16, SpO2 (oxygen saturation) = 100, Temp (Temperature) = 98.1. Patient 1 reported a pain score of 7 out of 10.
5:55 (3:55 p.m.): Patient 1 was triaged and identified as ESI Priority 2. [The Emergency Severity Index (ESI) is an emergency nursing association (ENA) and American College of Emergency Physicians (ACEP) approved triage system using a five-level triage scale where ESI level 1 is the
highest severity. ESI Level 1 concerns the highest acuity patients requiring immediate, life-saving interventions without delay. ESI Level 2 is a patient with an illness or injuries that place them at high risk for deterioration, or signs of a time-critical problem that require prompt attention.
ESI Level 3 is a patient with illnesses or injury that is stable but require prompt medical attention and require two or more resources. ESI Level 4 is a patient who has no medical emergency and has an illness or injury that requires one resource. ESI priority 5 is a patient who has no
medical emergency and requires no resources, such as seeking care for a chronic or routine problem.]
16:11 (4:11 p.m.): Blood samples, including troponin (the biomarker of choice for detecting heart muscle damage) were obtained from Patient 1.
16:54 (4:54 p.m.): Patient 1's blood sample results indicated normal troponin levels.
17:29 (5:29 p.m.): Patient 1's vital signs were rechecked; BP = 126/78, HR = 72, Resp = 16, SpO2 = 95. Patient 1 reported a pain level of 10.
17:30 (5:30 p.m.): Patient 1 was sent back to the ED lobby and awaited room placement for an MSE.
23:30 (11:30 p.m.): Patient was roomed to TR14, asystole (no heartbeat) from triage, CPR (or cardiopulmonary resuscitation is an emergency technique used on someone whose heart or breathing has stopped) in progress. Official time of death was called at 23:59 (11:59 p.m.).

During a concurrent interview and record review on 12/19/23 at 11:35 a.m. with Director B, Patient 1's ED Encounter on 12/8/23 was reviewed. Director B confirmed there were no notes between Patient 1's vital signs at 5:29 p.m., and his CPR Notes at 11:30 p.m. When pointed about the six-hour span, Director B nodded and stated, "There was a gap." Director B stated Patient 1 was brought back out to the waiting room and was never assigned a physician.

During an interview on 12/20/23 at 3:08 p.m., RN C stated after a patient was checked in by the ED Clerk, the triage nurse would take the patient into the triage room for vital signs and ask them why they are here, take their history. RN C stated based on that information, the triage nurse would determine the patient's ESI level. RN C stated bed placement in the ED depended on the patient's ESI priority. RN C stated a patient with an ESI 2 level was urgent, but not critical, and was ideally roomed as soon as possible. RN C stated ANMs (Assistant Nurse Managers) were notified when room placement was needed. RN C stated the ED was very busy with a lot of patients the night Patient 1 came in. RN C stated, "There's usually another triage nurse and a Nurse First, but I think I was the only triage nurse that night." RN C stated she notified the ANMs that shift of Patient 1's ESI level but was told that there were no beds available. RN C stated ESI 2 patients were reassessed every two hours and have their vital signs retaken and monitored for any changes of condition. When asked how Patient 1 was not reassessed during a six-hour period, RN C stated she was literally checking in patients one after another that night. RN C stated it was the triage nurse or the "Nurse First" who did the patient reassessments. RN C stated they were very short-staffed that night.

During an interview on 12/21/23 at 1:38 p.m., RN D stated a "Nurse First" was a licensed nurse assigned to sit in the waiting room to see over the patients who have been triaged, and constantly observe for any changes among the patients. RN D stated part of the Nurse First role was to do additional assessments such as vital signs, start order protocols, answer patient questions, and explain what is going on to the patients. RN D stated patient reassessments in the waiting room were done at least every two hours. RN D stated that in the absence of a Nurse First, the triage nurse would do the patient reassessments.

During an interview on 12/21/23 at 2:21 p.m., RN E stated patients in the ED go through triage and get roomed depending on their level of severity, while some would have to wait for beds. RN E stated there is a nurse that recheck the patients' vital signs while they wait for beds. RN E stated ESI Level 2 patients could be "heavy" and need to be roomed as quickly as possible.

During an interview on 12/21/23 at 3 p.m., ED Clerk F stated she recalled the evening Patient 1 came to the ED. ED Clerk F stated Patient 1 came in, accompanied by his family, for chest pain. ED Clerk F stated she asked Patient 1 for some history, and Patient 1 denied any history of heart attacks or surgeries. ED Clerk F stated she put an "EKG Alert" on Patient 1, a protocol for every patient coming in with chest pain. ED Clerk F stated a nurse and tech came to evaluate Patient 1, then Patient 1 went back out to the waiting room. ED Clerk F stated sometime after, she saw fire trucks drive outside the building. ED Clerk F stated she got up and went to the lobby, found Patient 1 on a wheelchair with his family members, speaking with the fire emergency crew. ED Clerk F stated the family had called 911, and she heard the fire emergency crew tell Patient 1 that they could not do anything because he's inside the [hospital] facility. ED Clerk F stated she wheeled Patient 1 back to the EKG room and notified the nurse of Patient 1's continued pain. ED Clerk F stated she was not sure what happened to Patient 1 after. ED Clerk F stated the ED was "crazy busy" that night, with maybe 30 or 40 patients around, and added the waiting area was almost "standing room only". ED Clerk F stated she recalled seeing Patient 1 seated on a wheelchair, at the overflow hall with his family, later that night. ED Clerk F stated it was around the end of her shift at 11:30 p.m. when nurses responded to an overhead page about an emergency in the ED lobby. When asked if anyone checks on the patients while they wait in the waiting room, ED Clerk F stated the Nurse First usually did, every two hours. ED Clerk F stated the Nurse First had left at 6 p.m. that evening.

During an interview on 12/22/23 at 11:30 a.m. RN G stated she was "Nurse First" the evening of 12/8/23. When asked what her role was as "Nurse First," she stated you are at the front desk re-assessing patients (taking vital signs, and draw bloods for the lab, and room patients inside the ED) after they have been triaged until they are roomed for an MSE. RN G stated she only worked from 4:30 p.m. to 6:30 p.m. that evening, during that time the ED was extremely busy, and she was pulled to assist patients that were inside the ED to help with patient lab draws, and x-rays. RN G stated there was only one triage nurse on that evening and there was no "Nurse First" during the day shift or on the night shift after she left. RN G was asked if she felt comfortable asking the charge nurse for additional staff to help. RN G stated she did request additional help from the nurse manager, but there was not enough staff that evening.

During an interview on 12/22/23 at 12:21 p.m., ANM H was asked if she remembered the events of the evening of 12/8/23. ANM H stated she had left before the incident occurred, but remembered the ED was extremely busy that evening with long wait times. When asked if the triage nurse spoke with her about finding a room for Patient 1, ANM H stated she did not remember speaking with the triage nurse about Patient 1. When asked what the expectation was if a patient was triaged with an "ESI of 2," ANM H stated her expectation was patient's received continuous care and reassessment and roomed as soon as possible. The role of the "Nurse First" was to ensure the patients' that had been triaged were re-assessed in the waiting room every 2 to 4-hours or as needed. The first nurse helped expedite the medical orders and recommended a patient to be roomed. When asked if ANM H asked for additional help for the ED that evening, ANM H stated she did ask for additional help, but there wasn't any available staff.

During a record review on 12/22/23 at 12:40 p.m., Patient 2's "ED records" dated 12/8/23 were reviewed. Record review revealed the following timeline:
15:06 (3:06 p.m.) Patient 2 was wheeled over to the ED from internal medicine department by wheelchair with complaints of "Shortness of Breath."
15:32 (3:32 p.m.) Patient 2 was triaged as an ESI-3- Urgent, Patient 2's vital signs were BP = 98/47, HR = 54, Resp = 20, SpO2 = 96%, Temp. 97.1F.
23:03 (11:03 p.m.) Patient 2's next set of vital signs were BP = 108/48, HR = 54, Resp = 18, SpO2 = 98%.
23:15 (11:15 p.m.) Diagnostic imaging (Head CT) was ordered for Patient 2, History and Physical notes indicated that Patient 2 was alert and oriented when arrived but seems to have become delirious.
12/9/23 01:51 (01:51 a.m.) Patient 1 was roomed.
12/9/23 03:24 (3:24 a.m.) an MSE was conducted by an MD.
12/9/23 06:17 (06:17 a.m.) Patient 2 was admitted to the ICU.

During the record review, the Medical Records Assistant M was asked to verify the assessments taken in the ED for Patient 2. The Medical Records Assistant M verified the only assessments/re-assessments conducted were upon admission and after 11:03 p.m.

During an interview on 1/5/23 at 10 a.m., ANM stated he had been the ED ANM for about 11 years at the facility. ANM I stated parts of his responsibility as an ANM were to guide the movement and flow of the patients coming in from triage to the physician or a room or a nurse and monitor the ED as a whole. ANM I stated he would know of patients' ESI levels through the board, or they would get notified via phone or radio by the triage nurse. ANM I stated he worked until 7 p.m. the evening Patient 1 came to the ED. ANM I stated the goal for ESI 2 patients was to get them roomed as quickly as possible. ANM 1 stated was aware Patient 1 was in the lobby, but he could not recall if he had specific notifications about Patient 1's ESI 2 Level. ANM I stated the ED was busy that day, and even had to triage several ESI 2 patients in the waiting room. ANM I stated there were "significant struggles" in the back as well, with multiple Team Stats (emergencies), stroke alerts, gunshot wound patients, mass transfusions and admission holds. ANM I stated the Nurse First would reassess the patients in the waiting room and check their vital signs every two hours. ANM I stated in the absence of the Nurse First, the second triage nurse would do the reassessments. ANM I stated the facility tries to keep all three nurses at the front, but the second triage nurse could have been pulled to the back or reassigned somewhere that night.

During an interview on 1/5/23 at 10:30 a.m., Physician A stated patients should have been reassessed while they were out in the waiting room and patients identified as ESI 2 should be reassessed every two hours. Physician A stated Patient 1 was neither reassessed nor had his vitals retaken and was not referred to a doctor when his pain escalated from 7 to 10. When asked if reassessments could have prevented Patient 1's demise, Physician A stated, "It would be hard to say if that could have helped." Physician A stated the expectation remained that reassessments should have been done per ED goals.

During an interview on 1/5/23 at 11:30 a.m., RN J stated his shift was supposed to end at 7:30 p.m. the night Patient 1 came to the ED but stayed until 10:30 p.m. because "he knew they (ED) needed help." RN J stated he was the second triage nurse until 7:30 p.m., then was "floating all over the place" helping with transporting patients and expediting discharges. RN J stated the roles of the second triage nurse included helping with second triage, keeping eyes on the next patient, making sure orders were done, and catching up with the triage nurse in the front. RN J stated it was "so busy" that night with a gunshot wound, two strokes, an overdose, and a massive transfusion protocol in the ED. RN J stated patients in the waiting room get reassessed, but as the ED was so busy, with patients waiting and coming in at the same time, patients waiting in the other hallway and some just leaving, it was "impossible" to get back to all of them.

During an interview on 1/5/23 at 3:01 p.m., ED Tech L stated recalling doing the EKG on Patient 1 the evening he came to the ED. ED Tech L stated Patient 1 was brought back out to the waiting room after the EKG. ED Tech L stated ED techs recheck the vital signs of patients "sometimes" or "as needed" or "when asked by the nurses. ED Tech L stated she could not recall any nurse requesting her to recheck Patient 1's vital signs that night.

During an interview on 1/5/23 at 3:18 p.m., Director B stated Patient 1 had no reassessments done after his vital signs were last checked. Director B stated triage nurses were expected to reassess patients while they were in the waiting area. Director B stated patient reassessment was important to catch emergencies, prevent any delay of care, and prevent such things from happening [Patient 1's demise].

During a review of the facility's policy and procedure titled, "Basic Unit of Care Standards for the Emergency Department", dated "10/2022", indicated, "Patients with an EDI level of 1 will be directly roomed. ESI 2 will be roomed as soon as possible. If no room available, the triage registered nurse will communicate with the ANM prioritize availability. These patients will be rechecked a minimum of every 2 hours while waiting to be roomed. The recheck will include vital signs ..."

During a review of the facility's procedure titled, "Nurse First", no date, indicated, Primary Role of the Nurse First was to recognize and facilitate treatment of deteriorating patients in the lobby through subjective and objective observations and second to facilitate throughput of stable patients in lobby. "Nurse First Duty highlights," indicated, Be Present-As much as possible stay in the clerk box, Reassess- Complete every 2-hours, and take this time to update their status, back up triage if no RN2 is present.