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Based on interview and record review, the facility failed to provide an appropriate Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for one of 21 randomly selected patients Patient 14 (Pt 14), that presented to ED for Chest pain.

The Facility failed to evaluate Pt 14's location, intensity and duration of Chest pain, abnormal EKG result and to further evaluate with assessments including lab tests which included Troponin levels and observation or cardiology consultation.

These deficient practices resulted in Pt 14 having continued chest pain on 4/1/20 after ED discharge. On 4/2/20, Pt 14 went to another facility (ED 2) for continued chest pain. Patient 14 was admitted for evaluation and treatment of Chest pain. Pt 14 had a Cardiac procedure at GACH 2.

On 7/1//2020, an unannounced visit was made to the facility to investigate a complaint regarding an EMTALA violation.

A review of Pt's medical records indicated on 4/1/2020, Pt 14 presented to the ED at 12:09 PM with a Complaint of "Asthma and Tightness in chest when walking too long". Pt 14's admitting diagnosis included Dyspnea (shortness of breath), Asthma, Chest pain, Type2 diabetes Mellitus and Essential hypertension.

A review of PT 14's nursing emergency department note, dated 4/1/2020, at 12:11 PM indicated Patient 14 was triaged as Emergency Severity Index (ESI) level 4 (Four).

A review of the nursing emergency department notes, dated 4/1/20 did not document any signs of Respiratory distress wheezing or hypoxia. Nursing assessment did not address the nature of Pt 14's Chest pain, duration or radiation. Pt 14 was assessed as Stable. Pt 14's VS at 12:11 were Temperature: 97.7 F (normal 97F to 99F), Pulse 79 normal (60 to 100), Respiration rate (RR) 16 breaths per minute (normal RR 12 to 20), Blood Pressure (BP)133/95 (normal BP 120/80) with Mean BP 108(normal BP 70 to 100). Pulse oximetry 99% on room air (RA). Pain scale was zero

A review of Pt 14's orders included: CXRay (Chest radiologic image). A review of Pt 14's CXRay indicated possible infiltrate in left lung base and left basilar atelectasis (Part of left lung collapse).

A review of the Physician notes (MD 2), titled" Emergency Room Report", dated 4/1/2020, indicated Pt 14 presented for chest pain. MD2's differential diagnosis of the chest pain included, bronchitis, pulmonary embolus (blood clot in artery in lung) unstable angina (heart does not get enough blood flow). MD 2 ordered an EKG (Electrocardiograph used to determine heart rate, heart rhythm and heart condition) Pt 14's EKG finding included "Abnormal EKG, and "T wave abnormality, consider inferior ischemia (lack of blood to part of the heart)". MD 2 documented he reviewed the EKG findings and "T wave inversions" (EKG changes that could result in life threatening event in acute coronary ischemia (when blood circulation is interrupted in part of the heart). MD 2 did not order additional test or studies. MD 2 documented in his notes Pt 14 did not have active chest pain and 'appeared to be stable for outpatient evaluation'. MD 2 instructed Pt 14 to seek outpatient cardiology evaluation and to return if chest pain worsened. Patient was given 40 mg prednisone by mouth (Steroid medication) and discharged at 1318.

A review of the nursing emergency department notes documentation of Pain intensity for Pt 14's at 12:11 PM documented pain intensity was zero. Pt 14 pain intensity at 13:18pm was documented as zero. The pain assessment did not include chest pain location intensity or duration.

During an interview with the ED Director on 7/2/20, when asked was there a protocol for Patients arriving with chest pain. She indicated Triage nurse will alert the MD and MD provide orders. For each Chest, pain patient. A review of the Standard Test set of Orders for Chest pain included Laboratory tests including Troponin 1 level, EKG, CXRay. When asked who reviews the EKG she indicated EKG are given to the MD for review by EKG tech.

A review of the Medical Records of Pt 12, Pt 17, and Pt 20 presented with Chest pain and had assessment including CXRay, EKG, and Labs including Troponin.

A review of the policy, Emergency Medical Treatment and Active Labor Act, approved 3/2020 documented "The medical screening exam must be the same appropriate exam that the Hospital would perform on any individual with similar signs and symptoms... The medical screening is a continuous process reflecting ongoing monitoring in accordance with an individual's needs". The policy indicated the facility would monitor the individual until the individual is either stabilized or transferred.

The Faculty failed to provide an appropriate Medical Screening Exam for Pt 14 who presented to the Facility with Chest pain.

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Based on record review and interview, the facility failed to provide appropriate Medical Stabilization and treatment for one of 21 randomly selected patients Patient (Pt 14), that presented to ED for Chest pain.
The Facility failed to evaluate Pt 14's Chest pain; abnormal EKG findings; further evaluate Pt 14 with assessment including lab tests including Troponin levels, observing patient, transferring or cardiology consultation.

These deficient practices resulted in Pt 14 having continued chest pain on 4/1/20 after ED discharge. On 4/2/20, Pt 14 went to another facility (ED2) for continued chest pain. Patient 14 was admitted for evaluation and treatment of Chest pain and a Cardiac procedure at General Acute Care Hospital 2.

Findings:

On 7/1/2020, during the unannounced visit made to the facility to investigate a complaint regarding an EMTALA violation. The review of a Randomly seected patients medical record (Pt 14), indicated on 4/1/2020, Pt 14 presented to the ED at 12:09 pm with a Complaint of "Asthma and Tightness in chest when walking too long". Pt 14 admit diagnosis included Dyspnea (shortness of breath); Asthma; Chest pain; Type2 diabetes Mellitus and Essential hypertension

A review of PT 14s nursing emergency department note, dated 4/1/2020, at 12:11 pm indicated Patient14 was triaged as Emergency Severity Index (ESI) level 4 (Four).

A review of the nursing emergency department notes, dated 4/1/20 did not document any signs of Respiratory distress wheezing or hypoxia. Nursing assessment did not address the onset of Pt 14's Chest pain, duration, frequency or radiation or when episode of chest pain last occurred. Pt 14 was assessed as Stable. Pt 14's Vital Signs at 12:11 were Temperature 97.7 F (normal 97F to 99F), Pulse 79 normal (60 to 100), Respiration rate (RR) 16 breaths per minute (normal RR 12 to 20), Blood Pressure (BP) 133/95 (normal BP 120/80) with a Mean BP of 108 (normal 70 to 100) and Pulse oximetry 99% on room air (RA). Pain scale was zero.

A review of Pt 14's doctor's orders at 12:24 pm included: CXRay (Chest radiologic image 1 view, EKG tracing only and Prednisone 40mg (Steroid medication) by mouth. A review of Pt 14's CXRay results included left basilar atelectasis (Part of left lung collapse) and possible infiltrate in left lung base. A review of Pt 14's EKG findings included "Abnormal EKG", and "T wave abnormality, consider inferior ischemia (lack of blood to part of the heart).

A review of the Physician notes (MD 2), titled" Emergency Room Report", dated 4/1/2020, indicated Pt 14 presented for chest pain. MD 2's differential diagnosis of the chest pain included, bronchitis, pulmonary embolus (blood clot in artery in lung) and unstable angina (chest pain from the heart not getting adequate blood flow). A review of MD 2's Physician notes documented a review of the EKG findings including: T wave inversions (EKG changes that could result in a life threatening event of acute coronary ischemia, when blood circulation is interrupted in part of the heart). No acute ST changes were identified on the EKG. There was no documentation of further evaluation of Pt 14's Chest pain with lab tests including Troponin levels, observing Pt 14, transferring Pt 14 or a cardiology consultation.

There is no documentation in the Nurses notes or the Physician notes indicating when PT 14's last onset of chest pain was, what medication might have been taken to alleviate the chest pain, how long the chest pain lasted and the frequency of the chest pain.

A review of the Physician notes (MD 2) indicated Pt 14 did not have active chest pain at time of exam and was stable for outpatient follow up. Pt 14 was instructed to seek outpatient cardiology evaluation and to return if the chest pain worsened. Pt 14 was given 40 mg prednisone by mouth (Steroid medication) and discharged at 1:18PM. Pt 14's pain intensity at time of discharge was documented as zero. Pt 14 documented continued chest pain and on 4/2/20 Pt 14 went to ED 2 and was admitted for chest pain and evaluation and treatment. Pt 14 had Cardiac procedure at GACH 2.

A review of ED 1's Medical Records of Pt 12, Pt 17 and Pt 20 that presented with Chest pain had screening and assessment including CXRay, EKG, Labs including Troponin levels, medications, pain assessments, observation, stabilization, follow-up and consultations prior to discharge or transfer.

During an interview on 7/2/20, the ED Director was asked if there was a protocol for Patients arriving with chest pain. The ED Director indicated that the Triage nurse will alert the MD and the MD will provide orders. A review of the Standard Test set of Orders for Chest pain included Troponin level, EKG and CXRay. When asked who reviews the EKG The ED irector indicated tha the EKG's are given to the MD for review by EKG tech.

A review of the policy, 'Emergency Medical Treatment and Active Labor Act', approved 3/2020, documented that "The medical screening exam must be the same appropriate exam that the Hospital would perform on any individual with similar signs and symptoms... The medical screening is a continuous process needs". The policy indicated the facility would monitor the individual, until the individual is either stabilized or transferred.

The Faculty failed to provide an appropriate Medical stabilization Exam and treatment for Pt 14 who presented to the Facility with Chest pain. As a result Pt 14 was discharged had continued chest pain.