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Based on current policies and procedures, Dedicated Emergency Department (DED) medical record review, and physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 25 sampled patients (Patient #18 ).

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

Based on policies and procedures, dedicated emergency department (DED) medical record reviews, physician and staff interviews, the hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 25 sampled patients (Patient #18).

Findings included:

Review of the hospital's "Emergency Medical Treatment and Labor Act (EMTALA)" policy effective 05/15/2018 revealed, "... Medical Screening Examination: A process of sufficient scope to conclude, with reasonable clinical confidence, whether an emergency medical condition does or does not exist and that utilizes necessary ancillary services that are routinely available to the hospital. ... If an individual: 1) presents at a (hospital system) Hospital's Dedicated Emergency Department and requests examination or treatment for a medical condition; ... then an appropriate Medical Screening Examination shall be conducted by qualified clinical personnel to determine whether the patient is in active labor or whether an Emergency Medical Condition exists. Such Medical Screening Examination and any further medical examination and treatment appropriate to the situation shall not be delayed to permit an inquiry regarding the patient's method of payment or insurance status. The medical screening examination shall be reasonably calculated to identify critical medical conditions that may be afflicting a symptomatic patient and shall be consistent with the screening examination afforded other patients presenting with the same complaints or symptoms. ..."

Review of a closed DED medical record on 01/22/2020 for Patient #18 revealed a 34-year old male that presented to Hospital A's DED via private vehicle on 12/22/2019 at 1347 with a chief complaint of chest pain that started earlier that day. Review revealed at 1352, the patient reported a pain level of 10. Review of vital signs documented at 1352 revealed a temperature (T) of 98 degrees Fahrenheit; pulse (P) 70; respirations (R) 18; blood pressure (BP) 108/85; and oxygen saturation of 97%. Review of the DED record revealed at 1355 an EKG 12-lead was completed for Pt #18 that resulted as "Normal Sinus Rhythm." Review of the EKG report revealed a handwritten documentation of "0 STEMI" signed by MD #1 at 1358. Review revealed the EKG final result was documented at 1741. Review of the final EKG report revealed documentation of "Normal sinus rhythm; Normal ECG when compared with ECG of 20-Aug-2019 08:43, No significant change was found ..." Review of the record revealed triage started at 1421. Review of the triage note revealed the patient's chief complaint was documented as complaining of chest pain since this morning with tightness and vomiting. Review of Nurse Practitioner (NP) #2's medical screening examination dated 12/22/2019 at 1421 revealed "Pt presents with midsternal CP (chest pain) since this am; tightness and dizziness. Worse with deep breath. + smoker. + chills; no fever. Dry cough x 2 weeks. Denies significant PMHx (past medical history)." Review of NP #2's notes revealed documentation that Pt #18's chest sounds were "clear to auscultation bilaterally with normal heart sounds" and Pt #18's skin was "warm, dry, normal color." Review of the record revealed at 1423, NP #2 wrote orders for an X-ray of chest and lab work to include a Comprehensive Metabolic Panel (CMP); Complete Blood Count (CBC) with Differential; Lipase; Creatine Kinase (CK); Total and MB Fraction (CKMB); and Troponin I. Review revealed triage was completed at 1423. Review of the DED record revealed documentation at 1508 (45 minutes after diagnostic orders written) that "Patient not found in waiting room or in bathrooms. X ray does not have him Charge notified [sic]." Review revealed documentation at 1510 "Called patient for room assignment x 2 without response. Will reattempt in a few minutes." Review of the DED record revealed documentation on 12/23/2019 at 0040, Pt #18's disposition was set to LBTC (left before treatment completed) and Pt #18 was discharged from the DED.

Review of a closed medical record for Patient #18 revealed the patient arrived at Hospital B's DED on 12/22/2019 at 1502 (1 hour and 15 minutes after arrival at Hospital A) with a chief complaint of chest pain. Review of the DED record revealed a medical screening examination was initiated by a DED physician upon arrival at 1502. Review of the DED physician's examination revealed the patient presented for evaluation of chest pain that had started earlier the same morning. Review of the notes revealed " ... His EKG was abnormal concerning for STEMI (ST elevation myocardial infarction) and he was brought back with code STEMI activated. Currently rates the pain is 9 out of 10 and pressure-like in the central chest and back. Nothing makes it better. He has had some nausea and vomiting as well ..." Review of the record revealed an EKG was completed at 1509 that resulted as normal sinus rhythm with ST elevation, consider inferior injury or acute infarct. Review of the record revealed a Code STEMI was activated and a cardiologist was at the bedside at 1514. Vital signs at 1515 were recorded as blood pressure 162/107; pulse 72; respirations 18; and oxygen saturation 98%. Review of the DED physician's notes recorded the patient was in "mild distress secondary to pain." Review of the DED notes recorded, "3:24 PM Progress note: He has an inferior STEMI with anterior lateral depressions. Code STEMI was called and cardiology was at bedside. They agree with the plan. ... Patient taken to the Cath Lab currently stable condition. Clinical Impression: ST elevation myocardial infarction (STEMI), unspecified artery." Review of the medical record revealed he patient was taken to the cardiac cath lab at 1524 and a cardiac catherization procedure started at 1528 (26 minutes after arrival). Review of a Cardiology Discharge Summary documented on 12/24/2019 at 1755 revealed a discharge diagnosis of "ST elevation myocardial infarction (STEMI) of inferior wall." Review revealed the patient had an aspiration thrombectomy (clot removal) and PCTA (Percutaneous transluminal coronary angioplasty - a procedure to open blocked coronary arteries). Record review revealed Patient #18 was discharged home from Hospital B on 12/24/2019 at 2019.

An interview was requested on 01/22/2020 and 01/23/2020 with NP #2 who documented the medical screening examination at Hospital A on 12/22/2019. NP #2 was not available for interview.

Interview on 01/22/2020 at 1450 with RN #3 revealed she was the nurse assigned to triage when Pt #18 presented to the DED at Hospital A on 12/22/2019. Interview revealed Pt #18 received an EKG prior to triage. Interview revealed the EKG was read by a DED physician. Interview revealed it was determined that Pt #18's EKG showed normal sinus rhythm with no significant changes. Interview revealed Nurse Practitioner (NP) #2 was the mid-level provider assigned to work triage in the DED on 12/22/2019. Interview revealed NP #2 initiated the medical screening exam for Pt #18. Interview revealed once the triage exam was completed at 1423, Pt #18 was directed to return to the waiting room to wait for a DED staff member to escort him to a room. Interview revealed at 1508, RN #3 attempted to locate Pt #18 in the DED and Pt #18 was not found. Interview revealed RN #3 notified the charge nurse that Pt #18 did not respond when called. Interview revealed Pt #18 did not notify RN #3 that he was leaving the DED prior to being examined by a physician.

Interview on 01/23/2020 at 1125 with RN #8 revealed she was the nurse working in the "Nurse First" position in the DED on 12/22/2019. Interview revealed RN #8 obtained Pt #18's vital sign measurements when he presented to the DED. Interview revealed that RN #8 was not notified that Pt #18 planned to leave the DED prior to being examined by a physician.

Telephone interview on 01/23/2020 at 1050 with RN #9 revealed he completed the EKG after Pt #18 arrived at the DED on 12/22/2019. Interview revealed that RN #8 was not notified that Pt #18 planned to leave the DED prior to being examined by a physician.

Interview on 01/23/2020 at 1030 with Radiology Tech #5 revealed she did not recall Pt #18. Interview revealed that Radiology Tech #5 received an order for Pt #18's chest X-ray. Interview revealed that per department procedure, Radiology Tech #5 changed the exam status to "begun" in order to communicate that Radiology Tech #5 went to the DED to retrieve Pt #18. Interview revealed Radiology Tech #5 went to the DED to locate Pt #18 to complete the X-ray. Interview revealed Pt #18 was not found in the DED. Interview revealed Radiology Tech #5 discontinued the order for the chest X-ray per physician's request.

Interview on 01/23/2020 at 1040 with Patient Registration Clerk #6 revealed that she was working at the registration desk in the DED on 12/22/2019. Interview revealed Pt #18 did not notify Registration Clerk #6 that he planned to leave the DED prior to being examined by a physician.

Telephone interview on 01/23/2020 at 0930 with RN #7 revealed she was the Charge Nurse during the 7pm-7am shift on 12/22/2019. Interview revealed Pt #18 was not in the DED during that time. Interview revealed Pt #18 was still on the board pending the ED provider acknowledging test results. Interview revealed that RN #7 updated Pt #18's disposition to "Discharged; Left before treatment completed ..."

Interview on 01/23/2020 at 0945 with the DED Nurse Manager (RN #10) revealed the goal is for chest pain patients to receive an EKG within 10 minutes of presentation to the DED. Interview revealed the "Nurse First" assist patients by obtaining vital signs, initiating protocol orders and can get a patient seen by a provider for medical emergencies. Interview revealed there is an ED provider in triage most days from 1100-2300. Interview revealed the triage nurse initiates the "Chest Pain Protocol" when there is not a provider working triage in the DED. Interview revealed when there is a provider present in triage, the provider's order supersedes the "Chest Pain Protocol." Interview revealed NP #2 wrote orders so RN #3 did not initiate the "Chest Pain Protocol." Interview revealed that RN #3 completed triage of Pt #18 at 1423. Interview revealed Pt #18 was assigned a room in the DED and called by the staff at 1508. Interview revealed the time between end of triage (1423) and being called by the DED staff (1508) was 45 minutes. Interview revealed that was not an excessive wait time based on Pt #18's age, vital signs and EKG results at the time of presentation to the DED.

Interview on 01/22/2020 at 1410 with MD #4 revealed he was assigned as the Attending provider for Pt #18. Interview revealed Pt #18 left the DED prior to being examined by MD #4. Interview revealed there was a Mid-level provider in Triage to initiate the medical screening exam and order diagnostic tests prior to Pt #18 being seen by a doctor. Interview revealed Pt #18 received a STAT EKG per protocol due to his complaint of chest pain. Interview revealed the EKG showed normal sinus rhythm. Interview revealed based on Pt #18's vital signs and EKG result, it was determined that Pt #18 could return to the waiting room pending a room assignment. Interview revealed Pt #18 received appropriate care based on signs and symptoms upon presentation to the DED.