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Based on facility policy review, medical record review, and interviews, the facility failed to provide an adequate Medical Screening Exam (MSE) and failed to provide stabilizing treatment for one patient (#3) of 24 Emergency Department (ED) patients reviewed. The facility was found not to be in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Refer to A-2406 for failure to provide an adequate MSE.
Refer to A-2407 for failure to provide stabilizing treatment.

Based on facility policy review, medical record review, and interviews, the facility failed to provide an adequate Medical Screening Exam (MSE) for one patient (#3) of 24 Emergency Department (ED) patients reviewed.

The findings included:

Review of the facility's policy Triage EMS 121 dated September 2004, revealed, "ESI [Emergency Severity Index] Level 2...Examples of High-Risk Situations...Cardiac: Chest pain...Constant or intermittent...Chest pain and shortness of breath..."

Medical record review of the facility policy Emergency Department Scope of Services EMS.280 dated March 2010, revealed, "...In accordance with applicable laws, regulations, and standards, a Medical Screening Exam (MSE) is performed by a qualified physician or physician designee on all patients who present to the ED and request medical care. The purpose of the MSE is to determine if the patient has an emergency medical condition...An Emergency Medical Condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of prompt and appropriate medical attention could result in: a) placing the health or safety of the patient...in serious jeopardy; b) serious impairment to bodily functions; c) serious dysfunction of any bodily organ or part. The following conditions are declared to be emergency conditions by statute and regulation...acute pain rising to the level of the general definition of emergency medical condition...The ED is staffed by qualified personnel with knowledge and skills sufficient to evaluate and stabilize, if reasonably possible, those who seek emergency care, especially those with potentially lethal or disabling conditions...Emergency patient evaluation and stabilization is provided to each individual presenting for such care...A triage exam and a MSE will be provided to each patient who enters the facility seeking care. Exams will be in accordance with the Emergency Medical Treatment and Active Labor Act, policies delineated in the medical staff bylaws or by the hospital board of trustees...Immediate evaluation and stabilization, to the degree reasonably possible, will be available for each patient who presents with an emergency medical condition...The emergency physician is responsible for the medical care provided in the ED. This includes the medical evaluation and screening exam, diagnosis, and recommended treatment and disposition of the emergency patient...

Medical record review revealed Patient #3 presented to the Emergency Department (ED) on 10/6/14 at 5:03 AM. The patient arrived at the ED by ambulance (EMS) for a complaint of chest pain and lower back pain since 10/5/14 at 7:00 PM (10 hours prior to arrival).

Medical record review of the EMS records dated 10/6/14 revealed EMS was at Patient #3's home at 4:28 AM, "...Primary Impression: Chest Pain (non-Cardiac)...Secondary Impression: Pain (Non-Traumatic)...Chief Complaint: Chest Pain...Duration: 9 hours...Secondary Complaint: Lower Back Pain...Duration: 9 Hours...Patient's Level of Distress: Moderate...Signs & Symptoms: Pain-Chest-Unspecified...lower back pain radiating to her upper back and chest...She states the pain woke her up and was now radiating into her upper back and chest...NTG [nitroglycerin given for cardiac chest pain] 0.4 mg [milligrams] SL [sublingual] without relief, ASA [aspirin given in cardiac emergencies] 324 mg...NTG 0.4 mg SL pain down to 8/10 [8 on a 0-10 pain scale, with 10 being the worse pain] at this time..." Further review revealed the patient's blood pressure was at 4:36 AM was 189/122 (normal is considered 120/80), 4:40 AM it was 185/109, and at 4:50 AM it was 174/112. The patient rated pain as a 10 (on a scale of 0-10 with 10 being the worse) at 4:36 AM, 4:39 AM, 4:40 AM, and as an 8 at 4:50 AM.

Medical record review of ED nursing documentation dated 10/6/14 from 5:03 AM to 5:09 AM, revealed the patient was triaged as an Emergency Severity Index (ESI) level 3 (stable) and "...lower back pain starting at 1900 10/5 [7:00 PM on 10/5/14]. Pt [patient] reports pain radiation to upper back and chest. Airway patent, conversing normally, appears uncomfortable...was taken directly to a treatment area for triage at the bedside..." Continued review revealed the patient's vital signs on arrival were blood pressure (BP) 153/80, pulse 64, respirations 20, oral temperature 97.2, oxygen saturation 97% on room air. Review of the nursing documentation at 5:06 AM revealed, "...Pain: to the mid back, to the lower back, Pain radiates, lower abdomen, Onset of pain 10/05/2014 1900, on a scale 0-10 [with 10 being the worse pain] patient rates pain as 8..." Review of the notes at 5:09 AM revealed, "...Cardiac monitoring indicated for back pain, Patient placed on cardiac monitor..."
Medical record review of the physician's history and physical dated 10/6/14 beginning at 5:28 AM, revealed, "...chief complaint...c/o [complaint of] sudden onset lower back pain at 1900 [7:00 PM] yesterday radiating suprapubically and into the upper back and chest this morning...Cardiovascular...reports chest pain, in the epigastric area...Respiratory...reports shortness of breath...GI [gastrointestional]...reports abdominal pain...Genitourinary Female...reports urgency...Physical Exam...Vital signs reviewed. Patient afebrile, Pulse normal, Blood pressure, hypertensive, Patient appears, in mild pain distress...Breath sounds clear, Chest exam included findings of chest movement symmetrical, Chest expansion equal...heart rate regular rate and rhythm, Heart sounds normal...abdomen nontender, Bowel sounds normal...back exam included findings of normal inspection, Costovertebral angle tenderness, bilaterally...Skin exam included findings of skin warm, dry, and normal in color..."

Medical record review revealed the only diagnostic tests ordered were an EKG (electrocardiogram), urine pregnancy test, and a urinalysis.

Medical record review of the EKG dated 10/6/14 at 6:29 AM revealed,"...Normal sinus rhythm...Biatrial enlargement...Left ventricular hypertrophy...T Wave abnormality, consider inferior ischemia...T Wave abnormality, consider anterolateral ischemia...Prolonged QT...Abnormal ECG [EKG]...Further repolarization abnormality since previous tracing..."

Medical record review revealed additional vital signs were as follows: 6:51 AM, B/P 180/118, pulse 73, respirations 20, pain 8, Oxygen saturation 96% room air; 7:15 AM B/P 166/99, pulse 85, respirations 18, pain 8, Oxygen saturation 100% room air.

Medical record review of the Doctor Notes dated 10/6/14 at 6:52 AM revealed, "...Pt says she believes her upper back pain to be a muscle spasm. Wants muscle relaxers. Will tx [treat]. Waiting on urine..."

Medical record review of a Nursing Assessment dated 10/6/14 at 7:15 AM, revealed, "...Pt unable to find position of comfort. Moving all over the bed. Restless..."

Medical record review of the ED record revealed the patient was diagnosed with a Urinary Tract Infection and Back Strain. The patient was discharged home on 10/6/14 at 7:29 AM with prescriptions for Flexeril (muscle relaxer) and Ultram (pain medication) and instructions to follow-up with the primary care physician in 2 to 3 days or return to the ED if symptoms do not resolve or get worse.

Medical record review of EMS records dated 10/6/14 revealed EMS arrived at a business location at 4:43 PM, "...Upon arrival at pt [Patient #3], pt is noted to not be breathing. Bystanders state pt. walked to the water fountain and just collapsed...skin pale/cool/cyanotic [appearance with lack of oxygen]/dry, Pupils 6 mm [millimeters, indicating pupils are dilated] and nonreactive...No peripheral pulsed noted, No obvious trauma noted...Pt intubated [for mechanical breathing]..."

Medical record review of the ED nursing documentation revealed the patient presented to the ED a second time on 10/6/14 at 5:10 PM, via EMS in respiratory arrest. Continued review revealed "...Resp. [respiratory arrest] brought in by [EMS], intubated...EMS state that they were called for seizure like activity, sats [oxygen saturation] in the 70s [below 92% is low] initially...Patient appears, unconscious...Skin abnormal, Skin temperature is cool, Unable to pick up O2 sat [oxygen saturation] d/t [due to] coolness of extremities...Per EMS, pt was working at...when she had a possible seizure, ambulance was called, found her in resp. arrest...Pt arrives to ER [Emergency Room] unresponsive...having difficulty obtaining accurate vital signs d/t coolness of pt extremities - carotid and femoral pulsed palpable but weak..."

Medical record review of the physician's notes dated 10/6/14 at 6:48 PM revealed "...brought in by EMS intubated, suffered respiratory arrest at work and collapsed. She had a pulse at that time...Her sats were initially in the 70's...collapse and possible Sz [seizure]...noted to have visit here today for back pain... Possible sz from tramadol, alternate etiology could include PE [pulmonary embolism]...Patient reassessed immediately when notified by nursin [nursing] staff of low voltage rhythm with lack of pulse. Patient's initial VS [vital signs] obtained and noted to have narrow complex, perfusing rhythm. During my re-eval [re-evaluation] no pulse present and ACLS [advanced cardiac life support] protocols started. Due to waveform of transient sinusoidal rhythm treated aggressively for possible hyper K [elevated potassium], hypoMg [decreased magnesium] with no improvement. During resus [resuscitation]...all pulse checks rapid bedside echo [echocardiogram] demonstrated no cardiac activity...asystole [absence of a heart rhythm] ...TOD [time of death] 1735..."

Interview with Medical Doctor #1 (MD) on 1/14/16 at 10:50 AM, in the conference room, revealed MD #1 and MD #6 saw the patient on her first arrival to the ED on 10/6/14. Continued interview revealed "...she came in early in the morning...complained of back pain...chest pain...headache...tender in her back...we did a urinalysis...her pain was consistent with muscle pain...she was hypertensive...sent her home with muscle relaxers...her blood pressure was up we thought due to her pain...EKG showed no evidence of ischemia...I saw her at 6:07 AM...she was given discharge instructions on back pain and a UTI and told to follow up with her primary care doctor in 2 to 3 days...her pain had improved...had decreased pain after Toradol [non-steroidal anti-inflammatory]...we don't x-ray everyone that comes in with back pain...only do an MRI if indicated...someone young with back pain...atraumatic...wouldn't normally do...would be indicated with someone with signs of spinal compression...weakness...numbness...loss of function...neurological symptoms...she didn't have any of these...she had a dissection...tear...a CT [computed tomography] with contrast would've picked it up..."

Interview with MD #3 and MD #7 on 1/14/16 at 11:10 AM, in the conference room, revealed MD #3 and MD #7 saw the patient on her second visit to the ED on 10/6/14. Continued interview revealed "...she coded in the emergency department...appeared to have cardiac arrest...significant decline...we both [attending and resident] saw her...at the time we pronounced her we were not aware of what caused the cardiac arrest...etiology could have been a PE..."

Interview with MD #8, the ED Medical Director, on 1/14/16 at 11:37 AM, in the conference room, revealed "...I looked at the chart because it went through MQIC [Medical Quality Improvement Committee]...she was treated for musculoskeletal pain...came back later and expired....diagnosed her with back pain and gave prescription...someone this age...asymptomatic...would not have done a CTA [computed tomography angiography]..."

In summary, the patient presented to the ED with severe pain that did not rate lower than an 8. The patient was hypertensive (high blood pressure) and had symptoms of back pain radiating to the chest with an abnormal EKG. No other labwork or diagnostic testing was completed to ensure an adequate MSE was provided to address the hypertension and chest pain. The patient presented to the ED approximately 9 1/2 hours later in respiratory arrest.

Based on facility policy review, medical record review, and interviews, the facility failed to provide stabilizing treatment for one patient (#3) of 24 Emergency Department (ED) patients reviewed.

The findings included:

Medical record review of the facility policy Emergency Department Scope of Services EMS.280 dated March 2010, revealed, "...The ED also provides for or arranges treatment necessary in attempt to stabilize emergency patient who are found to have an emergency medical condition...An Emergency Medical Condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of prompt and appropriate medical attention could result in: a) placing the health or safety of the patient...in serious jeopardy; b) serious impairment to bodily functions; c) serious dysfunction of any bodily organ or part. The following conditions are declared to be emergency conditions by statute and regulation...acute pain rising to the level of the general definition of emergency medical condition...The ED is staffed by qualified personnel with knowledge and skills sufficient to evaluate and stabilize, if reasonably possible, those who seek emergency care, especially those with potentially lethal or disabling conditions...Emergency patient evaluation and stabilization is provided to each individual presenting for such care...Immediate evaluation and stabilization, to the degree reasonably possible, will be available for each patient who presents with an emergency medical condition...The emergency physician is responsible for the medical care provided in the ED. This includes the medical evaluation and screening exam, diagnosis, and recommended treatment and disposition of the emergency patient...

Medical record review revealed Patient #3 presented to the Emergency Department (ED) on 10/6/14 at 5:03 AM. The patient arrived at the ED by ambulance (EMS) for a complaint of chest pain and lower back pain since 10/5/14 at 7:00 PM (10 hours prior to arrival).

Medical record review of the EMS records dated 10/6/14 revealed EMS was at Patient #3's home at 4:28 AM, "...Primary Impression: Chest Pain (non-Cardiac)...Secondary Impression: Pain (Non-Traumatic)...Chief Complaint: Chest Pain...Duration: 9 hours...Secondary Complaint: Lower Back Pain...Duration: 9 Hours...Patient's Level of Distress: Moderate...Signs & Symptoms: Pain-Chest-Unspecified...lower back pain radiating to her upper back and chest...She states the pain woke her up and was now radiating into her upper back and chest...NTG [nitroglycerin given for cardiac chest pain] 0.4 mg [milligrams] SL [sublingual] without relief, ASA [aspirin given in cardiac emergencies] 324 mg...NTG 0.4 mg SL pain down to 8/10 [8 on a 0-10 pain scale, with 10 being the worse pain] at this time..." Further review revealed the patient's blood pressure at 4:36 AM was 189/122 (normal is considered 120/80), 4:40 AM it was 185/109, and at 4:50 AM it was 174/112. The patient rated pain as a 10 (on a scale of 0-10 with 10 being the worse) at 4:36 AM, 4:39 AM, 4:40 AM, and as an 8 at 4:50 AM.

Medical record review of ED nursing documentation dated 10/6/14 from 5:03 AM to 5:09 AM, revealed, "...lower back pain starting at 1900 10/5 [7:00 PM on 10/5/14]. Pt [patient] reports pain radiation to upper back and chest. Airway patent, conversing normally, appears uncomfortable..." Continued review revealed the patient's vital signs on arrival were blood pressure (BP) 153/80, pulse 64, respirations 20, oral temperature 97.2, oxygen saturation 97% on room air. Review of the nursing documentation at 5:06 AM revealed, "...Pain: to the mid back, to the lower back, Pain radiates, lower abdomen, Onset of pain 10/05/2014 1900, on a scale 0-10 [with 10 being the worse pain] patient rates pain as 8..." Review of the notes at 5:09 AM revealed, "...Cardiac monitoring indicated for back pain, Patient placed on cardiac monitor..."
Medical record review of the physician's history and physical dated 10/6/14 beginning at 5:28 AM, revealed, "...chief complaint...c/o [complaint of] sudden onset lower back pain at 1900 [7:00 PM] yesterday radiating suprapubically and into the upper back and chest this morning...Cardiovascular...reports chest pain, in the epigastric area...Respiratory...reports shortness of breath...GI [gastrointestional]...reports abdominal pain...Genitourinary Female...reports urgency...Physical Exam...Vital signs reviewed. Patient afebrile, Pulse normal, Blood pressure, hypertensive, Patient appears, in mild pain distress...Breath sounds clear, Chest exam included findings of chest movement symmetrical, Chest expansion equal...heart rate regular rate and rhythm, Heart sounds normal...abdomen nontender, Bowel sounds normal...back exam included findings of normal inspection, Costovertebral angle tenderness, bilaterally...Skin exam included findings of skin warm, dry, and normal in color..."

Medical record review revealed the only diagnostic tests ordered were an EKG (electrocardiogram), urine pregnancy test, and a urinalysis.

Medical record review of the EKG dated 10/6/14 at 6:29 AM revealed,"...Normal sinus rhythm...Biatrial enlargement...Left ventricular hypertrophy...T Wave abnormality, consider inferior ischemia...T Wave abnormality, consider anterolateral ischemia...Prolonged QT...Abnormal ECG [EKG]...Further repolarization abnormality since previous tracing..."

Medical record review revealed additional vital signs were as follows: 6:51 AM, B/P 180/118, pulse 73, respirations 20, pain 8, Oxygen saturation 96% room air; 7:15 AM B/P 166/99, pulse 85, respirations 18, pain 8, Oxygen saturation 100% room air.

Medical record review of the Doctor Notes dated 10/6/14 at 6:52 AM revealed, "...Pt says she believes her upper back pain to be a muscle spasm. Wants muscle relaxers. Will tx [treat]. Waiting on urine..."

Medical record review of a Nursing Assessment dated 10/6/14 at 7:15 AM, revealed, "...Pt unable to find position of comfort. Moving all over the bed. Restless..."

Medical record review of the ED record revealed the patient was diagnosed with a Urinary Tract Infection and Back Strain. The patient was discharged home on 10/6/14 at 7:29 AM with prescriptions for Flexeril (muscle relaxer) and Ultram (pain medication) and instructions to follow-up with the primary care physician in 2 to 3 days or return to the ED if symptoms do not resolve or get worse.

Medical record review of EMS records dated 10/6/14 revealed EMS arrived at a business location at 4:43 PM, "...Upon arrival at pt [Patient #3], pt is noted to not be breathing. Bystanders state pt. walked to the water fountain and just collapsed...skin pale/cool/cyanotic [appearance with lack of oxygen]/dry, Pupils 6 mm [millimeters, indicating pupils are dilated] and nonreactive...No peripheral pulsed noted, No obvious trauma noted...Pt intubated [for mechanical breathing]..."

Medical record review of the ED nursing documentation revealed the patient presented to the ED a second time on 10/6/14 at 5:10 PM, via EMS in respiratory arrest. Continued review revealed "...Resp. [respiratory arrest] brought in by [EMS], intubated...EMS state that they were called for seizure like activity, sats [oxygen saturation] in the 70s [below 92% is low] initially...Patient appears, unconscious...Skin abnormal, Skin temperature is cool, Unable to pick up O2 sat [oxygen saturation] d/t [due to] coolness of extremities...Per EMS, pt was working at...when she had a possible seizure, ambulance was called, found her in resp. arrest...Pt arrives to ER [Emergency Room] unresponsive...having difficulty obtaining accurate vital signs d/t coolness of pt extremities - carotid and femoral pulses palpable but weak..."

Medical record review of the physician's notes dated 10/6/14 at 6:48 PM revealed "...brought in by EMS intubated, suffered respiratory arrest at work and collapsed. She had a pulse at that time...Her sats were initially in the 70's...collapse and possible Sz [seizure]...noted to have visit here today for back pain... Possible sz from tramadol, alternate etiology could include PE [pulmonary embolism]...Patient reassessed immediately when notified by nursin [nursing] staff of low voltage rhythm with lack of pulse. Patient's initial VS [vital signs] obtained and noted to have narrow complex, perfusing rhythm. During my re-eval [re-evaluation] no pulse present and ACLS [advanced cardiac life support] protocols started. Due to waveform of transient sinusoidal rhythm treated aggressively for possible hyper K [elevated potassium], hypoMg [decreased magnesium] with no improvement. During resus [resuscitation]...all pulse checks rapid bedside echo [echocardiogram] demonstrated no cardiac activity...asystole [absence of a heart rhythm] ...TOD [time of death] 1735..."

Interview with Medical Doctor #1 (MD) on 1/14/16 at 10:50 AM, in the conference room, revealed MD #1 and MD #6 saw the patient on her first arrival to the ED on 10/6/14. Continued interview revealed "...she came in early in the morning...complained of back pain...chest pain...headache...tender in her back...we did a urinalysis...her pain was consistent with muscle pain...she was hypertensive...sent her home with muscle relaxers...her blood pressure was up we thought due to her pain..."

Interview with MD #6 on 1/14/16 at 10:54 AM, in the conference room, revealed "...low back pain...that's what pushed us to musculoskeletal...was tender to palpation...worse with movement...she was stable at discharge...her condition was resolved..."

Interview with MD #3 and MD #7 on 1/14/16 at 11:10 AM, in the conference room, revealed MD #3 and MD #7 saw the patient on her second visit to the ED on 10/6/14. Continued interview revealed "...she coded in the emergency department...appeared to have cardiac arrest...significant decline...at the time we pronounced her we were not aware of what caused the cardiac arrest...etiology could have been a PE..."

Interview with MD #8, the ED Medical Director, on 1/14/16 at 11:37 AM, in the conference room, revealed "...she was treated for musculoskeletal pain...came back later and expired....diagnosed her with back pain and gave prescription..."

In summary, the patient presented to the ED with severe pain that did not rate lower than an 8. The patient was hypertensive (high blood pressure) and had symptoms of back pain radiating to the chest with an abnormal EKG. No stabilizing treatment was provided to address the patient's high blood pressure or chest pain. The patient presented to the ED approximately 9 1/2 hours later in respiratory arrest.