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Based on medical record review and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

Based on medical record review and staff interviews, the hospital failed to ensure a timely Medical Screening Examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed (Patient #2). In addition, staff failed to monitor abnormal blood pressures for a patient (Patient #11) while in the DED. This affected 2 of 25 sampled patients, (Patient #2 and Patient #11).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on medical record review and staff interviews, the hospital failed to ensure a timely Medical Screening Examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed (Patient #2). In addition, staff failed to monitor abnormal blood pressures for a patient (Patient #11) while in the DED. This affected 2 of 25 sampled patients, (Patient #2 and Patient #11).

The findings include:

1. Patient #2 was a 46-year-old male who presented to the DED on 12/15/2021 at 1640 via private vehicle complaining of chest pain and shortness of breath. Review of a Triage Note written on 12/15/2021 at 1708 by a Triage Registered Nurse [TRN] revealed, "Pt. [patient] A&O x 3 [alert and oriented times 3 - normal], Arrived from home with co [complaint of] SOB [shortness of breath], chest pain x 3 days that has increased. Pain located in the mid chest to back, 10/10 with any movement and with deep breaths. Pt appears restless. States he was coughing up blood x 12 times yesterday morning. Pt states he has no relevant medical hx [history] but smokes several x a day." The following diagnostic studies were ordered by protocol: electrocardiogram [EKG], 2-view chest x-ray, Basic Metabolic Panel [BMP], Complete Blood Count [CBC], and a troponin level, with a second level to be obtained in 6 hours. Patient #2 was given 324 milligrams of aspirin orally. Patient #2 was called without response by hospital staff at 1915, 1944, and 2037. Patient #2's disposition was set to left without being seen and he was removed from the hospital's electronic medical record [EMR] system on 12/15/2021 at 2038.

Review of DED census data reveals on 12/15/2021 at 1514 [prior to Patient #2's arrival], the total number of patients in the department was 118, with 40 patients waiting for rooms. The average wait time for a room was 189 minutes. At 2036 [prior to Patient #2's discharge from the EMR], the total number of patients in the department was 111 with 33 patients waiting for rooms. The average wait time for a room was 168 minutes.

Patient #2 presented to Hospital B via private vehicle on 12/16/2021 at 1222, complaining of chest pain. Review of a Provider Note written by Medical Doctor #1 on 12/16/2021 at 1457 revealed, "...46-year-old male with intermittent weekly chronic chest pain for the past year presents with recurrent chest pain. Patient says that his pain has been lasting 3 days which is unusual, is located in the left inferior chest, worse with movement and deep breathing, improves with lying still and not breathing as deeply. Patient says is a [sic] sharp tightness to his left chest, can be 10 out of 10 pain, but currently is 0 out of 10 pain as he sits in the ER."

Staff interview was conducted on 02/23/2022 at 0850 with the Patient #2's Hospital A Triage Registered Nurse (TRN). The TRN did not recall the patient. Interview revealed if the triage process reveals emergent signs and symptoms the patient is immediately taken to a room for treatment and a provider is notified. Interview revealed if the department is full and a patient is triaged to be able to wait for a room, complaint-based protocols are initiated. If any diagnostic performed via protocol revealed an emergent condition the patient's acuity level would be increased. Interview revealed when it is time for a patient to either be reassessed or go to a treatment room the patient is called up to three separate times if they do not respond to the first or second call. If there is no response to the third lobby call, they are considered to have left the department. If a patient lets staff know they plan to leave, staff ensure they are not in an altered mental status, and they understand the risks of leaving. Staff will attempt to persuade the patient to stay, and if they still decide to leave, it is expressed that they are always welcome to return to the ED.

Staff interview was conducted with the DED Clinical Manager on 02/23/2022 at 1534. Interview revealed the ED lobby has pamphlets for patients to pick up explaining the "MyChart" system, in which patients can obtain access to their electronic medical records online. Interview revealed the patient has to create an account themselves for access to their medical records. Interview revealed if diagnostic studies initiated by protocol revealed any abnormal findings on patients that have left the department without being seen, providers are notified, and hospital staff attempt to call the patient back. If protocol diagnostic studies revealed no abnormal findings there is no call-back.

2. Review of the closed DED medical record on 02/22/2022 for Patient #11 revealed a 58-year-old female presented to DED on 08/24/2021 at 0101 for a complaint of fall. Review of the vital signs at 0139 revealed "Temp (temperature): 37.6 degrees Celsius; Heart Rate: 104; Resp (respirations): 16; BP (blood pressure): 223/124; SpO2 (oxygen saturation): 99%." Review of the ED Timeline at 0140 revealed Patient #11 was assigned an acuity of 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the ED Triage note at 0153 revealed "Pt (patient) has no neuro (related to the nerves/nervous system) deficits but has an odd demeanor (outward behavior or bearing)." Review of the CBC (complete blood count) auto differential resulted at 0232 revealed an abnormal result of Neutrophils (type of white blood cell) Relative: 82.3% [Ref (reference) Range: 35.0 - 75.0]; Lymphocytes Relative (type of white blood cell that is elevated more than 40% in the blood stream): 11.1 % [Ref. Range: 20.0-45.0]; Lymphocyte Absolute: 0.8x10^3/uL (units per liter) [Ref Range: 0.9-2.9]; IGRE (immature white blood cells): 0.9% [Ref. Range: 0.1-0.3]." Review of the CT (computed tomography - computerized series of x-rays /pictures of the internal body structure/organs) resulted at 0249 revealed "No acute intracranial abnormality. Mild chronic change." Review of the vital signs at 0412 revealed "Temp: 37.2 degrees Celsius; Heart Rate: 108; Resp: 16; BP: 210/141; SpO2: 98%; Oxygen Therapy: None (Room air)." Review of the ED Timeline revealed Patient #11 was roomed in the ED and the medical screening examination (MSE) started at 0617. Review of the vital signs at 0630 revealed "Temp: 37.3 degrees Celsius; Heart Rate: 97; Resp: 18; BP: 214/114; SpO2: 98%." Review of the electronic medication administration record revealed Patient #11 was given labetalol injection 10 mg (milligrams) intravenous (inside the vein) at 0710. Review of the ED Timeline revealed at 0715 the ED Disposition was set to admit. Review of the EKG resulted at 0724 revealed "Concerning for ST depression in the inferior leads..." Review of the ED Provider note signed at 0749 revealed Patient #11 had "uncontrolled HTN (hypertension) currently not on any medication ... having a migraine started a week ago ...Gait abnormal (unsteady) ... Review of Systems: ... Musculoskeletal: Positive for arthralgias (knee pain and facial pain); Skin: Positive for color change (bruising at the knee and right cheek): Neurological: Positive for weakness ... Cardiovascular: ... Tachycardia present ... Will admit patient for ACS rule out, hyperglycemia and uncontrolled hypertension..." Review of the vital signs at 0810 revealed "Temp: 37.4 degrees Celsius; Heart Rate: 84; Resp: 21; BP: 172/93; SpO2: 97%; Oxygen Therapy: None (Room air); ... Pain Score: 0 - no pain/denies pain." Review of the electronic medical record revealed Patient #11 was given a 324 mg chewable aspirin at 0953. Review of the Hemoglobin A1C at 1020 revealed an abnormal result. Review of the Neurological assessment at 1142 revealed a "within defined limits." Review of the vital signs at 1353 revealed "Heart Rate: 74; Resp: 20; BP: 194/97; SpO2: 95%; ... Oxygen Therapy: None (Room air)." Review of the POCT glucose meter resulted at 1554 revealed an elevated result of 242 mg/dL (deciliter). Review of the Neurological assessment at 1624 revealed a "Within Defined Limits." Review of the vital signs at 1715 revealed "Heart Rate: 85; Resp: 18; BP: 204/105; SpO2: 98%." Review of the electronic medication administration record revealed Patient #11 was given lisinopril 10 mg tablet at 1721 and hydralazine 10 mg injection at 1722. Review of the vital signs at 1732 revealed "Heart Rate: 79; Resp: 16; BP: 181/97; SpO2: 96%; Oxygen Therapy: None (Room air)." Review of the ED Patient Care Timeline revealed Patient #11 was admitted to the hospital on 08/24/2021 at 1747. Review of the NIH Stroke Scale performed on 08/24/2021 at 1840 revealed a change in "1C Blink Eyes & Squeezes ... Performs 1 Task ... 4. Facial Palsy ... 2 Partial paralysis ... 5B Motor - Right Arm ... 4 No movement ... 6B Motor - Right Leg ... 4 No movement ... 11 Extinction and Inattention ... 1 Visual, Tactile, Auditory, Spatial, or Personal Inattention ... NIH Stroke Scale 12 ." Review of the CT Head WO (without) Contrast performed at 1932 revealed "Impression: New left periventricular hypodensity. Differential diagnosis includes acute or subacute infarct. MRI of the brain recommended."

Interview on 02/23/2022 at 1453 with Emergency Department Charge Nurse (ED CN) #2 revealed she did not remember Patient #11. Interview revealed with the blood pressure Patient #11 presented with, Patient #11 should have been an ESI acuity of 2 and "evaluated more often." Interview revealed a provider should have been notified and it documented if the provider wanted to treat the blood pressure.

Interview on 02/23/2022 at 1602 with Medical Doctor (MD) #4 revealed he began seeing patients as soon as he came on duty at 0600 on 08/24/2021. Interview revealed MD #4 did not remember Patient #11 however he had reviewed his notes. Interview revealed "it would not be uncommon for someone with that blood pressure if they don't elicit organ damage or a concern, it would not generate a flag" that they needed to be seen sooner or as a higher priority.

Interview on 02/23/2022 at 1614 with a Registered Nurse (RN) #5 revealed she did not remember Patient #11. Interview revealed if a patient has an elevated blood pressure RN #5 would notify the provider and make sure the patient is on the cardiac monitor and has an iv (intravenous) line.