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Based on interview, record review and policy review, the hospital failed to follow their policies and did not provide a medical screening exam (MSE) sufficient to determine if an emergency medical condition existed for one of 20 patient records reviewed (Patient 1). Failure of the hospital's ED to provide a sufficient medical screening exam places patients at risk for an undetected emergency, further deterioration in their condition, or even death.


Findings Include:


Review of a hospital policy titled, "EMTALA (Emergency Medical Treatment and Labor ACT)-Medical Screening Examination and Stabilization" reviewed 08/2018 showed, the Purpose: to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment ... Procedure: When an MSE is required: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an EMC exists ... ...Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's symptoms: Depending on the individuals presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and other diagnostic tests and procedures. ...Stabilizing Treatment and Individuals Whose EMC's are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist.


Document review of the hospital policy titled, "EMTALA-Definitions and General Requirements, revised 02/01/16, showed, Medical Screening Exam (MSE) is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not and EMC exists ...

Review of the hospital document titled, "Medical Staff Bylaws" dated December 2015, showed, Qualified Medical Person or Personnel: In addition to a physician, Qualified Medical Persons may perform a Medical Screening Examination. Individuals in the following professional categories who have demonstrated current competence in the performance of Medical Screening Examinations, and who are functioning within the scope of his or her license and policies of the Hospital, have been approved by the Board as Qualified Medical Personnel: Registered Nurse in Perinatal Services and newborn areas; an APRN or physician assistant for low acuity Emergency Department/Section patients per their protocol; a registered nurse or an APRN/PA for ground or air transport.

Review of Patient 1's medical record showed she presented to the ED on 01/01/19 at 3:42 PM with complaint of chest pain that radiated from the center of her chest to her back that started about 3:30 PM. After her arrival she started feeling nauseated (sick stomach). Patient 1 initially rated her pain intensity at 5 on a scale of 0 to 10 with 10 being the worst. ED physician assistant-certified (PA-C) staff O, performed an initial history and physical (H&P) exam at 4:06 PM and documented patient # 1 complained of chest pain of unknown etiology, nausea, right arm numbness, and neck pain. PA-C staff O documented patient # 1 complained of substernal chest tightness and initiated the chest pain protocol which included blood testing, a chest x-ray, and an ECG (a recording of the electrical activity of the heart). Further documentation showed that patient # 1's cardiac (heart) risk factors included obesity (over weight) and family history of cardiac disease.

At 4:32 PM documentation showed that patient # 1 received an intravenous (IV) dose of Morphine (pain medication) 4 mg for pain she rated a 6 on a scale of 1-10 in addition to an IV dose of Zofran (anti-nausea medication). The medical record did not contain a description of the type, duration, quality or location of patient # 1's pain or the cause of her nausea or vomiting.

At 6:55 PM documentation by the ED nurse showed that patient # 1's "pain intensity" had decreased to 4 (moderate pain).

At 8:23 PM the ED physician printed discharge instructions and provided them to patient # 1. The discharge instructions specified that patient # 1 should make a follow up appointment with a cardiologist (contact information provided) and instructions for how to take Zofran (anti-nausea medication). The instructions continued and indicated that the cause of patient # 1's chest pain had not been determined and specified when chest pain is caused by a dangerous condition "like a heart attack, aorta injury, blood clot in the lung, or collapsed lung." The discharge instructions continued "It is unlikely that your pain is caused by a life-threatening condition if :" "Your chest pain lasts only a few seconds at a time; you are not short of breath, nauseated (sick to your stomach), sweaty, or lightheaded; your pain gets worse when you twist or bend; your pain improves with exercise or hard work."

At 8:40 PM documentation showed that patient # 1 received an IV dose of Fentanyl 100 mcg (powerful narcotic similar to Morphine but is 50 to 100 times more potent) for complaints of pain rated a 6 on a scale of 1-10. In addition, the ED nurse administered an IV dose of Zofran (anti-nausea medication) and Maalox mixed with viscous Lidocaine (a gastrointestinal cocktail to treat stomach upset). The medical record did not contain a description of the type, duration, quality or location of patient # 1's ongoing pain or the cause of her nausea and vomiting.

At 9:38 PM documentation showed that patient # 1 left the ED.

Review of a second record showed that Emergency Medical Service (EMS) was contacted at 1:14 AM on 1/2/20, less than 4 hours after patient # 1 was discharged from the ED. Further documentation showed that EMS could not resuscitate patient # 1 and declared her deceased at 2:02 AM.

During a telephone interview on 02/04/20 at 9:00 AM ED physician staff N stated "the majority" of the patients that come through the ED present with chest pain but not all patients with chest pain are admitted. He further stated part of the process of determining patient treatment as an inpatient or outpatient when a patient presents with chest pain is to consult the cardiologist on call who reviews the presentation with the ED physician and makes recommendations regarding further care. He also stated that he assessed and reassessed patient # 1 during the ED visit and the nursing staff kept him aware of her status when he was out of her room.

Refer to tag A 2406 for further details.

Based on document review, record review and interviews the hospital Emergency Department (ED) failed to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for one of 20 patient's records reviewed (Patient 1).

Failure of the hospital to provide an appropriate MSE for every patient presenting to the ED has the potential to allow an EMC to go unidentified which could place patients at risk for worsening of their condition, further complication or even death.

Findings Include:

Review of Patient 1's medical record showed she presented to the ED on 01/01/19 at 3:42 PM. The rapid initial assessment showed she complained of chest pain that radiated from the center of her chest to her back that started about 3:30 PM. After her arrival she started feeling nauseated (sick stomach). Patient 1 rated her pain intensity at 5 on a scale of 0 to 10 with 10 being the worst. Her initial vital signs showed her blood pressure (B/P)129/62 (normal B/P is less than 120/80), Pulse (P) 70 (normal 60-100 beats per minute), Respiration (R)18 (Normal 12-20 breaths per minute), and oxygen saturation (SPO2) 97% (normal 95-100% saturation). Her cardiac (heart) risk factors included obesity (over weight) and family history of cardiac disease.

ED physician assistant-certified (PA-C) staff O, performed an initial history and physical (H&P) exam at 4:06 PM, documenting the patient's chief complaint was chest pain of unknown etiology, nausea, right arm numbness, and neck pain. Further documentation showed the patient complained of substernal chest tightness that began at 3:30 PM on 1/1/2020. The chest pain protocol was initiated including obtaining laboratory blood tests, a chest x-ray, and an electrocardiogram (a recording of the electrical activity of the heart).

At 4:15 PM documentation showed that patient # 1's respiratory rate increased to 33 breaths per minute (normal respiratory rate at rest is 12 - 25). Further documentation showed that patient # 1 received Morphine (pain medication) 4 milligrams (mg) intravenous (IV) for pain intensity rated 6 on a scale of 1-10, 10 being the most severe pain, and Zofran 4 mg, IV (a medication used to treat nausea). There was no documentation of the type, duration, location or quality of patient # 1's pain at the time the ED nurse administered the morphine.

At 5:33 PM documentation showed that PA-C staff O contacted the on-call cardiologist staff R and reviewed patient # 1's lab results (normal), chest x-ray (normal) and EKG findings. Further documentation showed the cardiologist requested a second Troponin Level (test that measures Troponin in the blood, indicating a heart attack) and advised PA-C staff O to instruct patient # 1 to make an appointment with cardiology the following day. At 6:16 PM shift changed and PA-C staff O transferred patient # 1's care to ED physician staff N.

At 6:55 PM the ED nurse re-assessed patient # 1's pain and documentation showed the patient rated her pain intensity level a 4 (moderate) on a scale of 1-10.

At 7:53 PM ED physician staff N determined the repeat Troponin Level requested by the on-call cardiologist was less than 0.04 ng/ml (normal is less than 0.11 ng/ml, elevated levels may be an indication of heart damage or heart attack).

At 8:23 PM ED physician staff N printed discharge instructions and provided them to patient # 1. The discharge instructions specified that patient # 1 should make a follow up appointment with a cardiologist (contact information provided) and instructions for how to take Zofran (anti-nausea medication). The instructions continued and indicated that the cause of patient # 1's chest pain had not been determined and specified that "Sometimes chest pain is caused by a dangerous condition like a heart attack, aorta injury, blood clot in the lung, or collapsed lung." The discharge instructions continued "It is unlikely that your pain is caused by a life-threatening condition if : Your chest pain lasts only a few seconds at a time; you are not short of breath, nauseated (sick to your stomach), sweaty, or lightheaded; your pain gets worse when you twist or bend; your pain improves with exercise or hard work."

At 8:40 PM documentation showed the ED nurse administered an intravenous (IV) 100 mcg dose of Fentanyl (powerful narcotic similar to Morphine but is 50 to 100 times more potent) for complaints of pain rated a 6 on a scale of 1-10. In addition, the ED nurse administered an IV dose of Zofran (anti-nausea medication) and Maalox mixed with viscous Lidocaine (a gastrointestinal cocktail to treat stomach upset). The medical record did not contain a description of the type, duration, quality or location of patient # 1's unresolved pain or the cause of her nausea and vomiting or whether her pain was resolved following administration of Fentanyl. At 8:55 PM the ED nurse documented that patient # 1's oxygen saturation level dropped to 84% after receiving the pain medication and placed patient # 1 on 2 liters of supplemental oxygen. At 9:06 PM a different ED nurse documented that the flow of oxygen was lowered to 1 liter. Approximately 1 hour after receiving Fentanyl, the nurse documented that patient # 1 left the ED at 9:38 PM.

Review of a second record showed that Emergency Medical Service (EMS) was contacted at 1:14 AM on 1/2/20, less than 4 hours after patient # 1 was discharged from the ED. Further documentation showed that EMS arrived at patient # 1's location and was unsuccessful at resuscitating the patient. At 2:02 AM documentation showed patient # 1 was declared deceased in the field (non-hospital setting).

During an interview on 01/08/20 at 4:55 PM, Staff R, Cardiologist stated that he is available for consultation and to give recommendations only and that the ED physician is responsible for determining a diagnosis. He stated that "there is no magic level of troponin showing a patient is in trouble, it is only part of the picture and the physical assessment must be included in the determination."

During a telephone interview on 02/04/20 at 9:00 AM, ED physician staff N, stated "the majority" of the patients that come through the ED present with chest pain but not all patients with chest pain are admitted. He further stated part of the process of determining patient treatment as an inpatient or outpatient when a patient presents with chest pain is to consult the cardiologist on call who reviews the presentation with the ED physician and makes recommendations regarding further care. ED physician staff N further stated it is not always possible to relieve all pain and Patient 1 was discharged to home with a pain level of four (not documented in the medical record). He stated he discussed her pain with her and patient # 1 was agreeable with discharge. He further stated he did give the patient a prescription for nausea medication but did not give her a prescription for pain medication because she did not feel she required it. He further stated, "we were not able to get a clear picture of the cause of her chest pain; however, she was stable when discharged and she was deemed stable for outpatient cardiology workup."

During a telephone interview on 01/08/20 at 10:11 AM, a family member stated they brought patient # 1 to the ED because she complained of chest pain and thought she was having a heart attack. The family member stated this was the first time patient # 1 complained of these symptoms. The family member stated that at some point patient # 1 received morphine which affected her speech and she became groggy, however she was able to talk with family. About 9:30 PM patient # 1 called and said the doctors could not find anything wrong and to come and get her. The family member stated that someone brought patient # 1 out of the ED in a wheel chair and that she had a gray tub with her. The family member stated that Patient 1 threw up in the ED, in the car and then at home. The family member stated that they decided to call 911 around 11:00 PM and emergency medical services (EMS) came about 15 minutes later. The family member stated that EMS personnel worked on patient # 1 for about 45 minutes and they had to shock her 3-4 times. The family member stated that EMS finally said there was nothing else that could be done for her and they called the coroner and police.