HospitalInspections.org

Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings included:

The hospital's Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to prevent delay in determination of an Emergency Medical Condition (EMC) for one (1) of 21 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #41).

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

Based on policy review, medical record review, video footage review and staff interview the hospital's DED (Dedicated Emergency Department) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to prevent determination of an Emergency Medical Condition (EMC) for one (1) of 21 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #41).

The findings include:

Review of the policy "EMTALA - Definitions and General Requirements", effective 07/01/2024, revealed "...The hospital with an emergency department must provide to any individual....who 'comes to the emergency department' an appropriate Medical Screening Examination....within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition....exists... ."

Review of the DED medical record on 05/14/25 revealed Patient (Pt) # 41 was a 54 year-old male that presented to the Emergency Department on 02/10/2025 at 2250 with an arrival complaint of "SOB (shortness of breath)" Review of the Triage note at 2256 revealed "Pt presenting via EMS (emergency medical services) for COPD (chronic obstructive pulmonary disease - lung disease) exacerbation with increased work of breathing/SOB today - per EMS pt stated 'the only thing that helps my COPD is 2 oxycodone (opioid pain medication) + (plus) 1 shot of dilaudid (opioid pain medication)'. VSS (vital signs stable). No O2 (oxygen) @ (at) baseline Hx: asthma COPD.... Ambulatory Status: Ambulatory; Triage appearance: Awake, Alert ... Triage Breathing: Unlabored; Other: tachypneic (fast breathing).... Acuity: 3-Urgent..." Vital Signs at 2258 revealed "...Temperature Fahrenheit: 97.3... Heart Rate: 164... Respiratory Rate: 28... Systolic Blood Pressure: 118... Diastolic Blood Pressure: 76..." Review of the Provider note dated 02/11/2025 at 0014 revealed "Chief Complaint: RESPIRATORY DIFFICULTY.... History of Present Illness 54-year-old with AML (acute myeloid leukemia -cancer that affects blood and bone marrow), non-Hodgkin's lymphoma (cancer in the lymphatic system), COPD (chronic obstructive pulmonary disease) who presented with shortness of breath and went into cardiac arrest while in the ER waiting room. Per documentation the patient was triaged at 2256. While in the waiting room he went to the bathroom, subsequently was found unresponsive and pulseless in the bathroom.... He was brought back to the resuscitation area where I am working and at that point I assumed care of the patient at 2348....Medical Decision Making... 54-year-old ....who presented with shortness of breath by ambulance and was initially placed in the waiting room. I make note that the EMS run sheet recorded heart rate of 76, while the triage vital signs in the ER (emergency room) note heart rate 164 and respiratory rate 28. While in the waiting room the patient went to the bathroom and subsequently was found in cardiac arrest. CPR (cardiopulmonary resuscitation - emergency life saving procedure) was initiated and the patient was brought back to the ER critical care area... proceeded with standard ACLS (advanced cardiovascular life support)... patient was intubated for airway protection....He was given multiple rounds of epinephrine (medication to treat low blood pressure) as well as bicarb (medication used to regulate body acidity and basicity). Initial rhythm of asystole (complete cessation of electrical activity of the heart), subsequently PEA (pulseless electrical activity - abnormal heart rhythm where the electrical activity in the heart is too weak to maintain a heartbeat or pump blood through the body) and eventually ROSC (return of spontaneous circulation - return of a sustained heart rhythm that perfuses the body) was achieved several times. After his initial episode of ROSC he had several episodes of V-fib (ventricular fibrillation) and also ventricular tachycardia (abnormal heart rhythms).... ABG (arterial blood gas) demonstrated severely elevated potassium. He was given 2 g (grams) IV (intravenous) calcium, numerous boluses of bicarb. He was started on norepinephrine (used to treat life-threatening low blood pressure), amiodarone (medication that prevents and treats arrhythmia), Neo-Synephrine (drug used to treat low blood pressure). Ultimately after more than an hour of attempted resuscitation resulting in recurrent cardiac arrest the resuscitation was terminated at 0056.... Likely etiology of his arrest is multifactorial including hypoxic respiratory failure, hypokalemia.... Diagnosis/Disposition 1. Cardiac arrest 2. Hyperkalemia 3. Shortness of breath 4. Respiratory failure... "

Review of video footage from the ED waiting area on 05/15/2025 revealed on 02/10/2025 at 2301, Patient #41 was taken to the bathroom in the ED waiting room via wheelchair from the triage area (noted by staff during video review). At 2310, the bathroom light started blinking and at 2319, an Environmental Services (EVS) staff attempted to enter the bathroom, but did not appear to look up to see the blinking light or go inside the bathroom. An ED staff member was noted adjacent to the bathroom on a computer at 2325 but did not appear to acknowledge the blinking light. At 2329, another staff member took a different patient to a bathroom located beside the bathroom where the light was blinking. No acknowledgement of the blinking call light was observed. At 2333 an EVS staff member knocked on the door to the bathroom with the blinking light and appeared to attempt to open the door. At 2335, two staff members were observed in the area of the blinking light bathroom but did not appear to note or acknowledge the blinking light. At 2339 a female staff member knocked and opened the door of the bathroom with the blinking light. A male staff at the same bathroom runs out of the bathroom area. The female rolled the patient out of the bathroom into the IPA area via wheelchair and male staff brought a stretcher. Two other staff members presented and assisted with getting the patient placed on the stretcher and chest compressions were observed. At 2340, the patient was rolled out of the camera view.

In summary, Patient #41 arrived to the hospital by EMS on 02/10/2025 at 2250 with a chief complaint of shortness of breath. Patient #41 was taken to triage. Triage vital signs at 2256 were temperature 97.3, heart rate 164, respirations 28 and blood pressure of 118/76. Although the heart rate was noted as 164 and respirations 28, documentation indicated "VSS" (vital signs stable) and Patient #41 was assigned an acuity of 3 (acuity range 1-5 with 1 being most severe). Per video review, Patient #41 was wheeled into a waiting room bathroom at 2301 and left alone. A call system inside the bathroom was activated at 2310 (per video observation of a blinking light above the bathroom door). No one entered the bathroom over the next 8 minutes. At 2319 per video a staff member, noted as EVS staff, opened the door, then closed it without entering the bathroom. Video review indicated at 2339 another staff member knocked, opened the bathroom door, entered, wheeled the patient out of the bathroom and into the IPA area where Patient #41 was placed on a stretcher and CPR began. Per video review and staff interview during the review, the bathroom was not entered until 29 minutes after the call light was activated, and when found the patient was slumped over in the wheelchair unresponsive. CPR was performed but the patient subsequently expired. Record and video review revealed the 50-year-old patient with a history of COPD and unstable vital signs (pulse 164, respirations 28) was placed in a waiting room bathroom unattended for 29 minutes and found unresponsive. Patient #41 needed continuous monitoring, an EKG within 10 minutes, evaluation by a clinician and blood work and chest x-ray shortly thereafter. Instead, Patient #41 was found unresponsive and in cardiac arrest in a waiting room bathroom at 2339. Review revealed a delay in medical screening.

A meeting was held on 05/15/2025 at 1530 with hospital staff to discuss this event, the root cause analysis and actions taken. A review of the case indicated Patient #41 arrived via EMS to the ambulance bay and was determined stable enough to go to the triage area for triage. Per staff, vital signs from EMS included pulse of 74, respirations of 18. Hospital triage vital signs at 2254 included a pulse of 164 and respirations of 28. The patient's chief complaint was noted as respiratory difficulty, with increased work of breathing and shortness of breath. A triage ESI (acuity) of 3 was assigned. The patient demanded to go to the bathroom before further care, including having the EKG, and was wheeled to the bathroom and then left alone. Review of the root cause analysis performed revealed concerns arose with delay in response and triage acuity designation. Per discussion, the hospital reported the event to the accrediting and state agencies. Action items around the level 3 ESI designation included additional triage education and monitoring of ESI designation for the triage nurse. Additionally, 70 audits of ESI levels per month were started and are ongoing across all staff to review ESI determinations; if or when a fall-out is found, real time education occurs. The root cause analysis also found delayed response to the call light. The hospital reviewed the video and interviewed involved staff. Issues were identified that included that the audible could not be heard in the waiting room bathroom vicinity, the call alarm was silenced at the remote call system location after it was initially answered, there was no clearly identified person who was to respond and the call light above the bathroom door was on but not noted by several staff. Multiple actions were taken. The staff member who answered the call button and silenced the alarm was disciplined and no longer works at the hospital. Changes were made that the remote alarm could not be silenced until a confirmed response was received that the patient's light was answered. Audible alarms were added out front in the waiting room area. Additional lights were added for better visualization. A staff member is now formally assigned each shift to cover the waiting room bathrooms for clear designated responsibility. If that individual cannot immediately respond when a bathroom call light is triggered, they are to hand-off to another clearly designated person with required closed loop communication on who is responding. Discussion revealed a daily 9:00 am quality call to ensure oversight of the IPA (internal processing area in waiting room) bathrooms. Lastly, unannounced drills were put in place and are ongoing to ensure the changes have been consistently implemented and are working.