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Based on a review of Emergency Medical Services documentation, patient #1's emergency department (ED) record, interview, video, and other information on 11/27-28/18, it was determined that the hospital failed provide a timely and sufficient medical screening examination for patient #1.

Patient #1 (P1) was a patient with a recent diagnosis of atrial fibrillation (AFib). AFib is a condition in which an irregular, rapid heart rate may cause symptoms such as heart palpitations, fatigue, and shortness of breath. The condition can also cause life-threatening blood clots within the circulatory system. Per family, P1 was also noted to be recently diagnosed with blood clots to the lower extremities. P1 had awoken during the night with shortness of breath, and was subsequently transferred to the hospital via Emergency Medical Services.

Patient #1 had been placed on a cardiac monitor by the paramedic for transport which confirmed P1's atrial fibrillation. An Emergency Medical Services (EMS) form which documented patient #1's condition revealed a starting time of 0206 with vitals of, respirations (R) 30 rapid, heart rate (HR) of 126 regularly irregular, a blood pressure (BP) 156/86 and oxygen saturation of 88 on 10 liters of oxygen (nml oxygen saturation greater than 90%). A verbal report from EMS to the ED prior to P1 arrival to the hospital revealed in part, " Priority 2 ...history of afib and hypertension, stage 4 cancer, history of deep vein thrombosis (DVT-blood clots in the legs), home oxygen ...non-rebreather @10 liters, [oxygen saturation] to 90's, heart rate 110-140, BP 156/86, right now (patient) is afib."

P1 arrived to the ED at 0220 and per direction of the Emergency Department Manager, was immediately taken to a resuscitation room #3. Documentation indicated that once in the room, a higher priority patient came to the ED, and P1 was taken back to the triage area to be triaged. Vitals documented at 0237 revealed a BP of 142/84, P 108, R 17 (non-labored), temperature 96.1, Pain 0, and oxygen (O2) saturation 96% on Non-rebreather mask. The triage nurse assigned an Emergency Severity Index of 3 which meant P1 was urgent, but stable.

Interview with the triage RN during the survey on 11/27/18 at 1044 revealed in part that the triage RN thought P1 was on a cardiac monitor, but the RN did not review the cardiac monitor and reported no knowledge of P1 being in atrial fibrillation. Video revealed the triage RN remained sitting at the triage station with no attempts to transfer P1 to a hospital cardiac monitor. Nor did the triage nurse feel for a pulse or obtain vital signs other than by report from EMS.

The triage RN documented in the medical record in part, "Pt. presents to ER/Triage via EMS __ on stretcher with c/o shortness of breath and diaphoretic since 0030 ...New arrival is blurry and doubled vision ...complaint: SICK." In addition to no mention of Afib, no mention of DVT was noted.

Following triage, P1 was wheeled to a "staging area," [hallway] at 0239 that is usually attended by an RN for patients on gurneys who were awaiting room placement. However, per the triage RN, no RN was in attendance at that time. The triage RN stated that the Charge Nurse would "pick up on" the staging area. P1 remained on the paramedic cardiac monitor. Vitals from the monitor at 0346 revealed a BP of 150/87, regularly irregular P of 115, and R of 33. At 0408, vitals from the monitor revealed a BP of 135/70, P of 136, and R of 33. At that time, P1 was taken off the monitor by the emergency medical technician (EMT). Video confirmed that no RN or other hospital staff had approached or spoken with P1 since the triage time of 0241, though the EMT or Paramedic had inquired regarding a room.
Per video review, at 0510, the family member of P1 left the area as did an EMT. They returned with a physician who examined P1 in the staging area. P1 was subsequently moved to a room at 0514 where a 12-lead EKG was completed at 0526. The EKG revealed P1 to be experiencing a heart rate of 36 beat per minute, with multiple detected cardiac abnormalities.

The physician wrote at 0510 in part, "Patient seen initially on EMS stretcher, having arrived at 0241 and triaged. I saw the patient at approximately 0510hr. Patient was being attended by EMS on NRB in moderate respiratory distress able to speak in very short words ...Upon my initial evaluation in EMS stretcher, attempted to expedite with RN patient be placed in a medical treatment room ..."

While attempting to transfer P1 from the ambulance gurney to the stretcher in the room, P1 became unresponsive. Family indicated that P1 had decided on Do Not Resuscitate (DNR) and P1 was not resuscitated.

A physician note of 0530 revealed in part, "(Discussed with) family to confirm DNR/DNI. Informed family that at this the likely diagnosis is massive PE (pulmonary embolus--blood clots in the lungs) causing cardiopulmonary arrest in my clinical judgement ..."

Review of all available information confirms that the hospital failed to take responsibility for oversight of care when P1 presented to the hospital with shortness of breath and a rapid irregular pulse, and failed to perform a timely medical screening exam consistent with the patient's presenting symptoms and history.