HospitalInspections.org

Based on review of the facility EMTALA policies the Emergency Department staff facility failed to provide one (Patient 2) of 20 sampled patients from 5/1/2020 - 10/21/2020 with emergency care and treatment in accordance with its EMTALA policies. An unconscious patient presented on hospital property within 250 yards of the Dedicated Emergency Department (DED) and a friend requested immediate assistance. The ED staff failed to provide immediate assistance to the patient and did not provide medical attention until the friend was able to wheel the patient into the DED.

Findings are:
See also 2406.

A. Review of Facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department -(EMTALA) - Lakeside" last revised 2/2018 states "The hospital will provide an MSE for an individual who: Comes to an on-campus DED, requesting examination for treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need and examination or treatment for a medical condition."

B. Medical records, staff interviews and video recordings find the hospital did not provide Patient 2 a MSE after a request for immediate help was made for the patient in the parking lot (10/10/20 at 10:38 AM) until he was physically wheeled through the doors of the ED by a friend after struggling in the parking lot without any staff assistance for 6 minutes. An immediate response by staff to the patient in the parking lot would have immediately identified the patient had an EMC. This caused a treatment delay of his heart attack for 6 minutes allowing his condition and chances of survival to worsen.

Based on record reviews of 20 sampled patient Emergency Department (ED) records, review of facility security, ED registration and facility property video recordings, staff and provider interviews, the facility failed to provide 1 (Patient 2) of 20 sampled patients emergency care and treatment on 10/10/20 when presenting on hospital property within 250 yards of the Dedicated Emergency Department (DED) and a request made for immediate assistance for an unconscious patient in the car. The immediate initiation of a Medical Screening Examination (MSE)/assessment to determine if the patient is suffering from an Emergency Medical Condition (EMC) is necessary to ensure there is no delay in the provision of potential life saving treatment. The facility staff failed to render aid or initiate treatment until the patient was rolled into the DED by the friend (6 minutes after the friend came into the ED and requested help for his unconscious friend). A hospital ED employee Physician Assistant (PA) "A" walked by a few feet from the patient who was on the ground vomiting and having a seizure without assisting the friend or alerting other staff of the patient's dire condition near the facility entrance. Patient 2 died 1 hour and 49 minutes after his friend made the request for help. This failure has the potential to place all patients at risk of harm who are coming to the emergency room by private vehicle and are unable to come inside to obtain emergency treatment. The facility provided information that the DED has seen on average 1,739 patients per month since 4/1/20.

Findings are:

A. Review of the facility provided 3 videos of the parking lot, outside DED entrance and inside ED Registration waiting area revealed the following:
[Note the times on the videos are not synced so times using video 2, from the registration desk are used]

On 10/10/20 Video 3 shows Patient 2 parked in the ED parking lot across from the ED public entrance. The Friend tries to get the patient out of the passenger side but was unable to and runs to the ED registration desk to get help. Video 2 shows the time stamp for requesting help from Registrar 1 at 10:38 AM. Registrar 1 is seen on the phone and motions for the Friend to pull around to the ambulance entrance. Registrar 1 hangs up the phone and assists other patients. There is no evidence of immediate notification to ED medical staff of a patient needing help in the parking lot.

Video 1 shows the Friend struggling to support and walk the friend to the ED public entrance. The Friend gets as far as the circle drive directly in front of the ED doors when Patient 2 collapses and appears unconscious. An employee, later identified as ED Physician Assistant "A", walks by within a few feet of Patient 2, who is unconscious, vomiting and on the ground. A patient who is vomiting and unconscious is suffering from an Emergency Medical Condition and requires immediate assessment and life saving interventions. PA A does not turn toward the patient or provide any assist. The PA just kept walking at a normal pace right by the patient. Video 2 shows PA A entered the doors adjacent to the ED public entrance/Registration and does not enter the ED area to alert staff but walks calmly down the North Hall toward Administration. A recently discharged ED patient with a bandaged finger is leaving the ED wearing jeans and a screen printed T-shirt at 10:40 AM. This person sees Patient #2 and goes to the public ED outer doors and brings a wheelchair. The Friend and the discharged patient help lift Patient 2 into the wheelchair but he appears to become unconscious again with the legs are caught in the foot pedals. The Friend is unable to move the wheelchair. Another patient/visitor comes out sees the patient and goes back into the ED. This person and is seen speaking to Registrar 1 and motioning to the parking area. Registrar 1 is seen getting up from the desk and looking out the entrance door toward the patient. At 10:42 AM Registrar 1 is seen making a phone call. Meanwhile, the Friend is seen alone with Patient 2 in the wheelchair and unable to wheel the him inside to get emergency care. The Friend is seen waving his arms for attention toward the ED entrance.

Video 2 shows ED Charge Registered Nurse "C" and other staff come through the Registration area with a ED wheeled bed at 10:44 AM. The patient appears to have regained consciousness. The Friend is able to wheel the patient into the ED at 10:44 AM to get the immediate medical assistance he first requested at 10:38 AM. The patient was on hospital property, within 250 yards of the Dedicated Emergency Department, and was not provided emergency medical assistance, initiation of a Medical Screening Examination and initiation of life saving treatment after a request for help was made to ED staff.

B. Review of the electronic medical record for Patient 2 on 10/10/20 reveals the Patient was taken directly to an ED room by Charge RN C. RN A documented at 10:45 AM that she received a call from Registration that the patient "was needing help from a car in the roundabout [half circle drive outside ED entrance]. Bed taken out to waiting room." The record notes the patient was had already been placed in a wheelchair by a friend and he was brought to ED Room 8. The timeline for the ED record begins with arrival in the ED at 10:46 AM. At 10:50 RN A documented the patient was "alert, able to answer questions appropriately. Pt [patient] pale in color, diaphoretic [sweating], unable to obtain blood pressure. [Name of ED Medical Doctor B] called to bedside."

Documentation by ED MD B on 10/10/20 at 11:02 AM describe the patient's stay in the ED noting that the patient presented with Chest Pain. ED MD B stated he was called back immediately to see the patient given his clinical appearance. The ECG (electrocardiogram showing the electrical activity of the heart) showed the patient had a STEMI. A STEMI according to ecgmedicaltraining.com dated 6/24/15 is a "very serious type of heart attack during which one of the heart's major arteries (one of the arteries that supplies oxygen and nutrient-rich blood to the heart muscle) is blocked. ST-segment elevation is an abnormality detected on the 12 lead ECG. It is a profoundly life-threatening medical emergency." The patient's blood pressure was too low to measure initially until Intravenous Fluids (IV) were given. A manual blood pressure of 70 systolic was obtained at 11:11 AM. Normal systolic pressure is between 120 and 90.

The ED MD called the Interventional Cardiologist On-Call, MD "D". MD D arrived to the ED at 11:23 AM. The patient's condition declined in the ED despite IV Fluids and medications. At 11:28 RN C noted the patient was short of breath, wheezing, grey in color, diaphoretic and anxious. Oxygen was applied. The patient was taken to the Heart Catheterization Lab for an emergency Heart Catheterization accompanied by RN C and ED MD B. While in the Heart Catheterization Lab documentation at 11:33 AM notes an absence of respirations. A code was called (brings in additional medical professionals when a patient has an absence of respirations and or heart beat). While Cardio Pulmonary Resuscitation (CPR) was being performed MD D began the heart Catheterization with balloon insertion documented at 11:51 AM. The balloon is a type of heart catheter tube that has a balloon that inflates to widen arteries to restore circulation to damaged heart arteries. The patient never regained a pulse and was pronounced dead in the Heart Catheterization Lab at 12:27 PM.

C. Phone Interview with the Registrar 1 on 10/26/20 at 1:30 PM: Registrar 1 recalled being a Registrar at the hospital for 10-12 years. Registrar 1 confirmed was on duty 10/10/20 doing ED Registration of patients. The Registrar recalled it being very hectic with patients in front of her when a person [Friend of Patient 2] came in and while talking to another patient peaked head around and said "Friend in car is passed out." She asked if he could get him out of the car and he said no -not responding. She then asked them if they could see the garage (ambulance entrance) and told him to pull up to the garage, the doors will open and the nurses will come out. He said OK and she finished registration on another patient. The Registrar said she told RN C and another ED RN that a patient was coming to the garage, he was unresponsive, and they were ready for him. The Registrar said she was in the back with them but they never came to the garage. Registrar 1 then went back to the Registration area and patients told her there was a "guy on ground outside." She told RN C who grabbed a gurney (ED bed) and they came running. They then saw him in a wheelchair, other patients had gotten him off the ground. He was parked in the parking lot and did not come to the ambulance circle area. The Registrar said the patient was awake, alert and not in acute distress.

The Registrar said that they have cameras and "always tell patients to pull up to the garage, other patients will jump in to help and that is not a good idea so we want them to pull up to circle (another circle drive for the ambulance garage entrance separate from the main public ED circle drive). "The Registrar stated "We did everything we could have done. Friend parked his car instead of pulling up. Don't understand why he didn't pull up to circle."

D. Interview with Emergency Room Physician Assistant , PA A on 10/26/20 at 4:45 PM. The PA was scheduled for work in the ED at 11 AM on 10/10/20 and recalled coming in early, parking in front (front entrance lot in front of the main ED entrance) and entered through the Emergency Entrance. The PA stated she had been a PA for 20 years. The PA was shown the Video's during the interview. PA A recalled seeing 2 guys in workout clothes as she was walking from the parking lot. Looked like one "was hopping. Then vomiting in the driveway outside the ER (Emergency Room). He was on his side then on all 4's (hands and knees supporting body). I saw a person coming out the doors with a wheelchair. Thought it was a staff person." PA A stated that upon seeing Patient 2 on all 4's and vomiting that she said to them "I'll get you help." Video 1 fails to demonstrate any evidence of interaction between PA A and the Patient/Friend. PA A is not observed to even look in the direction of Patient 2 on the ground in front of the ED entrance. The PA continues to walk inside the hospital ED doors at a steady normal pace. PA A was asked if she talked to anyone inside (ED staff) about the patient and responded "No, I had to go down the hall (North hall by administration through a magnetic Proxy Badge access door) because my badge did not work." Video 1 and 2 show PA 1 walked right by the ED Registration doors and did not alert anyone of Patient 2's presence outside the ED doors on the ground and in distress. These doors open automatically for patients to enter to be registered. Proxy card access data reveals PA A's card access was working and she was admitted through the access doors at 10:41 AM on 10/10/20.

PA A was asked if she thought the patient may be suffering from an Emergency Medical Condition. She responded that she "knew he was sick and vomiting, but was conscious, was on all fours. He looked to be in pain, was vomiting, not like he needed CPR. He was pale and diaphoretic, but he was in workout clothes." PA A also stated that she thought the person helping with the wheelchair (the discharged patient in jeans and a T-shirt with a freshly wrapped bandaged finger) was the Triage nurse. Triage ED nurses do initial assessments on ER patients on arrival. All ED nurses in this hospital system wear color coded scrub clothing with ID badges clearly identifying them as "RN." The PA recalled being aware of EMTALA (Emergency Medical Treatment Act and Labor Act) regulations and the 250 yard rule. This references that if a patient comes to the hospital and is on hospital property defined as the entire main campus, the parking lot, sidewalk, driveway that is within 250 yards of the hospital and a request is made for an examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition then EMTALA regulations apply which require a Medical Screening Examination and treatment to stabilize the patient with an Emergency Medical Condition.

E. Interview with the Quality Assurance Manager on 10/27 at 10:15 AM confirmed Patient 2 was within the 250 yard rule and treatment not provided for a MSE immediately on request for an unconscious person.

F. Interview with ED Charge RN C on 10/26/20 at 2:55 PM confirmed being the Charge Nurse and the Triage Nurse when Patient 2 came to the ED on 10/10/20. RN C recalled getting a call from Registration to the main desk of the ED telling staff that a patient was coming in with a syncopal episode at a gym and they were coming around to the garage/ambulance entrance. The technician got a wheelchair and was waiting by the garage. The Registrar opened the door from the ED waiting room (main entrance) and told us he was outside there. The technician, myself and another ED RN took a bed out to the door entrance. the patient was in a wheelchair and a friend was pushing him in. RN C recalled Patient 2 was pale, diaphoretic, talking and oriented. RN C stated the patient was "in acute distress and was immediately rolled back to ED Room 8." The RN stated the time from notification by the Registration Desk to ED desk and getting the patient from the front door was 1 minute.

RN C recalled getting the patient on the cardiac monitor and realizing the patient was having a heart attack. ED MD B came to the patient's bedside immediately. The patient told her " I see a white light, I'm gonna die." RN C said the patient looked like he could "code" at any time. RN C said the patient went from the ED to the Heart Cath lab and died. RN C said they got the patient to the ER in a timely manner. RN C said that "if a pt [patient] comes in and friend/family says are unconscious, direct them to the garage." The RN further stated that staff "Don't go out to them unless in the garage or waiting area. If passed out outside would go but were not informed he was."

G. Phone interview with ED MD B on 10/26/20 at 12:00 PM revealed MD B was first aware of Patient 2 when the Charge RN called him to come immediately to the Patient's room. On arrival MD B described the patient was in "Critical Condition and had an apparent Emergency Medical Condition." The vital signs were critical, ECG showed a STEMI. He activated a Code STEMI bringing additional staff needed to care for a critical cardiac patient. Interventional Cardiologist on call (MD D) was called and came immediately. The 2 MD's were conversing on the phone while MD D was enroute from another hospital on preparations for heart cath and what to do if the patient "Codes" (stops breathing/heart stops). Blood clot busting drug TPA was prepared if needed. The patient was given Aspirin and Heparin blood thinners. The patient had a precipitous decline as he was taken to the cath lab which MD B stated was about a 90 second trip from the ED.

H. Phone Interview with the Interventional Cardiologist MD D on 10/27/20 at 9:30 AM. MD D stated he quickly saw the patient in the ED and stated the patient had a "horrible ECG." The patient was taken for heart catheterization as soon as the team was complete. On arrival to the heart catheterization lab the patient was in severe distress, anesthesia was called, Critical Care MD arrived. The patient was intubated and then the heart stopped. CPR, Advanced Cardiac Life Support medications and multiple shocks could not revive the pulse. MD D got the clots out of the coronary arteries (using a balloon heart catheter device) but there was no movement of the heart. The documentation from the heart catheterization shows 67 minutes transpired from the time the patient entered the ED until the potential life saving heart balloon catheter was inserted at 11:51 AM. It was 73 minutes from the time the friend came to the ER and requested help for the patient and the heart balloon catheter was inserted.

MD D stated the target goal for their STEMI treatment program is to have the STEMI patient go from the ER door to having heart catheter balloon access in the heart catheterization lab within 60 minutes. MD D stated "The longer the time the worse the outcome, so you want to get it done as quickly as possible." MD D stated the loss of the 6 minutes, related to delay in getting into the ED, could be significant stating "I have seen 1 minute delay significant. The optimal care is to get the patient into the ER and to the cath lab."

I. Interview with the ED Nursing Manager, RN E, on 10/26/20 at 3:25 PM regarding Patient 2' care, confirmed that "Yes, our nurse should have gone out to check on the patient."

J. Review of Facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department -(EMTALA) - Lakeside" last revised 2/2018 states "The hospital will provide an MSE for an individual who: Comes to an on-campus DED, requesting examination for treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition." The hospital did not provide Patient 2 a MSE after a request for help was made for the patient in the parking lot until he was physically wheeled through the doors by a friend after struggling in the parking lot without any staff assistance for 6 minutes. An immediate response by staff to the patient in the parking lot would have immediately identified the patient had an EMC. This caused a treatment delay of his heart attack for 6 minutes allowing his condition and chances of survival to worsen.