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Based on video review, medical record review, interview, and Emergency Room Standing Orders: Adult Care Policy Number review, the Emergency Department failed to ensure an individual who comes to the Emergency Department was provided with an appropriate medical screening examination within the capability of the hospital Emergency Department (ED), including services routinely available in the ED to determine whether or not an additional emergency medical condition existed. Patient presented a complaint of a change in condition, chest pressure with a warm sensation to ED staff. The ED staff who was notified completed a set of vital signs but did not report the patient's complaint of chest pressure with warm sensation, and vital signs to licensed medical staff. No additional vital signs or assessment was conducted from 7:24 PM on 8/31/2021, when the patient complained of a change in condition, until 1:53 AM on 9/01/2021, when patient was found unresponsive and absent of vital signs, (Patient #1).

Findings:

Refer to A2406: Medical Screening Examination.

Based on video review, interview, record review, postmortem examination report, policy, and Emergency Room Standing Orders: Adult Care Policy Number review, the facility failed to provide necessary stabilizing treatment and to ensure that all individuals presenting to the Emergency Department for care received an appropriate medical screening examination within the capability of the Hospital Emergency Department, in one (1) out of 35 sampled patients (Patient #1), the patient was found unresponsive and did not survive.

Findings:

Review of the medical record for Patient #1 revealed the patient presented to the Emergency Department (ED) on 8/30/2021 at 10:13 AM. The past medical history includes end stage renal disease, awaiting a kidney transplant, and hypertension (high blood pressure).

Review of the Emergency Department (ED) triage notes dated 8/30/2021 at 10:16 AM authored by Staff A, Registered Nurse (RN) read: "44 yr.[year] old arrives to ED via walk in due to swelling of the throat and inability to eat/swallow. Pt [patient] says he also has had a migrain [sic] since 8:00 PM yesterday due to possibly being off his Niphedipine [a blood pressure medication] since Friday. Pt denies SOB [shortness of breath] and CP [Chest pain]. Patient acuity [Emergency severity index] was documented as a 3." Vital signs: Blood Pressure 174/102, pulse 90, respirations 15, SPo2 (oxygen saturation) 95%, temperature 37.3 centigrade (99.1 Fahrenheit).

Review of the Medical Screening note dated 8/30/21 at 11:03 AM authored by PA-C (Physician Assistant-Certified) read: "[Patient #1's name] is a 44 y.o [year old] male who complains of throat swelling, difficulty swallowing and headache. Patient states he's had trouble swallowing for the past 1 week. He states over the past 5 days he's been having more trouble swallowing and has had to have water with any food to be able to swallow. He states since about 2100 [9:00 PM] last night he's been having a headache with associated nausea and vomiting. He states that he restarted nifedipine about 10 days ago but denies any other new medications. He states that since he thought his symptoms were possible due to allergic reaction, he stopped the nifedipine last week. He states that his headache is due to not being on blood pressure medication now it feels like a hypertension headache. Assessment and Plan: [Patient #1's name] is a 44 yo male who complains of throat swelling, difficulty swallowing, and headache. Clinical Impression: Ddx [differential diagnosis]: GERD [gastroesophageal reflux disease], esophageal stricture [a narrowing of the esophagus], migraine, medication side effect, allergic reaction, medical noncompliance. Disposition: Return to lobby until a bed is available."

Review of the CT (Computerized Topography) thoracic esophagram imaging results dated 8/30/2021 read: "Impression: Aneurysmal ascending aorta [a bulging, weakened area of the major blood vessel of the body] up to 5.3 cm [centimeters] the level of the mid ascending aorta [the main blood vessel that carries blood away from the heart]."

Review of the vital signs dated 08/30/2021 at 2:30 PM revealed blood pressure 160/105, pulse 83, respirations 18, SPo2 96%, temperature 36.4 centigrade (97.5 Fahrenheit).

Review of the vital signs dated 08/30/2021 at 6:07 PM revealed blood pressure 179/118, pulse 79, respirations 18, SPo2 97%, temperature 36.4 centigrade (97.5 Fahrenheit).

Review of the Emergency Department Video footage was completed on 9/8/2021 at 4:08 PM with the Risk Manager, Video of Emergency Department on 8/30/21 at 7:16 PM through 7:22 PM of the West camera view, Patient #1 is observed at a counter which has a large, red colored sign above the counter on the wall which reads "Chest Pain Check-In area." Patient #1 was observed leaning on the counter, standing up and leaning back on the counter multiple times during the observation period. At 7:22 PM Patient #1 was observed getting his vital signs taken by Staff B, CCT (Critical Care Technician). Patient #1 was observed speaking with Staff B while putting his hand to his chest multiple times and bending over.

Review of the vital signs dated 8/30/2021 at 7:24 PM reads blood pressure 121/78, pulse 63, respirations 20, SPo2 98%, temperature 37.1 centigrade (98.8 Fahrenheit).

Review of ED Notes dated 8/30/2021 at 7:34 PM authored By Staff B, CCT read: "PT [patient] c/o [complained of] chest pressure starting 20 minutes ago accompanied by a 'warm sensation.'

Review of the facility video showed dated 8/30/2021 starting at 10:23 PM Patient #1 was observed standing up, taking a walk out of the camera range, and returns with a blanket, and sits back down. Between 11:07 PM and 11: 24 PM Patient #1 was observed with the blanket on his lap, moving around. At 11:30 PM Patient #1 was observed sitting up in the chair with the blanket on his lap. At 11:50 PM Patient #1 was observed sitting up in the chair, placing the blanket over his head. On 8/31/2021 at 12:11 AM, Patient #1 was observed repositioning, the blanket remained over his head. At 12:27 AM Patient #1 was observed moving around, the blanket remained over his head. At 12:29 AM Patient #1's head falls back, his body slumps back into the chair. He was not observed moving after this time and his face remained covered with the blanket. For the period of 12:30 and 1:53 AM Patient #1 was not observed moving, the blanket remained covering his face. No staff approached or interacted with the patient during this time. At 1:53 AM Staff B, CCT was observed approaching Patient #1. Staff B mouth was observed moving, he touched the patient's right shoulder, and was observed checking Patient #1's pulse at the right wrist. Staff B removed the blanket off of Patient #1's face and was observed do a sternal rub to the patient's chest. There was no movement observed from Patient #1. Staff B checked for a radial pulse at the patient's right wrist and checked the patient's oxygen saturation. At 1:54 AM Staff B, CCT leaves the patient's side. At 1:56 AM Staff B returned with Staff C, RN. Staff C is observed checking Patient #1 for a pulse and attempting CPR (Cardiopulmonary Resuscitation) while the patient was in the chair. At 1:57 AM a security guard arrives on scene the patient was on the floor, Staff C continues CPR. At 1:58 AM the MD (medical doctor) arrives, and Staff D, RN arrives in the lobby and continues the resuscitation efforts.

Review of the ED notes dated 8/31/2021 at 1:57 AM authored by Staff C, RN read: While attempting to revitalize Pts [patients] in the lobby, [Staff B's name] was unable to arouse PT and called this RN [Registered Nurse] for assistance and further assessment. Upon assessment, Pt was unresponsive with no discernable carotid pulse. This RN sent Staff B to call code and get assistance, and lowered PT to the floor with assistance from security to begin immediate compressions. 1 round was performed when [Medical Doctor's name] came and began her assessment. [Staff B's name] took over compressions and this RN went to retrieve Ambu bag [a self-inflating bag that is used to provide respirations to a person that is not breathing] assist while other RNs arrived with crash cart and PT was placed on the monitor. Code was continued per note by [Staff's name].

Review of the medical record revealed no documentation related to Patient #1 from 8/30/21 7:34 PM to 8/31/21 at 1:57 AM.

Review of the Code documentation dated 8/31/2021 at 2:01 AM read: "2:01 AM: Approximate time of start of code, no palpable pulses; compressions initiated. 2:03 AM: Pulse check; PEA [Pulseless electrical activity- a condition when the heart stops beating and there is no pulse but still produces an electrical impulse]; compressions resumed. 2:05 AM: Pulse check; PEA; compressions resumed. 2:07 AM: Pulse check; PEA; compressions resumed. 2:10 AM: Pulse check; PEA; compressions resumed. 2:12 AM: Pulse check; PEA; compressions resumed. 2:14 AM: Pulse check; PEA; compressions resumed. 2:16 AM: Pulse check; Asystole [when the heart stops beating and there is no electrical activity]; compressions resumed. 2:19 AM: Pulse check; Asystole; compressions resumed. 2:21 AM: Pulse check; Asystole; TOD [time of death]."

Review of the Postmortem examination conducted on 9/1/2021 read: "Date of Death: 8/31/2021 at 2:21 AM. Internal description:450 ml [milliliters] of serosanguinous fluid [a fluid that contains both blood and a clear yellow liquid known as blood serum] in right pleural cavity [the area around the lungs], 100 ml of serosanguinous fluid in left pleural cavity, 400 ml of blood in pericardial cavity [the area around the heart] and 150 ml of serosanguinous fluid in peritoneal cavity [the area in the abdomen]. Cardiovascular System: Ascending Aorta [the main blood vessel that carries blood away from the heart] had a dissection [a serious condition where there is a tear in the wall of the major artery that carries blood out of the heart] tear in the through [sic] the tunica intima measuring .5 cm [centimeter] leading to hemopericardium [an accumulation of blood in the sac around the heart]. 75% stenosed [narrowing] RCA [Right Coronary Artery]."

During an interview conducted on 9/7/2021 at 10:45 AM the ED Nurse Manager stated, "The CCT saw the patient around 7:00 PM - 7:30 PM, he did vital signs and documented that the patient had chest pain after he took the vital signs. The chest pain was not relayed to the triage nurse. The CCT should have told the nurse and an ECG [electrocardiogram] should have been done and high sensitivity troponins [a blood test that helps detect heart injury] should have been done and all of this should have been relayed to the physician. We have standing orders for all patients that complain of chest pain, we did not follow our standing orders, we did not notify a provider that he was having chest pain or pressure."

During an interview conducted on 9/7/2021 at 10:25 AM with the Director of Clinical Risk Management, he stated, "We did have a patient expire in the ED waiting room, named [Patient #1's name] and he expired around 2:00 AM on 8/31/2021. We received a call on the 24/7 risk hotline and were informed of this. On 8/31/2021 we began our investigation, and an RCA [root cause analysis] was completed approximately 2-3 days later. We found that the patient arrived in the ED for complaints of 7 days of throat swelling, that he was on the transplant list for a kidney and receiving peritoneal dialysis [a form of dialysis that is completed using a catheter in the abdomen]. Once he came into the ED we did tests, lab work and a CT esophagram [an x-ray used to evaluate the esophagus], he was seen by telehealth, he was able to complete the study, drank the contrast, did imaging, drank more, and did more imaging. He was okay, and sent back to the waiting room. The physician's plan was they were going to discharge as he had nothing emergent any longer. He was stable in the ED, and we did not have any open beds in the emergency department. At about 7:30 PM the CCT was notified by the patient that he had a complaint of chest pressure, with warmth or burning in his chest. At that time his vital signs were stable, the CCT did not tell the triage nurse or the MD, or anyone else that the patient was suffering chest pain or pressure, there was no ECG or cardiac work up started and there should have been. He thought the vitals were stable, he meant to tell the nurse but didn't, he meant to do it but got busy and forgot. There was a process in place for patients that complain about chest pain, there is a protocol that the triage staff follow when a patient complains of pain. The patient placed a blanket over his head and was not directly visualized by staff. This was a perfect storm. There was not a level of urgency when the staff was told by the patient that he was experiencing chest pain, he did not act with urgency and should have."

During an interview conducted on 9/8/2021 at 7:00 AM Staff D, RN stated, "I am responsible for staffing, bed placement, the general ED flow of patients, expediting the process so we can triage effectively, and get the patients the care they need. When a patient comes to the ED with chest pain, they normally get a standing order set which includes an ECG, vital signs and stat labs for high sensitivity troponins. Staff would find a physician to read the ECG, usually the core 3 MD at night. The expectation is once a patient complains of chest pain that an ECG is done immediately and sent to the physician to review within 15 minutes. [Staff B's name], he should have let [Staff C's name] know the patient was complaining of chest pain, he should have done an ECG, and [Staff C's name] would have started the standing orders for chest pain. [Staff B's name] should have told [Staff C's name], it was an oversight. I did respond to the code in the lobby, [Staff C's name], the triage nurse was performing CPR, I think the doctor and I arrived at the same time. He was brought back to a trauma bay and CPR and treatment continued. He did not have ROSC [return of spontaneous circulation] and was pronounced dead. I notified my nurse manager and the risk management line."

During an interview conducted on 9/8/2021 at 8:03 AM Staff C, RN stated, "I was assigned in triage on 8/30/2021. I was not told about [Patient #1's name] chest pain. I should have been told but [Staff B's name] he simply forgot. When a patient has chest pain, we have standing orders that an ECG is done, and I would put in standing orders for serial trops [troponins] and vitals. I would have assessed him and reviewed his chart to see what he came in for and what tests were completed. I would have alerted one of the Core 3 doctors and had them review the ECG and chart. We are to get vitals every 4 hours on an ESI [Emergency severity index] 3 patient that is in the ED."

During a telephone interview conducted on 9/8/2021 at 8:28 AM Staff B, CCT stated, "When I came on that day I was assigned to the lobby, when we got in [Patient #1], there were 40-45 people in the lobby with more coming in to get checked in. At about 7:15 [Patient #1's name] came up to the desk and said he was having some chest pressure, so I rechecked his vitals, they looked normal, I saw nothing of note visually. I really intended to do the ECG and tell [Staff C's name], but I simply forgot. There was a whole line of people to get checked in or to get information on their family that had come in by ambulance and they needed to find out about their family. It was a very busy night. I was trying to expedite the process. Some people had chest pain and I did get them an ECG and labs. I just forgot about him after I did his vitals. I should have checked his vital signs sooner, but I wasn't able to get to it because I was so busy. When I went to finally get his vitals, he wasn't responding. I checked his pulse, tried a sternal rub, and checked his sat [oxygen saturation]. I went to get [Staff C's name] and call the code so people would come. I would normally do an ECG and tell the nurse, but I just didn't."

During a telephone interview conducted on 9/8/2021 at 8:48 AM the Medical Doctor stated, "I came on that night at 11 PM. I was not aware of [Patient #1's name] until the code blue in the lobby. He did not present with anything that was pressing or urgent. I was not notified that the patient had any complaints of chest pain. Absolutely chest pain or pressure gets addressed, this was a failure of communication. They should have done an ECG and notified a provider that the patient had new and additional complaints. There are standing order sets for chest pain, and this is a standard that should have happened. Knowing that he was diagnosed with an aneurysm and with complaints of chest pain, he would have been brought to the back and a dissection study might have been ordered, but it probably would not have changed the outcome."

During a telephone interview conducted on 9/8/2021 at 10:44 AM the Physician Assistant (PA) stated, "I did evaluate [Patient #1's name] on 8/30/2021 via telemedicine. He came in around 10 or 10:30 in the morning. He was having some difficulty swallowing and a sore throat for about a week before he came in. The patient told me that his nephrologist advised him to come in for an EGD, but as you know we do not do EGD's in the ED. I did speak with his kidney transplant coordinator, and they had no concerns. I ordered some labs which were WNL [within normal limits] for him and the closest thing to an EGD, a CT Thorax esophagram. I was concerned for any possible esophageal narrowing/stricture or mass. I was not remotely thinking he could have an aneurysm. This was not resulted when I began my follow up on the patients who were left in the lobby at about 6:30 PM. I inquired why the CT wasn't done and I think that was done around 6 PM but when I went to review his chart it was still not resulted. My tele medicine shift started at 9:00 AM and ended at 7: 00 PM. I did no sign out of patients in the lobby and I did not sign him out to anyone. He was stable at the time I left for the day, but I will typically give report to a Core 3 provider if I have any concerns about a patient in the lobby. I have no answer to this question related to the lack of a sign out. I did not get any report that the patient was experiencing any new symptoms before I went off duty. We do have a chest pain protocol that would have the staff do an ECG, and serial labs and have the ECG evaluated by a provider. I would have requested a bed in the back if I knew that he was having chest pain in light of the CT findings and followed up with one of the physicians in the back."

During an interview conducted on 9/8/2021 at 9:15 AM the Emergency Room Medical Director, stated, "I was very aware of what occurred with [Patient #1's name], this is truly unfortunate and not representative of what we do. There was a process that was not followed. The CCT did not inform the nurse, there was no ECG done, no labs were completed per the chest pain standing orders. Certainly, staffing is a variable which affects care. Currently we are down both providers and nursing staff, I relate this to Covid. The process that was in place to prevent this was not followed that night, an ECG was not done, the nurse was not notified, and a provider was not notified that the patient had new symptoms. The process we have in place should have been followed."

During an interview conducted on 9/8/2021 at 3:15 PM the Vice President of Nursing, Chief Nursing Officer stated, "I was notified on 8/31/2021 of the death of the patient and was in contact with the ED Nursing Manager to give guidance and direction as to what was needed to be completed. I absolutely think that we did not follow our protocols that day for chest pain, that we needed more staff, that a provider should have been notified. But we did what we were supposed to, we provided our patient an emergency medical screening, he was receiving care when he was here, but we did not follow our protocol, the nurse was not notified, and a provider was not notified that he had chest pain."

Review of the Emergency Room Standing Orders: Adult Care Policy Number: ED-PAP-001 last reviewed on January 2021 read: "Policy statements: I. Initiate testing and care for patients who arrive to the emergency department and fall into the following guidelines. II. Initiate appropriate standing orders set if a provider is unable to initiate care within 15 minutes of triage assessment. Special Instructions: Chest pain utilizing ACS [acute coronary syndrome] standing orders decision tree. 1. Obtain a 12 Lead ECG and have it interpreted by the ED attending within 10 minutes of patient's arrival to the Emergency department. 2. Administer Aspirin 325 mg [milligrams] po [by mouth] or chewable, unless there is a contraindication such as an allergy or the patient has already taken ASA [Aspirin] prior to arrival to the emergency department. If patient has taken a lower dose give remainder of ASA to equal 325 mg po dose. 3. Place IV [intravenous] saline lock. 4. Perform I stat creatinine point of care tests. Draw and send CBC [complete blood count] with diff, Troponin HS [high sensitivity] (now, 1 hour, 3 hours), BMP [basic metabolic panel], and rainbow draw.

Emergency Department Vital Signs and Reassessment #ED-AG-007 last reviewed on 5/2021 read: "Policy Statements: iii. Emergency provider(s) should be notified of any abnormal vital signs prior to discharge. Special instructions: Vital signs recommended frequency based on Emergency Severity Index [ESI]. ESI 1 q [every] 15 minutes, ESI 2 q 2 hours, ESI 3 q 4 hours, and ESI 4&5 q 8 hours."