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Based on policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 6 of 11 (Patient #1, 2, 3, 4, 6, and 20) sampled patients with chest pain and 1 of 1 (Patient #19) sampled patients with back pain.

The findings included:

Refer to 2406.

Based on policy review, document review, video footage review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 6 of 11 (Patients #1,2,3,4,6 and 20) sampled patients with chest pain, and 1 of 1 (Patient #19) sampled patients with back pain.

The findings included:

1. Review of the hospital policy "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA" revised on 3/4/2021 revealed, "...Definitions..."Medical screening examination" [MSE] means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC [Emergency Medical Condition] or not. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage...If an individual who is not already a patient presents to the Hospital with an apparent emergency medical condition and a request is made for (or prudent layperson would believe patient is in apparent need of) treatment, then EMTALA procedures below should be initiated to the extent required by the EMTALA law...Hospital QMP [qualified medical personnel] or trained Labor and Delivery registered nurses should provide a MSE appropriate to the individual's presenting symptoms that is within the capacity and capability of Hospital, to determine whether or not an EMC exists..."

Review of the hospital policy "Triage of Emergency Patients" revised on 12/16/2022 revealed, "...Triage of patients arriving to the Emergency Department will be conducted by a RN [Registered Nurse]. The triage RN shall verify the data collected by the Emergency Department Technician [EDT] and assign the final triage acuity based upon a five-level triage system known as the Emergency Severity Index [ESI]... Acuity is determined by the stability of vital signs and potential for life, limb or organ threat based on ESI five level triage system... The Acuity assignments include the following categories... Level I: Emergent - requires immediate life-saving intervention... Level II: High risk situation, is confused/lethargic/disoriented, severe pain/distress, or vitals are in danger zone... Level III: Multiple resources (lab, x-ray, IV [intravenous], etc.) are required to stabilize the patient, but vitals are not in the danger zone... Level IV: One resource needed to stabilize the patient... Level V: No resources required to stabilize patient... Patients will be assigned to available treatment rooms based upon acuity of condition. Emergent patients will be the highest priority and will be taken to the treatment area immediately. Levels 2, 3, 4, and 5 will be seen in the appropriate care area as condition warrants..."

Review of the hospital policy "Assessment, Re-assessment, and Plan of Care" revised on 7/25/2023 revealed, "... Emergency Department: A complete assessment and history is performed for emergency department patients with an Emergency Severity Index [ESI] level of 1 or 2. A focused severity index level of 3, 4, or 5 minimally includes... Vital Signs... Pain Assessment... A focused reassessment based on presenting complaint can be performed by a RN, LIP [licensed independent provider] or Emergency Department Technician with completed competency. Frequency of reassessment is determined by ESI level or significant change in patient condition..."

Review of the hospital's "Pain Assessment Policy" revised on 3/5/2020 revealed, "...all patients will be assessed for pain based upon their clinical presentation... When pain is identified, the patient is treated or referred for treatment... pain Assessment Frequency Outpatients... During the initial evaluation and managed based on each individual's needs 2. If pain medication is administered, patients will be reassessed for intensity of pain or sleeping within 2 hours... Pain assessment and interventions are documented in the medical record..."

2. Review of the hospital document "Emergency Department Waiting Room Reassessment Guidelines" reviewed on 2/24/2023 revealed, "...this document is intended to be used as a guide for approximate reassessment times for patients in the waiting room... The ED Triage Nurse or Waiting Room Coordinator will assess and reassess patients according to guidelines below. For patient who have notified the staff of leaving the waiting room, the patient be called 3 times 15 minutes apart. If no response, the triage nurse will depart the patient from the ED as eloped, Left Without Being Seen (LWBS) or AMA [against medical advice]...The Medical Screening Exam is a process, and continues throughout the visit until the LIP [licensed independent provider] determines an Emergency Medical Condition does not exist. Document focused reassessments and vital signs (BP [blood pressure], HR [heart rate], RR [respiratory rate], Temp [temperature] if pertinent to the presenting complaints, and pain level) of patients based on their acuity level per ESI guidelines... Level 1... Q [every] 1 Hour... Level 2... Q 3 Hours... Level 3... Q5 Hours... Level 4/Level 5... Q8 Hours... Take vital signs within 1 hr. [hour] prior to discharge..."

Review of the hospital document "Physician Orders Adult ED Triage Standing Chest Pain/ACS [acute coronary syndrome] Symptoms Orders" revised 6/8/2022 revealed, "...Criteria for use: Chest pain/discomfort...Vital Signs... Routine... NPO [nothing by mouth]... PIV [peripheral intravenous catheter] insert... O2 Sat Spot Check... Telemetry (ED Only) (Cardiac Monitoring (ED Only) STAT [immediately]... Send patient to chest pain center... CMP [comprehensive metabolic panel]... STAT... ED Troponin-1 HS [high sensitivity] Series (0 and 3 hour)... STAT... CBC [complete blood count]... STAT... If patient complaints of abdominal pain, order Lipase Level... STAT... If patient complains of shortness of breath, order... BNP Pro... STAT... Electrocardiogram (EKG) Stat... Obtain left sided for MI [myocardial infarction or heart attack happens when an artery supplying blood to the heart suddenly becomes partially or completely blocked by a blood clot]... Chest 2 views...and present to MD [medical doctor] immediately..." (Telemetry or cardiac monitoring is used to continuously monitor the patient's heart rate and rhythm, respiratory rate and/or oxygen saturations while automatically transmitting information to a central monitor. Troponin 1 is a test that measures the protein troponin in the blood stream. Those types of troponin only occur in heart muscle cells and only enter the blood because of heart muscle damage. An EKG records the electrical signals in the heart.)

3. Medical record review revealed Patient #1, a 39 year old male, presented to the hospital's ED via private vehicle on 2/12/2024 at 8:08 AM with complaint of chest pain. A triage assessment was completed at 8:12 AM and revealed, "Chief Complaint: pcp [primary care physician] for uri [upper respiratory infection] not ge3tting [getting] better for 1 wk [week] is on abx [antibiotics]. States has lost voice and chest pain when take deep breath..." The patient's presenting vital signs were Blood Pressure (BP) 161/94, Pulse (P) 67, Respirations (R) 16, Oxygen saturation (O2 sat) 95 percent (%). The patient was assigned an ESI level 3. The Standing Chest Pain order set was initiated at 8:14 AM.

A respiratory virus panel was collected at 8:13 AM. All results were negative.

A chest x-ray was completed at 8:14 AM and interpreted at 8:38 AM and showed, " ...No acute findings ..."

An EKG was obtained at 8:19 AM that documented, "Normal sinus rhythm with sinus arrhythmia"

The EKG was reviewed and signed by the ED provider at 8:19 AM who documented, "NO STEMI." (A STEMI, ST- Segment Elevation Myocardial Infarction is the most severe type of heart attack.)

Patient #1's lab work, including a CMP, CBC, GFR and initial Troponin, was collected at 8:21 AM. (Initial Troponin was within normal limits).

Nursing documentation dated 2/12/2024 revealed, "First call from waiting room/no answer...19:28 [7:28 PM]...Second call from waiting room/no answer...20:10 [8:10 PM]...Third call from waiting room/no answer...20:44 [8:44 PM]"

Nursing documentation dated 2/12/2024 at 9:22 PM revealed, "...ED Depart LWBS...No meds [medications] given on this visit..."

There was no documentation Patient #1 was re-assessed or monitored by hospital staff after lab work was obtained at 8:21 AM.

There was no documentation why the second Troponin level was not obtained.

There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1 was at the hospital's ED from 8:08 AM until staff documented the patient LWBS at 9:22 PM, a total of 13 hours and 14 minutes.

Review of video footage dated 2/12/2024 verified Patient #1 entered the hospital's ED at 8:08 AM. Patient #1 is seen walking into the waiting room area and sitting down at 8:34 AM. Patient #1 is seen departing the ED at 3:32 PM. There was no video footage of hospital ED staff reassessing or monitoring Patient #1 while in the ED waiting room from 8:34 AM until 3:32 PM.

4. Medical record review revealed Patient #2, a 39 year old male, presented to the hospital's ED via private vehicle on 2/12/2024 at 8:38 AM with complaints of chest pain. A triage assessment was completed at 8:46 AM and revealed, "Chief Complaint: reports yesterday at work started feeling like bp [blood pressure] was high and this am [morning] started having chest pain when woke up..." The patient's presenting vital signs were BP 151/98, P 84, R 16 and O2 sat 96 %. The patient was assigned an ESI level 2. The Standing Chest Pain order set was initiated at 8:49 AM.

An EKG was completed at 8:55 AM which showed the patient had a normal sinus rhythm with a nonspecific T wave abnormality.

The patient's lab work, including an initial Troponin 1 HS level, CBC, GFR, and CMP was collected at 8:59 AM.

A chest x-ray was completed at 9:09 AM and interpreted at 9:17 AM and showed, "...No acute cardiopulmonary abnormality..."

The EKG was reviewed and signed by the ED provider at 9:19 AM who documented, "No STEMI."

There was no documentation Patient #2 was re-assessed or monitored by any hospital staff from 9:09 AM when the chest x-ray was completed until 5:23 PM, a total of 8 hours and 14 minutes later. At 5:23 PM, the patient's vital signs were BP 169/96, P 75, R 20, and O2 sat 98% and the patient reported chest pain at an intensity level of 10 on a scale of 0 to 10.

There was no documentation Patient #2 received any interventions to address his reported pain.

A second Troponin 1 HS level was collected at 5:37 PM, a total of 8 hours and 38 minutes after the 1st level was collected.

Review of the ED Provider Note dated 2/12/2024 revealed Patient #2 wasn't seen by the ED Provider until 7:30 PM, a total of 10 hours and 52 minutes after his arrival time. The ED Provider documented, "...patient presents with chest pain...Risk factors consist of hypertension and family history of coronary artery disease...Cardiovascular: Regular rate and rhythm...Pain intensity...10...Troponin...normal limit...Labs unremarkable...Diagnosis Chest pain...Family history of heart disease...HTN [hypertension]...Condition: Stable...EMC ruled out...Discharged..."

Patient #2's vital signs were re-assessed prior to his discharge from the ED at 8:38 PM with BP 137/88, P 72, R 18, and O2 sat 99%. There was no documentation Patient #2 was re-assessed for pain.


5. Medical record review revealed Patient #3, a 75 year old female, presented to the hospital's ED via private vehicle on 2/12/2024 at 8:56 AM with complaints of chest pain. A triage assessment was completed at 9:11 AM and revealed, "Chief Complaint: reports hcest [chest] pain and diaphoresis [excessive sweating due to an underlying health condition or medication] for 1 day..." The patient's presenting vital signs were BP 155/63, P 79, R 16 and O2 sat 97%. The patient was assigned an ESI level 2. The Standing Chest Pain order set was initiated by the triage nurse at 9:13 AM.

An EKG was completed at 9:04 AM which showed "...Normal sinus rhythm...Possible Left atrial enlargement...Septal infarct [infarction], age undetermined...Abnormal..."

The EKG was reviewed and signed by the ED provider at 9:19 AM who documented, "No STEMI."

The patient's lab work, including an initial Troponin 1 HS level, CMP, CBC, GFR (a test to check how well the kidneys are working) was collected at 9:22 AM. The patient had a low Potassium level of 3.1, (normal level is 3.5 - 5.2 milliequivalents per liter (mEq/L) and an elevated Troponin-1 HS of 16.2 (normal is less than 14 nanograms per liter (ng/L). There was no documentation the ED provider reviewed the patient's lab work.

A chest x-ray was completed at 10:05 AM and interpreted at 10:11 AM and showed, "...No acute pulmonary findings..."

A second Troponin-1 HS level was collected at 1:30 PM. Patient #3's Troponin level had increased from 16.2 to 16.5. There was no documentation the ED Provider reviewed the patient's Troponin Level.

There was no documentation Patient #3 was re-assessed or monitored by any hospital staff from 1:30 PM when the chest x-ray was completed until 5:23 PM, a total of 8 hours and 14 minutes later. At 5:32 PM, the patient's vital signs were BP 159/84, P 69, R 20, and O2 sat 97% and the patient reported chest pain at an intensity level of 10 on a scale of 0 to 10. There was no documentation the patient's pain was addressed.

The nursing documentation dated 2/12/2024 revealed, "First call from waiting room/no answer...17:33 [5:33 PM]...Second call from waiting room/no answer...19:29 [7:29 PM]...Third call from waiting room/no answer...20:44 [8:44 PM]..."

The nursing documentation dated 2/12/2024 at 9:06 PM revealed, ED Depart LWBS [left without being seen]...No meds given on this visit..."

There was no documentation Patient #3 was seen or evaluated by the ED Provider. Patient #3 was at the hospital's ED from 8:56 AM until staff determined the patient left without being seen at 9:06 PM, a total of 12 hours and 10 minutes.

In an interview on 2/21/2024 at 10:24 AM, the ED Director confirmed there was no documentation the patient was evaluated by the ED Provider.

6. Medical record review revealed Patient #4, a 33 year old female, presented to the hospital's ED via private vehicle on 2/12/2024 at 8:03 AM with chief complaint of "other chest pain". A triage assessment was completed at 8:34 AM and revealed, "Chief Complaint: reports chest pain for 1 day that radiates to back. Had back pain for months is upper right side hx [history] of htn [hypertension] ..." The patient's presenting vital signs were BP 182/103, P 69, (R) 16, O2 sat 97%. The patient was assigned an ESI level 2. The standing Chest Pain order set was initiated at 8:36 AM.

A chest x-ray was completed at 8:36 AM and interpreted at 8:56 AM and showed, "No acute findings"

A Urine Pregnancy test was completed at 8:43 AM with negative results.

An EKG was obtained at 8:46 AM that showed, "Sinus rhythm with fusion complexes...Marked ST abnormality...Abnormal..."

Lab work was collected at 9:07 AM that included a CMP, GFR, initial Troponin level and CBC.

An EKG was reviewed and signed by the ED Provider at 9:19 AM who documented, "NO STEMI"

An order for Labetalol (a medication used to treat high blood pressure) 100 milligram (mg) tablet, 1 tablet by mouth, was initiated at 12:00 PM.

Review of a Medication Administration Record (MAR) revealed the Labetalol was not administered to Patient #4.

The nursing documentation dated 2/12/2024 revealed, "First call from waiting room/no answer...12:05 [12:05 PM]...Second call from waiting room/no answer...17:17 [5:17 PM]...Third call from waiting room/no answer...17:56 [5:56 PM]"

The nursing documentation dated 2/12/2024 at 5:56 PM revealed, "ED Depart LWBS...No meds given on this visit..."

There was no documentation Patient #4 was re-assessed or monitored by hospital staff after lab work was obtained at 9:07 AM.

There was no documentation why elevated blood pressure was not addressed until an order for medication at 12:00 PM.

There was no documentation why the second Troponin level was not obtained.

There was no documentation why ED staff waited 5 hours between the first call from the waiting room until the second call.

There was no documentation Patient #4 was seen or evaluated by an ED Provider. Patient #4 was at the hospital's ED from 8:03 AM until staff determined the patient LWBS at 5:56 PM, a total of 9 hours and 53 minutes.

7. Medical record review revealed Patient #6, a 44 year old female, presented to the hospital's ED via private vehicle on 1/10/2024 at 2:52 PM with complaints of chest pain. A triage assessment was completed at 3:02 PM and revealed, "Chief Complaint: Patient c/o [complains of] chest pain and palpitations [abnormally rapid or irregular beating of the heart] x's [times] 30 min [minutes] ago; patient states that she took phentermine [prescription medication used to decrease the appetite and promote weight loss] and a weight loss shot today..." The patient's presenting vital signs were BP 151/87, P 108, R 20 and O2 sat 100%. The patient rated her pain at level 4 on a scale of 0-10. The patient was assigned an ESI level 2. Orders for Troponin-1 HS Series, CMP, CBC, and Urine Pregnancy Screen were initiated by the triage nurse at 3:10 PM.

An EKG was completed at 3:01 PM which showed "...Sinus tachycardia [a regular heart rhythm where the heart beats faster than normal]... Septal infarct, age undetermined...ST & T wave abnormality, consider inferolateral ischemia...Abnormal..." (Ischemia is inadequate blood supply due to blockage of the blood vessels supplying the area.) There was an apparent signature on the EKG; however, there was no date and time the signature was placed.

The patient's lab work, including an initial Troponin 1 HS level, CMP, CBC and GFR was collected at 3:10 PM. The patient had a low Potassium level of 2.9. There was no documentation the ED provider reviewed the patient's lab work.

Orders for a chest X-ray were entered by the triage nurse at 5:38 PM.

There was no documentation the chest x-ray was completed.

There was no documentation the second Troponin-1 HS level was collected.

There was no documentation Patient #6 was re-assessed or seen by any hospital staff after 3:10 PM when the lab specimens were collected.

The nursing documentation dated 1/10/2024 revealed, "First call from waiting room/no answer...19:36 [7:36 PM]...Second call from waiting room/no answer...20:00 [8:00 PM]...Third call from waiting room/no answer...20:46 [8:46 PM]..."

The nursing documentation dated 1/10/2024 at 9:12 PM revealed, ED Depart LWBS [left without being seen]...pt [patient] no answer in the waiting room...no meds given on this visit..."

There was no documentation Patient #6 was seen or evaluated by the ED Provider. Patient #6 was at the hospital's ED from 2:52 PM until staff documented the patient left without being seen at 9:12 PM, a total of 6 hours and 20 minutes.

In an interview on 2/21/2024 at 11:08 AM, the ED Director confirmed there was no documentation the patient was evaluated by the ED Provider.

8. Medical record review revealed Patient #19, a 20 year old female, presented to the hospital's ED on 9/3/2023 at 2:38 PM with complaint of back pain. A triage assessment was completed at 2:52 PM and revealed, "Chief Complaint: c/o [complained of] headache, backache, diarrhea, cough productive, slight sore throat" The patient's presenting vital signs were BP 135/89, P 78, R 20, O2 sat 97 %. The patient was assigned an ESI level 3.

Nursing documentation dated 9/3/2023 revealed, "First call from waiting room/no answer...22:29 [10:29 PM]...Second call from waiting room/no answer...23:02 [11:02 PM]...Third call from waiting room/no answer...23:15 [11:15 PM]"

Nursing documentation dated 9/3/2023 at 11:23 PM revealed, "ED Depart LWBS...No meds given on this visit..."

There was no documentation why 30 minutes passed between the first and second call from the waiting room.

There was no documentation Patient #19 was re-assessed or monitored after the first triage assessment at 2:52 PM, until being documented as LWBS at 11:23 PM.

There was no documentation Patient #19 was seen or evaluated by an ED Provider. Patient #19 was at the hospital's ED from 2:38 PM until staff documented the patient LWBS at 11:23 PM, a total of 7 hours and 45 minutes.

9. Medical record review revealed Patient #20, a 65 year old female, presented to the hospital's ED via private vehicle on 9/3/2023 at 2:56 PM with complaint of chest pain. A triage assessment was completed at 3:12 PM and revealed, "Chief Complaint: c/o [complained of] chest pains with productive cough since yesterday" The patient's presenting vital signs were Blood Pressure 125/81, Pulse 84, Respirations 20, Oxygen Saturation 100 percent. Pain intensity was rated 7 on a scale of 0-10. The patient was assigned an ESI level 3. The Standing Chest Pain order set was initiated at 3:21 PM.

The patient's lab work was collected at 3:14 PM which included a CMP, GFR, initial Troponin level and CBC.

An EKG was completed at 3:15 PM which showed sinus rhythm with baseline wander. There was no documented signature by an ED Provider to indicate the EKG was reviewed by an ED Provider.

A chest x-ray was completed at 3:21 PM and interpreted at 3:38 PM and showed, " ...Patchy airspace opacities in the lung bases possibly representing early airspace disease ..."

Nursing documentation dated 9/3/2023 revealed, "First call from waiting room/no answer...22:29 [10:29 PM]...Second call from waiting room/no answer...23:02 [11:02 PM]...Third call from waiting room/no answer...23:15 [11:15 PM]..."

Nursing documentation dated 9/3/2023 at 11:24 PM revealed, "ED Depart LWBS...No meds given on this visit..."

There was no documentation Patient #20 was re-assessed or monitored by hospital staff after chest x-ray was obtained at 3:21 PM.

There was no documentation Patient #20's pain level of 7 was addressed.

There was no documentation Patient #20 was seen or evaluated by a ED Provider. Patient #20 was at the hospital's ED from 2:56 PM until staff documented LWBS at 11:24 PM, a total of 8 hours and 28 minutes.

In an interview on 2/21/2024 at 8:50 AM, the hospital's SVP (Senior Vice President) stated they had begun using a new ED provider group as of January 28th (2024). The SVP stated there had been an adjustment period, that was still ongoing. Stated things had been slower (in the ED) at times.

In an interview on 2/22/2024 at 10:04 AM, the ED Medical Director (EDMD) was asked what measures have been put in place to decrease the waiting times and number of patients leaving the ED without being seen. The EDMD stated the hospital had been working on a "Blue Dot" system which signifies which patients had already had a workup and were waiting for disposition. The EDMD continued and stated the hospital was also working to transition Fast Track providers to work in both Fast Track and assist with performing MSEs in the main ED. The EDMD was asked how often patients waiting in the waiting room should be reassessed. The EDMD stated, reassessments are "based on their ESI" and the hospital's "formal policy." The EDMD continued and stated he was unable to recall the exact policy the triage nurse follows regarding reassessments. The EDMD verified cardiac monitoring is a standing order for patients that present to the ED with complaints of chest pain. When asked how cardiac monitoring is completed on patients who were triaged then sent to the waiting room, the EDMD stated, the triage nurse gets an EKG on the patient and shows it to the ED provider. If the EKG is normal, there would be less need to use the cardiac monitor. The EDMD continued and stated if the EKG was abnormal or concerning for a STEMI, that would signify immediate concern. The EDMD was asked how the flow of the ED changed during times of Critical Advisory. The EDMD stated, "Critical Advisory doesn't change anything we do."

In an interview on 2/21/2024 at 9:40 AM, the ED Director stated, "vital signs should be taken every 4 hours for patients with an ESI level 2."

In an interview on 2/22/2024 at 10:27 AM, the ED Director stated if staff called for a patient in the waiting room and the patient didn't respond, they should go back every 15 minutes and call the patient 2 more times before determining the patient left without being seen.

In an interview on 2/22/2024 at 11:20 AM, the ED Director stated the ED providers sign the EKGs when they've reviewed them.

In an interview on 2/22/2024 at 12:30 PM, the ED Director stated she expected pain to be addressed. The Director stated Tylenol could be given without physician consultation.

In an interview on 2/23/2024 at 9:00 AM, ED RN #1 verified nurses are able to initiate the chest pain standing orders without consulting the physician. The nurse stated they are able to give Tylenol for pain without a physician's order. The nurse stated there is a tab in Cerner (their computer system) to tag them of patients, and vitals/re-assessments. Stated patients are re-assessed every 3-5 hours depending on their level (ESI). The nurse stated the back-up in the waiting room is often caused from the "holds" that are in the non-acute area of the ED. This takes up beds that could be used for waiting room patients. When a bed does come free, if an ambulance patient is waiting, they get that room before a waiting room patient.