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Based on record review, Emergency Department Log, policy and procedure, and interviews, the facility failed to be in compliance with 42 CFR 489.24 as evidenced by the facility's failure to perform an appropriate medical screening exam to determine whether SP #1 (Sample Patient #1) out of 20 sampled patients had an emergency medical condition.

The findings included:

Refer to findings A 2406.

Based on record review, Emergency Department (ED) Log, facility policy, and interviews the facility failed to ensure that an appropriate medical screening examination was conducted that was 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 existed for Sampled Patient (SP) #1, one out of 20 sample patients.

The findings include:

Review of the Emergency Department (ED) Log dated 07/29/2021 documented SP#1 was checked into the ED on 07/29/2021 at 2:54PM.

Interview with the Emergency Department Director on 10/04/2021 at 10:45AM revealed, SP#1 was registered upon arrival to the emergency department and then brought to the COVID-19 waiting area. The ED Director reported, the location the patient was placed, was in poor visibility to the ED staff. The ED Director reported, ED staff called the patient's name and because there was no answer, they removed the patient out of the system. The ED Director reported at the time of this event, there was no way in the computer system to indicate the patient was waiting for triage. The ED Director reported, the staff was alerted to the patient when a visitor saw the patient having a seizure.

Interview with the Director of Risk Management on 10/04/2021 at 1:40PM revealed, SP#1 was assessed by a triage night nurse to be almost pulseless and have agonal breathing on 07/29/2021 at 11:53PM.

Review of SP#1 Emergency Department Chief Complaint Description dated 07/29/2021 at 11:55PM documented, patient presents from triage in respiratory arrest, apneic and unresponsive.

Review of SP#1 cardiopulmonary resuscitation record dated 07/30/2021 at 1:10AM documented, a Code Blue was called on 07/29/2021 at 11:55PM. Patient was intubated, and advanced cardiac life support (ACLS) protocols were initiated. SP#1 was pronounced dead at 12:30AM on 07/30/2021.

Review of the hospitals Emergency Care Services Policy No. 306, Subject: Triage Management, Last Revised: 04/04/2019, documented when an individual presents to the emergency department triage seeking a Medical Screening Examination (MSE) the individual will present chief complaint to senior emergency room technician or Registered Nurse (RN) and the patient will be registered. Any clinical staff can obtain vital signs. An RN will perform the patient assessment and determine the individual's acuity.

Interview on 10/05/2021 at 1:45PM with Staff C, an Advanced Practice Registered Nurse assigned to the ED Triage on 07/29/21 and on 10/05/2021 revealed, patients are seen according to the Emergency Severity Index (ESI) score assigned by the triage nurse. Staff C reported, the responsibility includes a medical screening examination, ordering diagnostic tests and treatments, follow-up and status updates.

After record review and interviews were completed, it was determined:

SP#1 waited in the Emergency Department waiting room for more than 10 hours without an assessment.

SP#1's record has no evidence of initial vital signs, triage nursing assessment, emergency severity index (ESI) acuity level or a medical screening exam.