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Based on document review, medical record review, and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) In 3 of 21 (Patient #1, Patient #3, and Patient #4) medical records reviewed of patients who presented to the emergency department (ED), the hospital failed to provide a timely medical screening exam (MSE) to determine if an emergency medical condition existed. 2) In 1 of 4 (Patient #5) medical records reviewed of patients who were transferred to a higher level of care, it lacked documentation of the benefits and risks of transfer specific to the patient's medical condition.

Please reference findings at Tag 2406 and Tag 2409.

Based on document review, medical record review, and interview, the facility failed to implement a process to ensure prompt triage and medical screening exam (MSE) of patients who walk into the emergency department (ED). Specifically, 1) In 3 of 21 (Patient #1, and Patient #3) medical records reviewed of patients who presented to the ED the facility failed to provide a timely MSE to determine if an emergency medical condition existed.

Findings include:

-- Review of the facility's policy and procedure titled, "Emergency Department Standard of Care," revised 2/23/2023, indicated "patients arriving to the Emergency Department (ED) will be triaged by a RN [registered nurse] and receive an Emergency Severity Index (ESI) number based on their presentation to the ED." Emergency Severity Index is a a tool used to prioritize patients based on signs/symptoms ranging from 1 - resuscitation to 5 - non-urgent.

-- Per interview of Staff C, ED, RN, on 9/18/2024 at 1:30 pm, the process for ED walk ins is that patients walk into the ED then sign in by filling out the presentation form with their information and chief complaint then place the completed form into a basket. The emergency department aide (EDA) will get the completed presentation forms from the basket and see the patients one at a time to get their vital signs (VS) and start the registration process. Staff C explained the EDA can be backed up due to being busy and the registration process can take up to 15 minutes per patient. Staff C stated the EDA may show the RN what a patient wrote down for a chief complaint if it is a potential priority, but otherwise the RN will start triage after the patient is registered. Staff C indicated having concerns for delay in patient assessments and discussed it with the former ED manager.

-- Per interview of Staff E, ED, RN, on 9/18/2024 at 3:15 pm, they described the current ED walk in process. Patients present and fill out the presentation form with their information and complaint, and drop the form in the basket. An EDA picks up the forms to review the complaints, then gets the patient to do their VS and quick registration. The EDA will notify the RN of any potential critical concerns. The RN then performs triage.

Findings specific to Patient #1:

-- Review of Patient #1's medical record revealed, Patient #1 presented to the ED on 5/15/2024 at 12:45 pm and documented their reason for visit being "pain" on the Emergency Patient Presentation Record form.

At 1:49 pm, staff obtained Patient #1's VS - blood pressure (BP) 80/50, pulse (P) 79, respirations (R) 20, and temperature (T) 98.2.

At 1:54 pm, an RN triaged Patient #1 as a level 3 on the ESI scale. Patients #1 presenting complaint was abdominal pain radiating to the back since that morning. Patient #1 reported their pain intensity being an 8 (0 - no pain, 10 - most painful).

At 2:16 pm, Patient #1 was assigned a bed in the ED and had VS obtained every 2 - 5 minutes by ED RN until being transferred.

At 2:35 pm, 1 hour and 50 minutes after arrival to ED, Patient #1 was seen by a provider for their MSE. Patient's condition was listed as critical with diagnosis of dissecting ascending aortic aneurysm (tear occurs in the body's main artery). At 2:36 pm, the provider ordered imaging, a computed tomography angiography (CTA) of the abdomen and pelvis. Reason for exam listed hypotension and abdominal pain into the back, rule out dissection.

At 3:04 pm, CTA was completed with findings of a dissecting aneurysm extending from the thoracic aorta and both common iliac arteries.

At 3:28 pm, Patient #1 required intubation (medical procedure to keep airway open) due to respiratory failure after developing hemoptysis (coughing up blood) and needing airway protection.

At 3:40 pm, the provider ordered to transfer Patient #1 to a higher level of care facility for vascular surgery evaluation.

At 4:00 pm, Patient #1's was transferred.

-- Per interview of Staff B, ED, RN, on 9/18/2024 at 10:45 am, they remembered caring for Patient #1 in the ED. Staff B stated Patient #1 waited in the waiting room longer than desired before being seen by the triage RN. Staff B stated Patient #1 was very pale, hypotensive (low BP), and complaining of extreme pain 10 out of 10 upon coming from the waiting room into the main ED. Staff B indicated Patient #1 was slowly given intravenous (IV) fluids to help support their BP but went into flash pulmonary edema (fluid builds up in the lungs) and needed to be intubated. Staff B indicated a provider was in with Patient #1 ordering testing to rule out a dissection soon after being brought to a room in the main ED. Patient #1 had a CTA and then was transferred to a different facility due to the dissection.

-- Per interview of Staff F, ED, Provider, on 9/18/2024 at 4:00 pm, Patient #1 looked very ill when they walked back in to the main ED. Staff F recalled having immediate concerns for Patient #1 having a dissected aneurysm. Staff F indicated Patient #1 was hypotensive, began complaining of shortness of breath, and developed flash pulmonary edema requiring intubation. Staff F reached out to another facility's vascular department and then started the transfer process. Staff F indicated the ED walk in process has loopholes resulting in patients being able to blend into the crowd in the waiting room, without any staff seeing how sick they really are.

-- Per interview of Staff I, EDA, on 9/19/2024 at 11:45 am, the quick registration along with getting a patient's VS takes 10 - 20 minutes depending on the patient's needs. Staff I indicated being 10 papers deep when the walk-in area has multiple patients waiting to be registered before being triaged by the RN. Staff I remembered Patient #1 presenting to the ED with complaint of abdominal pain and instructing them to fill out the presentation form. Staff I indicated Patient #1's appearance at time of walking into the ED did not raise any flags for concern. Staff I recalled Patient #1 waiting about 1 hour to have VS done and be quick registered. At that time, the patient's BP that was an immediate red flag.

-- Per interview of Staff J, Vice President (VP) of Medical Affairs and Chief Medical Officer (CMO), on 9/27/2024 at 11:30 am, leadership is monitoring the ED wait time and identified it was too long. Staff J indicated hypotensive patients should be seen within minutes of walking into the ED.

Findings specific to Patient #3:

-- Review of Patient #3's medical record revealed, Patient #3 presented to the ED on 8/13/2024 at 10:50 am with chief complaint of chest pain.

At 11:30 am, Patient #3 began the registration process with the EDA. Patient #3's VS were BP 170/99, P 74, R 18, and T 97.8.

At 11:44 am, Patient #3 had an EKG completed by the EDA.

At 11:46 am, Patient #3 was triaged by RN noting the presenting complaint of "chest pressure starting last eveing while at rest ... intermittent pressure since." Patient #3 was assigned an ESI score of 2.

At 12:11 pm, 1 hours and 21 minutes after arrival to ED, Patient #3 was seen by provider for their MSE.

At 3:54 pm, Patient #3 was transferred to another facilty with a discharge diagnosis of non-ST-elevation myocardial infarction (NSTEMI) (type of heart attack).

-- Per interview of Staff J, VP of Medical Affairs and CMO, on 9/27/2024 at 11:30 am, they acknowledged the above findings.

Based on medical record review, document review and interview, in 1 of 4 (Patient #4) medical records reviewed of patients who were transferred to a higher level of care, 1 lacked documentation of the benefits and risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer.

Findings include:

-- Per review of Patient #4's medical record, they presented to the emergency department (ED) on 5/31/2024 at 11:05 am with a chief complaint of dizzy spells. The provider determined Patient #4 needed to be transferred to a higher level of care for a transischemic attack (TIA- a temporary blockage of blood flow to the brain) and a carotid aneurysm (a bulge in one of the arteries supplying blood to the brain and nearby structures).

The transfer form titled "Interfacility Transfer," dated 10/2022, under the section titled "Risks" contained a generic statement of "MVA [motor vehicle accident] and decompensation enroute". The section titled "Benefits" contained a generic statement of "vascular".

The provider did not document the specific risks and benefits of transfer that related to this patient's condition.

-- Review of the facility's policy and procedure titled "Transfers," dated 2/25/2022, indicated (in part) "any EMTALA [Emergency Medical Treatment and Active Labor Act] Transfer will meet the requirements of an appropriate transfer including the patient or other appropriate parties' consent to the transfer and the qualified medical profession (QMP) certification of the risks and benefits of the transfer ... "

-- Per interview of Staff J, Vice President (VP) of Medical Affairs and Chief Medical Officer (CMO), on 9/27/2024 at 11:35 am, it can be difficult to get the physicians to document properly. There is a mandatory physician education packet that includes documenting the specific risks and benefits. Staff J acknowledged these findings.