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Based on interview and record review, the facility delayed the Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) examination and subsequent treatment for one of 24 patients (Patient [PT] 8) by:
1. failing to accurately triage (assign urgency) PT 8 by obtaining the pulse oximetry (O2 Sat - blood oxygen levels) on room air and neurological status;
2. failing to continuously monitor PT 8's VS prior to the physician's examination; and,
3. failing to continuously assess and monitor PT 8's medical condition, including neurological and respiratory status prior to the physician's examination.

These deficient practices resulted in PT 8's cardiac arrest (abrupt loss of heart function) and death.

On 6/4/2020 an unannounced visit was made to the facility to investigate a complaint regarding an EMTALA violation.

A review of Patient (PT) 8 's nursing emergency department note, dated 6/6/2020, indicated Patient 8 was admitted on 4/8/2020. PT 8 was brought in by nurse from a skilled nursing facility with complaints of desaturation (low blood oxygen levels).

A review of PT 8's nursing emergency department note, dated 6/5/2020, indicated Patient 8 was triaged as Emergency Severity Index (ESI) level-2 (two) on 4/8/2020 at 2:19 p.m. The ESI is a tool used to categorize emergency department (ED) patients. Level 2 indicates the triage nurse has determined that it would be unsafe for the patient to remain in the waiting room for any length of time. Level 2 patients are also very ill and high-risk and need immediate care. There is no documented evidence PT 8's vital signs (VS), including pulse oximetry level on room air was obtained. There is also no documented evidence the triage nurse assessed PT 8 neurological status.

A review of the ESI Triage algorithm indicated, patients who are ESI level-one are those who require hemodynamic intervention, including supplemental oxygen. The patient may also have severe respiratory distress and acute mental status changes. Level-one patients require immediate life-saving intervention.

A review of the nursing emergency department notes, dated 6/5/2020, indicated on 4/8/2020 at 2:19 p.m. during PT 8's triage, PT 8's O2 Sat was 95% on 100% oxygen (supplemental oxygen).

A review of PT 8's hand off report, dated 6/5/2020, indicated the VS for PT 8 were obtained on 4/8/2020 at 2:56 p.m. PT 8's VS were:
Respiratory rate (Normal is 12 to 20 breaths per minute at rest) - 25 breaths per minute
O2 Sat - 95% (normal is 95 - 100% on room air) on 100% oxygen.

A review of the doctors notes, dated 6/5/2020, indicated the emergency department physician (MD 2) performed the examination of PT 8 on 4/8/2020 at 2:57 p.m. MD 2 documented PT 8's room air O2 Sat was "unclear." PT 8 was unresponsive.

A review of the nursing emergency department notes, dated 6/5/2020, indicated on 4/8/2020 at 4:38 p.m., PT 8 appeared to be in respiratory distress (trouble breathing). PT 8 had retractions (rib muscles suck inward; this is a sign of a blocked or narrowing airway) and jugular vein distention (bulging of the neck veins - a sign of heart failure).

A review of the hand off report, dated 6/5/2020, indicated the second documented VS for PT 8 were obtained at 3:39 p.m. PT 8's VS were:
Respiratory rate - 29 breaths per minute
O2 Sat - 84% on 100% oxygen.

A review of the doctors' notes, dated 6/5/2020, indicated on 4/8/2020 at 4:45 p.m., PT 8 was intubated (placing a breathing tube). At 4:52 p.m., patient went into pulseless electrical activity (PEA - no pulse but has presence of electrical activity in the heart). PT 8 also began to have episodes of bradycardia (a heart rate that is too slow). The physician went to the bedside and patient was hypotensive (low blood pressure) and bradycardic. PT 8 then coded (cardiac arrest) again and CPR (cardiopulmonary resuscitation - life saving procedure for cardiac arrest) was initiated. PT 8 was pronounced dead at 6:10 p.m.

On 6/5/2020 at 2:45 p.m., during an interview with the Clinical Supervisor and concurrent review of the PT 8's medical record, the Clinical Supervisor confirmed there was no documented evidence PT 8's respiratory status and VS were communicated to MD 2 (the time between triage and the physician's assessment).

On 6/9/2020 at 10:30 a.m., during an interview with the ED Director on 6/ 9/20, the ED Director could not explain why PT 8's O2 Sat on room air was not obtained during the triaging at 2:19 p.m. The ED Director stated PT 8's O2 Sat should have been provided by the skilled nursing facility; however, the ED Director confirmed there is no documented evidence the SNF provided the O2 Sat on room air. The ED Director confirmed obtaining a O2 Sat on room air is a criterion used with the ESI during triaging. The ED Director could not explain how PT 8 was triaged as level-2 when there is no documented evidence PT 8's O2 Sat on room air was obtained.

A review of the policy, Triage/Assessment of Patients in the Emergency Department, revised June 2019, indicated the definition of triage is: An assessment of a rapid, systemic collection of data related to a patient's chief complaint. Patient priorities are established according to the severity of condition/acuity and anticipated resource needs upon arriving in the Emergency Department. A reliable ESI is central to the sorting of patients based on the severity of their illness/injury. ESI Level 1: Conditions that are immediately life threatening or those that will cause serious permanent physical impairment if not treated immediately. Examples include severe respiratory failure. ED physician on duty is to be notified immediately of all patients who are categorized as ESI level 1 or ESI level 2. Patients categorized as ESI level 1 will be seen first and are to be immediately placed for evaluation and treatment by the emergency department physician.

A review of the policy, Emergency Medical Treatment and Active Labor Act, revised October 2015, indicated a Medical Screening Examination is the process to determine, within reasonable clinical confidence, whether an individual who comes to the emergency department has an emergency medical condition or is in labor. The medical screening is an ongoing process, including monitoring the individual, until the individual is either stabilized or transferred.