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Based on policy review, record review, Fire Rescue Report (EMS -Emergency Medical Services), and interviews, it was determined, the facility failed to ensure that an appropriate medical screening (MSE) examination was provided 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 1 (#1) of 20 sampled patient who presented to the emergency department with signs and symptoms of an elevated temperature of 100.6 (normal temperature range 97.5 to 98.9), and a non -rebreather mask ( a device used to deliver high concentration of oxygen in emergency situations) over her tracheostomy (opening surgically created through neck into windpipe to allow air to fill the lungs). There was an inappropriate delay between Patient #1's arrival (4/22/23 at 5:00 A.M.) to the emergency department. The patient was triaged and vital signs obtained. The patient was not seen again until 7:32 A.M. (2.5 hours later) by a nurse and found to be unresponsive, and in cardiac arrest.

Based on policy review, record review, Fire Rescue Report (EMS -Emergency Medical Services), and interviews, it was determined, the facility failed to ensure that an appropriate medical screening (MSE) examination was provided 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 1 (#1) of 20 sampled patient who presented to the emergency department with signs and symptoms of an elevated temperature of 100.6 (normal temperature range 97.5 to 98.9), and a non -rebreather mask (a device used to deliver high concentration of oxygen in emergency situations) over her tracheostomy (opening surgically created through neck into windpipe to allow air to fill the lungs). There was an inappropriate delay between Patient #1's arrival (4/22/23 at 5:00 A.M.) to the emergency department. The patient was triaged and vital signs obtained. The patient was not seen again until 7:32 A.M. (2.5 hours later) by a nurse and found to be unresponsive, and in cardiac arrest.

The findings included:

Facility policy, titled, "EMTALA Medical Screening Examination and Stabilization", dated 03/31/23 was reviewed. The policy revealed in part, "Policy: An EMTALA obligation is triggered when:
1. an individual or a representative acting on the individual's behalf, including EMS or a transferring hospital, requests emergency services and care ... 3. Extent of the MSE
a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP (Qualified Medical Personnel).
b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer ...
e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms:
i. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures."


Review of Ambulance records, dated 04/22/23, documentation revealed the nursing home facility contacted 911 on 04/22/23 at 4:20 AM, reporting Patient #1 had low oxygen saturation and difficulty breathing. Upon arrival to the nursing home, Patient #1 had oxygen saturation of 87 percent (%) via a non-rebreather mask connected to her tracheostomy. The paramedics were able to raise the oxygen level to 93 percent by administering 15 liters of oxygen and transported the patient to JFK North Hospital [Hospital A]. Vital signs included blood pressure 148/85, heart rate 91, respirations 16 and pulse oximetry 90 percent. The paramedic documented due to the expedited transport, an electrocardiogram was not obtained, and intravenous (IV) access was unsuccessful due to the patient's poor venous access.


Clinical medical record review conducted on 05/16/23 revealed Patient #1 presented to the Emergency Department (ED) on 04/22/23 at 4:51 AM. The patient was brought in by Fire Rescue with chief complaint of low oxygen saturation and difficulty breathing. The record documents Patient #1 was triaged as a Priority 2, "Emergent" at 5 AM.

The nurse documented vital signs at 5:13 AM, temperature 100.6, pulse 86, respirations 18, blood pressure 102/51 and oxygen saturation 96% and noted "called by rehab facility as patient was hypoxic" (body tissues and organs do not receive enough oxygen).

Progress notes dated 04/22/23 revealed the following: At 4:57 AM, "Patient POA (Power of Attorney) called and is refusing that the patient be treated or seen at this hospital and requests that the patient be transferred to facility [name documented / Hospital B] immediately. Secretary is contacting [Name of ambulance service] to arrange transport." The record has no written evidence of the patient's power of attorney, health care surrogate or living will.

At 5:17 AM, vital signs noted in chart and informed MD.

At 7:34 AM, this nurse went into room to check vital signs on patient, patient was found unresponsive, without a pulse, code blue called, and CPR (Cardiopulmonary Resuscitation) initiated.


The Code Blue Record dated 04/22/23 at 7:34 AM documents Patient #1 had pulseless electrical activity, absent respirations and pulse, CPR initiated, ACLS (Advanced cardiovascular Life Support) guidelines followed. Patient #1 expired at 7:49 AM.

Review of the medical record revealed no evidence of further reassessment for Patient #1 until 7:34 AM. Continued review that no medical screening examination, and no diagnostic testing was done prior to the patient being found unresponsive and in full cardiac arrest.


The Physician's Notes dated 04/22/23 at 7:59 AM documented the following: "I was called to bedside by due to patient being unresponsive and pulseless. Unable to obtain any other history from patient due to her medical condition.
Chief Complaint Cardiac arrest in ED.
Focused PE, General unresponsive, Head Atraumatic, Normocephalic, Respiratory/Chest clear bilateral sounds with bagging, Cardiovascular pulseless, Abdomen/GI Atraumatic, Soft, Skin Atraumatic, Neurologic unresponsive, Cardiopulmonary Resuscitation,
Attestations I oversaw / performed CPR, ACLS protocol followed. I was called to bedside due to patient becoming pulseless in the emergency room. Standard ACLS protocol was followed. Patient received several rounds of CPR. She received 1 defibrillation for Ventricular fibrillation, but remainder rhythms were PEA (pulseless electrical activity). After multiple rounds of CPR unable to resuscitate patient and time of death was declared. Family notified."

On 5/17/23 at 8:04 A.M. an interview was conducted with the ED Physician who was on duty When Patient #1 presented to the ED on 4/22/2023. The ED Medical Director was also present during this interview. The ED physician revealed his recollection of Patient #1: It was a busy night, and recalls EMS (Emergency Medical Services / Ambulance) called advising they were bringing in a patient from a nursing home, with complains of weakness. The physician stated he was at the station when the EMS arrived with the patient, he talked to EMS crew, they had very little information, the patient was in a vegetative state, the report given included vital signs, oxygen level and blood sugar, and the values did not raise any red flags. The physician could see the patient on the stretcher, she was breathing and was nonverbal. Then the patient's power of attorney (POA) called the hospital and spoke to the secretary. The POA did not want us [Hospital A] to see the patient, they wanted us to transfer her to [name documented / Hospital B], where they have all of her records. That request put me in a different situation. The physician explained EMS told them they could not transport the patient to facility DMC, so he asked the secretary to call the nursing supervisor and find a way to transfer the patient. The staff were making arrangements for the transfer, and he was told the patient would be picked up at 8 AM. They assigned the patient to a room; he was aware the family refused treatment and withheld the documentation to prevent a bill for the family. Obviously, he was not expecting the patient to expire, he was trying to balance the family satisfaction with their request to transfer and at the same time avoid an unnecessary bill. He states that his shift ended around 7 AM and he later learned the patient had expired. The ED Medical Director, stated the facility would proceed with a medical screening exam, would communicate with the family, and would explain the process for transferring the patient to another facility. In addition, the ED Medical director added the staff would verify the power of attorney in writing.


Interview with Staff D, Unit Secretary, conducted on 05/17/23 at 8:29 AM via phone, revealed she was the secretary on duty on 04/22/23 and she spoke to Patient #1's family member who identified herself as the patient's POA. Staff D recalled the family member was upset, yelling, saying the nursing home knew better, and that the patient was to go to [Name documented / Hospital C], not to [name documented / Hospital A]. Staff D advised her [POA] that she would inform the physician and the nurse of her request. Staff D then gave the information to the triage nurse and the physician and did not speak to the family member again. Staff D continued by saying the physician asked her to call the nursing supervisor and the transfer center. So, she called the transfer center and explained what happened and that the patient's family was requesting a transfer. Staff D updated the physician and about thirty minutes later, the transfer center call back stating the ambulance would pick up the patient at a certain time, she could not remember the exact time and that was the end of her involvement.

Interview with Staff B, Registered Nurse on the 7 AM-7 PM shift on 04/22/23, conducted on 05/17/23 at 8:50 AM, revealed she was the incoming nurse assigned to care for Patient #1. Her shift begins at 7 AM, the night nurse gave her report by saying, the patient came in from a nursing home, she had shortness of breath and dyspnea. The night nurse told her the family wanted nothing to be done for the patient and the doctor did not give any orders, so she did not do anything for the patient. Staff B felt very uncomfortable with the situation and went to the charge nurse, who then started to talk to the night nurse. Staff B then explained she went on to see another patient who had high blood pressure, had had stool, was vomiting, and she medicated that patient, cleaned her up, and then she went in the room to see Patient #1. The nurse tried to talk to the patient, she was nonresponsive, her chest was not rising, and the pulse oximeter was off her finger. She immediately called for backup, and the code blue protocol was initiated.

Interview with Staff A, the Primary Registered Nurse (RN), conducted on 05/17/23 at 12:12 PM via phone, revealed Patient #1 came in via EMS. Staff A stated she received report that the patient was having difficulty breathing and was placed on a T collar for oxygen supplementation. Then Staff C, the triage nurse, came in the room and "told her not to do anything for the patient", that the family was angry, and they didn't want the patient treated here and that the patient was going to be transferred. Staff A explained the patient was hypoxic and had elevated temperature, so she knew they had to complete a sepsis screen and Staff A went to the physician, who told her we are not doing anything 'she is going to be a transfer', and they started the transfer paperwork.
Staff A verified she did not reassess Patient #1 as she was told of the family wishes, her shift ended at 7 AM, before the patient coded and recalls giving report to the incoming nurse and documenting everything that she had told the surveyor. Staff A stated she did not speak to the patient's family member regarding the request to withhold assessment and treatment.

Interview with Staff C, the Triage Nurse, conducted on 05/17/23 at 12:21 PM via phone, revealed her recollection of Patient #1: she was up front when the patient arrived. Staff C received the patient, with fire rescue, and subsequently accompanied EMS and the patient to the room. Staff C recalled talking to the physician regarding the patient's oxygen level, which was 94% and then went back up front to triage area. Staff C stated she did not talk to the family members but received the information from the secretary. After inquiry, the nurse verified she went in the room and spoke to the primary nurse (Staff A) and told her the family member wanted the patient moved to another hospital, and the secretary was talking to the family member.

The facility failed to ensure that their Policy was followed as evidenced by failing to ensure that on 4/22/23 Patient #1 received an appropriate MSE (prior to being found in full cardiac arrest) related to her presenting signs and symptoms within the capability and capacity of the hospital to determine whether or not an EMC existed. The facility's policy stated the patient will be continuously monitored according to the individual's needs, MSE included a brief history, and physical examination, ancillary studies, clinical laboratory tests, and other diagnostic procedures.