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Based on interview and record review, the facility failed to provide an appropriate Medical Screening Exam (MSE, the process required to within reasonable clinical confidence whether an emergency medical condition exist) for two of 20 sampled patients (Patients 1 and 20) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), when the MSE was delayed for approximately one (1) hour, after it was determined that Patient 1 and 20 required immediate aggressive interventions.

This deficient practice resulted in a delay in treatment for Patient 1 and Patient 20 and resulted in Patient 1's death.

Findings:

1. During a review of Patient 1's "Patient Care Timeline," dated 5/24/2023, the Timeline indicated the following:

At 7:10 p.m., Patient 1 arrived to the Emergency Department (ED).

At 7: 11 p.m., The registered nurse (RN 1) checked Patient 1 into the ED for diarrhea and weakness and assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...).

At 7:27 p.m., Patient 1 was triaged (a process to determine order in which patients will be provided a medical screening examination by a physician ...) by RN 2. History of present illness: Patient 1 complained of diarrhea, dizziness for three (3) days, generalized weakness ...Associated symptoms: Patient 1 complained of shortness of breath, appears pale. RN 2 assigned Patient 1 an ESI level of 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...).

At 7:29 p.m., Patient 1's Vital signs were taken. Respiratory rate (RR) was 22 (high, Normal is between 12 to 16), oxygen saturation (percentage of oxygen in the blood) was 85 % (low, normal is between 95 to 100 %), Blood Pressure (BP) was 88/43 (low, normal is 120/80), heart rate (HR) was 46 (low, normal is between 60 to 100), and pain was 5/10 (0 means no pain, 10 means worse pain), the location of the pain was not documented.

At 7:33 p.m., RN 2 placed Patient 1 on oxygen via nasal cannula, oxygen saturation was 94 %. RN 2 re-assigned Patient 1 an ESI Level 2.

At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions).

At 7:40 p.m., an electrocardiogram (EKG, a recording of the heart ' s electrical activity) was done and given to the Physician (MD 1), per RN 4 ' s note.

At 7:57 p.m., Charge nurse (CN) 1 documented that Patient 1 was awake, alert, and oriented ...expressed marked relief of shortness of breath with oxygen, in NAD (no apparent distress). Patient 1 will be roomed as soon as bed available. Otherwise, Patient 1 is on oxygen and IV (intravenous- vein access) started with labs (laboratory tests) drawn. EKG done. Patient 1 withing eyesight of triage.

At 8:33 p.m., Patient 1 was roomed (placed in a ED room).

At 8:35 p.m., Physician (MD 2) was assigned to Patient 1

At 8:39 p.m., "ED Provider (MD 2) Started."

At 8:41 p.m., MD 2 placed orders for a chest x-ray, atropine (treat heart rhythm problems) ...

At 9:03 p.m., "ED Notes," by RN 5 indicated the following: Received Patient 1 from Bed K, MD 2 at bedside, Patient 1 placed on cardiac pacer (a small device that prevents the heart from beating too slowly) ...responsive, awake, alert, + weakness, continue on cardiac and pulse monitoring ...hypotensive 78/38 (low blood pressure), MAP (mean arterial pressure, pressure within the arteries) is 43 (low, below 60 indicates not enough pressure to perfuse vital organs, normal is between 70 and 100) ... at 9:16 p.m., BP noted 72/38, Patient 1 remains calm, awake, oriented, denied any discomfort ...MD 2 at bedside for close monitoring. At 9:40 p.m., Patient 1 started vomiting ...MD 2 aware ...

At 9:19 p.m., Troponin (collected on 5/24/2024 at 7:59 p.m.) final result at 9:19 p.m., was 16,986 (high, may indicate heart attack), Critical Result called to MD 1.

At 9:38 p.m., Dopamine (helps support blood pressure) was given.

At 9:48 p.m., Magnesium Sulfate (treats abnormal heart rhythms) ordered by MD 2.

At 9:48 p.m., "ED Notes, Addendum," indicated: At 9:46 p.m., Patient 1 is gagging, becoming altered ...At 9:48 p.m., Code (Code Blue, an adult is having a medical emergency, usually cardiac or respiratory arrest) started. MD 2 witnessed cardiac rhythm of Vfib (Ventricular fibrillation, a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), Heart Rate (HR) 241 (high, normal is 60 to 100). Patient woke up after defib (the delivery of electrical shocks across the chest), opens eyes, started gagging, vomited ...Given Zofran (ondansetron, treats nausea and vomiting) ... Magnesium ...started. At 9:49 p.m., HR is 232 (high) ...MD 2 remained at bedside. Patient 1 is becoming more confused, gagging, became unresponsive. MD 2 ordered defib ... HR is 163 ...BP is 129/87 (high), MAP is 93 (high) ...Dopamine discontinued. At 9:52 p.m., started Amiodarone (treats heart rhythm problems) ... Patient 1 becoming altered ...defib given ...

At 9:54 p.m., "Code Documentation, Addendum," At 9:54 p.m., 3rd and 4th defib ...9:55 p.m., compressions start, Bag valve mask (BVM, airway management technique allows for oxygenation and ventilation of patients), Epi (epinephrine, a medication used to restore cardiac rhythms) given ...At 9:59 p.m., no pulse, PEA (a condition where the heart stops because the electrical activity in the heart is too weak to make the heart beat), intubated (a tube is inserted through the mouth or nose, then down into the airway, to allow air to get through) started. Compression continued ...At 10:14 p.m., Death pronounced by MD 2 ...

During a review of Patient 1's "EKG," dated 5/24/2024 at 7:40 p.m., the EKG indicated Sinus tachycardia (regular cardiac rhythm in which the heart beats faster than normal) with complete heart block (or third degree heart block is considered a medical emergency, there is a complete loss of communication from the atria [upper chamber of heart] to the ventricles [lower heart chamber]) ...Abnormal ECC (EKG). There were no initials on the EKG that indicated the EKG resulted were reviewed by a physician or emergency room provider.

During a review of Patient 1's "ED Provider (MD 2) Notes," dated 5/24/2024 at 8:41 p.m., the ED Provider Noted indicated the following: Patient 1 presents with weakness, diarrhea ...Patient 1 ...presenting with complaints of two (2) days of generalized weakness and fatigue with diarrhea x four (4) episodes without melena (dark tarry stool or visible blood) ...Denies fevers ...nausea/vomiting, chest pain ...On presentation EKG showing new complete heart block, patient hypotensive (low blood pressure) and hypoxic (absence of enough oxygen in the tissues to sustain body functions). Delay in evaluation secondary to bed availability, Patient 1 placed on nasal cannula (a device used to deliver supplemental oxygen) and labs ordered by nursing triage prior to patient being roomed ... Physical Exam: Vitals: BP: 88/43 (low), pulse: 46 (low), oxygen saturation: 85 % (low) ...Patient pale, clammy ...bradycardic (low heart rate or pulse) ... Assessment: 1. AV (Atrio-Ventricular- the heart ' s upper and lower chambers) Block, Complete. 2. Acute Respiratory Failure (an inability to maintain adequate oxygenation for tissues) ... 4. Ventricular Tachycardia (when the lower chambers of the heart, beat very quickly) sustained ...5. Cardiac Arrest (sudden, unexpected loss of heart function, breathing, and consciousness) due to unspecified cause 6. Acute Non-ST Elevation Myocardial Infarction (NSTEMI, a type of heart attack that usually happens when the heart ' s need for oxygen cannot be met, it does not have an easily identifiable electrical pattern, like other heart attacks) ...

Re-assess at 9:19 p.m., Cardiology on call contacted ...Patient 1 with pacemaker capturing and BP not improving, recommend patient be placed on dopamine ...Patient started to have nausea ... Patient then found to go into Vtach (Ventricular Tachycardia), Dopamine stopped. Patient 1 given Magnesium ...Patient 1 awake, alert, continued to deny chest pain, troponin 16,986. Heparin drip with bolus ordered but not started before patient altered mental status with loss of consciousness in between patient neuro infarct. After 2nd episode decision to intubate patient for airway protection ... while preparing to intubate patient lost pulses, ACLS protocol started ...Multiple rounds of epinephrine given without ROSC (Return of Spontaneous Circulation, restart of a sustained heart rhythm) ...Time of death called at 10:14 p.m.

During a review of Patient 1's "Progress Note," dated 5/24/2024 at 9:42 p.m., by a Cardiac Physician (MD 3), the Progress Note indicated the following: "I (MD 3) was called with report that pt (Patient 1) is hypotensive and bradycardic with CHB (complete heart block) and he is hypoxic ...In terms of acute cardiac treatment, would support BP (blood pressure) and HR (heart rate) with pressors (medications that raise blood pressure and increase cardiac output) ...Heparin ...recommended for NSEMTI ...His (Patient 1) shock (the body ' s response to a sudden drop in blood pressure) certainly could be MI (myocardial infarction, heart attack, blockage of blood flow to the heart) related and I did recommend transfer to an outside hospital ' s cath lab (catheterization laboratory, where test and procedures can be carried out) tonight emergently if this the primary etiology thought to be occurring ...

During a concurrent interview and record review, on 5/14/2024 at 10:35 a.m., with Assistant Clinical Directors (ACD) 2 & 3, ACD 3 reviewed Patient 1 ' s Triage notes and Medical Screening Exam dated 5/24/2023 and stated the following: Patient 1 walked into the ED on 5/24/2024 at 7:11 p.m., for diarrhea and weakness. At 7:11 p.m., the Intake or Check-In Nurse (RN 1) assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Registered Nurse (RN) 2 triaged Patient 1. Patient 1 ' s blood pressure was 88/43 (low, normal is 120/80), heart rate was 46 (low, normal is 60 - 100), oxygen saturation (percentage of oxygen in the blood) was 85 %, (low, normal is 95 % to 100%)and assigned Patient 1 an ESI Level 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). An EKG was performed for Patient 1 at 7:40 p.m. and shown a physician (MD 1). ACD 3 verified that the EKG did not have MD 1 ' s initials, acknowledging that the EKG had been interpreted, nor that MD 1 wrote any progress notes relating to Patient 1. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). ACD 3 stated that Patient 1 should have been placed in a room at 7:37 p.m., for immediate care, if no beds were available the nurse should have created a bed to place Patient 1 at 7:57 p.m., instead, Charge Nurse (CN) administered oxygen to Patient 1 and placed him (Patient 1) in front of the waiting room, within eyesight of triage area. Patient 1 was placed in a room at 8:35 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m. MD 2 started evaluating Patient 1 at 8:41 p.m., approximately an hour after Patient 1 was assigned an ESI Level of 1, at 7:37 p.m. ACD 3 stated Patient 1 should have been assigned a bed and a physician should have been notified to examine Patient 1 at 7:37 p.m., to assess Patient 1 and provide care.

During an interview on 5/15/2024 at 7:42 a.m. with Registered Nurse (RN) 3, RN 3 stated the following: On 5/24/2023 at 7 p.m., he (RN 3) worked in the ED, as the Emergency Flow Coordinator (EFC) which included duties such as "traffic coordinator" for patients who have been triaged. RN 3 has no patient contact, but looks at the computer screen, checks patient ESI levels, vital signs and decides who should be placed in a room. Patient 1 arrived to the ED at 7:10 p.m. for weakness and diarrhea, an ESI Level of 3 was assessed by RN 1 (Intake /Check-In Nurse). At 7:27 p.m., RN 2 (triage nurse) triaged Patient 1, now complaining of shortness of breath and appeared pale. At 7:29 p.m., Patient 1 ' s BP was 88/43 (low), HR was 46 (low), and oxygen saturation was 85 % (low). Pain was 5 of 10, the location was not documented. At 7:37 p.m., He (RN 3) noticed Patient 1 ' s low blood pressure, pulse and oxygen saturation, and changed Patient 1 ' s ESI level of 2 to ESI Level 1 and notified the Charge Nurse (CN 1) and RN 4 of the ESI level change and inform them to find a room for Patient 1. RN 3 stated that in his (RN 3) opinion Patient 1 should have been assigned an ESI Level 1 at 7:29 p.m. RN 3 stated Patient 1 had an EKG done at 7:40 p.m. RN 3 reviewed the nursing "ED Notes," at 7:57 p.m., and stated CN 1 placed Patient 1 on oxygen and placed within view of triage, but could not say where Patient 1 was placed, could only say that Patient 1 was not in a room. Patient 1 was placed in a room at 8:33 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m., and MD 2 started examining Patient 1 at 8:39 p.m. Patient 1 was moved to a bigger room at 8:57 p.m. RN 3 stated that eventually Patient 1 coded and passed away.

During an interview on 5/15/2024 at 2 p.m. with Emergency Room Physician (MD 1), MD 1 stated the following: He (MD 1) worked in the ED on 5/24/2023 and was the two-star (**) physician between 6 p.m. to 8 p.m. that night. The two-star physicians were required to interpret all EKGs and receive critical labs values for those 2-hours. MD 1 stated he (MD 1) remembers an Emergency Room Assistant (ERA 1) showed him (MD 1) an EKG (for Patient 1) that he (MD 1) interpreted as a Third-degree Heart Block. MD 1 stated he (MD 1) told ERA 1 that Patient 1 needed to be brought to the "back (in a room)" immediately. MD 1 assumed Patient 1 was placed in a room, but he (MD 1) did not follow up with Patient 1.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department Patient Flow," dated 4/2021, the P&P indicated the following: All patients requesting treatment or emergency care to the ED will have a medical screening examination ...to determine if an emergency medical condition exist ....Triage ...a process to determine order in which individuals will be provided a medical screening examination by a physician ...Emergency Severity Index (ESI) - a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent to 5 (least urgent) based on acuity and resource needs ...All patients presenting to the ED will be initially interviewed by the Intake Registered Nurse (RN). The Intake RN will determine via the interview assessment and process, the presenting complaint of each patient and will assign a triage activity following the ESI ....The Level 1 and Level 2 triage activity patients will be immediately escorted to the treatment area by the ED personnel, and the nurse shall immediately notify an ED physician or the RN staff of any patients that present with a life-threatening emergency ...All other patients will be seen by the triage nurse and have a secondary assessment completed ...

Emergency Severity Index (ESI)

Level 1 = Resuscitation conditions - conditions that are threats to life or limb (or imminent deterioration) requiring immediate aggressive interventions.

Level 2 = Emergent conditions - conditions that multiple resources are a potential threat to life, limb or function, requiring rapid medical interventions or delegated task.

Leve 3 = Urgent conditions - conditions that could potentially progress to a serious problem requiring emergency intervention given chief complaint or injury will determine number of resources needed to determine diagnosis ...

Assessment by RN: Initial assessments will be done an RN. This secondary assessment shall include: ...presenting information ...The triage RN shall transport any patients with a life-threatening emergency directly to the ED treatment area and endorse the care of the patient to the assigned RN.

Attachment A: Emergency Severity Index Algorithm:

A - requires immediate life-saving intervention, arrow point to 1 (Level 1). A. Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic (how blood flows through the blood vessels) intervention ...; and/or any of the following clinical conditions: intubated, apneic (when breathing temporarily stops), pulseless (without a pulse), severe respiratory distress, SPO2 (oxygen saturation) less than 90%, acute mental status changes, or unresponsiveness.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 1/08/2023 indicated the following:

Emergency Medical Condition (EMC) - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and / or symptoms of substance abuse, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual ...in serious jeopardy, serious impairment to bodily functions; or serious dysfunction of any bodily organ or part ...

Medical Screening Examination (MSE) - The process required to determine within reasonable clinical confidence whether an emergency medical condition exist. It is an ongoing process, including monitoring of an individual until the individual is either stabilized or transferred. As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE.

Medical Screening Examinations (MSE). All hospitals...will provide an appropriate MSE to any individual who comes to the ED to determine if an EMC exist. A MSE will be provided: ...The scope of the MSE is tailed to the presenting symptoms and medical history of the individual ...The extent of the necessary examination to determine whether an EMC exists is within the judgment and discretion of the physician ...

2. During a review of Patient 20's Emergency Department Note (ED note, patient assessment, diagnoses and interventions completed by ED physician), dated 6/24/2023, the ED note indicated Patient 20 came to the facility ' s ED with complaint of left sided non radiating chest discomfort. MD 6 evaluated Patient 20 ' s EKG and identified Patient 20 had STEMI. MD 6 ordered to transfer Patient 20 to another facility for higher level of care for cardiac catheterization.

During an interview on 5/15/2024 at 10:27 a.m. with the ED Assistant Clinical Director (ACD) 1, ACD 1 stated facility has STEMI protocol in place for patients who come in with chest pain. ACD 1 stated per STEMI protocol, chest pain patients would receive EKG within 10 minutes from door entry. ACD 1 stated the EKG is then interpreted by a 2-star physician (ED physician assigned to perform EKG interpretation) immediately to screen for STEMI. ACD also stated if STEMI is identified, the facility will transfer patient to STEMI center (hospital specialized in handling STEMI patients) for cardiac catheterization.

During a concurrent interview and record review on 5/15/2024 at 10:43 a.m. with ACD 1, Patient 20's "Patient Care Time Line (ED timeline, document shows the assessment and care flow patients received in ED)," from 6/23/2024 to 6/24/2024 was reviewed. The "ED timeline" indicated the following:

At 11:30 p.m. Patient 20 arrived in ED

At 11:32 p.m. Patient 20's chief complaint was blood pressure problem and chest discomfort. Patient 20 was triaged (sorting of and allocation of treatment to patients) with Emergency Severity Index (ESI, ED triage algorithm that sorts patients into 5 groups from level 1 [most urgent] to level 5 [least urgent]) level 2.

At 11:33 p.m. EKG ordered

At 12:07 a.m. EKG completed

At 12:15 a.m. Vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level): Temperature 98 degrees Fahrenheit (F, unit of measure), blood pressure 158/85 millimeter of mercury (mmHg, unit of measure), heart rate 40 beats per minute (bpm, unit of measures), respiration 20 breath per minute, Pain level 3 out of 10 (pain scale from 0 to 10 with 0 means no pain while 10 means most severe pain) at left chest

At 12:39 a.m. MD 6 completed Medical Screening Examination

At 12:58 a.m. Patient 20 was discharged to another facility

ACD 1 stated Patient 20's EKG was not done within 10 to 12 minutes from door entry and there was no interpretation documented by MD 5 which resulted in delay in MSE and STEMI identification.

During a concurrent interview and record review on 5/15/2024 at 11:25 a.m. with ACD 1, Patient 20's ED note, dated 6/24/2023, the ED note indicated MD 6 interpreted EKG at 12:39 a.m. ACD 1 stated Patient 20's EKG should have been read by MD 5 immediately after when EKG was completed at 12:07 a.m. ACD 1 stated delay EKG interpretation could delay care and treatment.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 4/2023, the P&P indicated, "As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE ... All hospitals operated by [the facility] will provide an appropriate MSE to any individual who comes to the ED to determine if an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity requires immediate medical attention) exists.

Based on observation, interview, and record review, the facility failed to post written notice or signage informing patients of their right to receive a medical screening examination, stabilizing treatment and an appropriate transfer, regardless of their ability to pay, in a conspicuous (attracts notice or attention) way in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma).

This deficient practice had the potential for patients in the ED not knowing their rights when they visit the ED seeking treatment for a medical condition, which may negatively impact the patients ' ability to take an active role in their treatment plan.

Findings:

During an observation on 5/13/2024 beginning at 1:35 p.m., in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), a sign informing patients of their right to a medical screening, stabilizing treatment ...regardless of their ability to pay, was posted on a wall behind the Check-In window, and behind the nurse who checks patients into the ED. No other signs were observed in the entrance of the ED, ED waiting rooms or ED treatment areas.

Concurrently, during an interview, on 5/13/2024 at 1:46 p.m., the Assistant Administrator for Quality (AAQ) stated there was no signage posted in the waiting room. The sign should be posted in an area where the public can see it (referring to the sign regarding Patient Rights).

During an interview on 5/13/2024 at 1:47 p.m. with Assistant Clinical Director (ACD) 3, ACD 3 stated the sign behind the Check-In window was not accessible to the patients in the waiting room. The sign should be posted in an area that was accessible to the patients, so patients can see and read the notice and be informed of their rights.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 1/08/2023, the P&P indicated the following: Signage: Conspicuous signs will be posted at hospital entrances and in places likely to be noticed by all individuals who entered the Emergency Department (ED) (e.g., parking garage, entrance, admitting area, waiting room, treatment area). Signage will specify the rights of individuals to examination and treatment for emergency medical conditions regardless of the ability to pay, and the rights of women in labor for health care services, and whether the hospital participates in the Medicaid (a government program that provides health insurance for adults and children with limited income and resources) program ...

Based on interview and record review, the facility failed to provide an appropriate Medical Screening Exam (MSE, the process required to within reasonable clinical confidence whether an emergency medical condition exist) for two of 20 sampled patients (Patients 1 and 20) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), when the MSE was delayed for approximately one (1) hour, after it was determined that Patient 1 and 20 required immediate aggressive interventions.

This deficient practice resulted in a delay in treatment for Patient 1 and Patient 20 and resulted in Patient 1's death.

Findings:

1. During a review of Patient 1 ' s "Patient Care Timeline," dated 5/24/2023, the Timeline indicated the following:

At 7:10 p.m., Patient 1 arrived to the Emergency Department (ED).

At 7: 11 p.m., The registered nurse (RN 1) checked Patient 1 into the ED for diarrhea and weakness and assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...).

At 7:27 p.m., Patient 1 was triaged (a process to determine order in which patients will be provided a medical screening examination by a physician ...) by RN 2. History of present illness: Patient 1 complained of diarrhea, dizziness for three (3) days, generalized weakness ...Associated symptoms: Patient 1 complained of shortness of breath, appears pale. RN 2 assigned Patient 1 an ESI level of 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...).

At 7:29 p.m., Patient 1 ' s Vital signs were taken. Respiratory rate (RR) was 22 (high, Normal is between 12 to 16), oxygen saturation (percentage of oxygen in the blood) was 85 % (low, normal is between 95 to 100 %), Blood Pressure (BP) was 88/43 (low, normal is 120/80), heart rate (HR) was 46 (low, normal is between 60 to 100), and pain was 5/10 (0 means no pain, 10 means worse pain), the location of the pain was not documented.

At 7:33 p.m., RN 2 placed Patient 1 on oxygen via nasal cannula, oxygen saturation was 94 %. RN 2 re-assigned Patient 1 an ESI Level 2.

At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions).

At 7:40 p.m., an electrocardiogram (EKG, a recording of the heart ' s electrical activity) was done and given to the Physician (MD 1), per RN 4 ' s note.

At 7:57 p.m., Charge nurse (CN) 1 documented that Patient 1 was awake, alert, and oriented ...expressed marked relief of shortness of breath with oxygen, in NAD (no apparent distress). Patient 1 will be roomed as soon as bed available. Otherwise, Patient 1 is on oxygen and IV (intravenous- vein access) started with labs (laboratory tests) drawn. EKG done. Patient 1 withing eyesight of triage.

At 8:33 p.m., Patient 1 was roomed (placed in a ED room).

At 8:35 p.m., Physician (MD 2) was assigned to Patient 1

At 8:39 p.m., "ED Provider (MD 2) Started."

At 8:41 p.m., MD 2 placed orders for a chest x-ray, atropine (treat heart rhythm problems) ...

At 9:03 p.m., "ED Notes," by RN 5 indicated the following: Received Patient 1 from Bed K, MD 2 at bedside, Patient 1 placed on cardiac pacer (a small device that prevents the heart from beating too slowly) ...responsive, awake, alert, + weakness, continue on cardiac and pulse monitoring ...hypotensive 78/38 (low blood pressure), MAP (mean arterial pressure, pressure within the arteries) is 43 (low, below 60 indicates not enough pressure to perfuse vital organs, normal is between 70 and 100) ... at 9:16 p.m., BP noted 72/38, Patient 1 remains calm, awake, oriented, denied any discomfort ...MD 2 at bedside for close monitoring. At 9:40 p.m., Patient 1 started vomiting ...MD 2 aware ...

At 9:19 p.m., Troponin (collected on 5/24/2024 at 7:59 p.m.) final result at 9:19 p.m., was 16,986 (high, may indicate heart attack), Critical Result called to MD 1.

At 9:38 p.m., Dopamine (helps support blood pressure) was given.

At 9:48 p.m., Magnesium Sulfate (treats abnormal heart rhythms) ordered by MD 2.

At 9:48 p.m., "ED Notes, Addendum," indicated: At 9:46 p.m., Patient 1 is gagging, becoming altered ...At 9:48 p.m., Code (Code Blue, an adult is having a medical emergency, usually cardiac or respiratory arrest) started. MD 2 witnessed cardiac rhythm of Vfib (Ventricular fibrillation, a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), Heart Rate (HR) 241 (high, normal is 60 to 100). Patient woke up after defib (the delivery of electrical shocks across the chest), opens eyes, started gagging, vomited ...Given Zofran (ondansetron, treats nausea and vomiting) ... Magnesium ...started. At 9:49 p.m., HR is 232 (high) ...MD 2 remained at bedside. Patient 1 is becoming more confused, gagging, became unresponsive. MD 2 ordered defib ... HR is 163 ...BP is 129/87 (high), MAP is 93 (high) ...Dopamine discontinued. At 9:52 p.m., started Amiodarone (treats heart rhythm problems) ... Patient 1 becoming altered ...defib given ...

At 9:54 p.m., "Code Documentation, Addendum," At 9:54 p.m., 3rd and 4th defib ...9:55 p.m., compressions start, Bag valve mask (BVM, airway management technique allows for oxygenation and ventilation of patients), Epi (epinephrine, a medication used to restore cardiac rhythms) given ...At 9:59 p.m., no pulse, PEA (a condition where the heart stops because the electrical activity in the heart is too weak to make the heart beat), intubated (a tube is inserted through the mouth or nose, then down into the airway, to allow air to get through) started. Compression continued ...At 10:14 p.m., Death pronounced by MD 2 ...

During a review of Patient 1 ' s "EKG," dated 5/24/2024 at 7:40 p.m., the EKG indicated Sinus tachycardia (regular cardiac rhythm in which the heart beats faster than normal) with complete heart block (or third degree heart block is considered a medical emergency, there is a complete loss of communication from the atria [upper chamber of heart] to the ventricles [lower heart chamber]) ...Abnormal ECC (EKG). There were no initials on the EKG that indicated the EKG resulted were reviewed by a physician or emergency room provider.

During a review of Patient 1 ' s "ED Provider (MD 2) Notes," dated 5/24/2024 at 8:41 p.m., the ED Provider Noted indicated the following: Patient 1 presents with weakness, diarrhea ...Patient 1 ...presenting with complaints of two (2) days of generalized weakness and fatigue with diarrhea x four (4) episodes without melena (dark tarry stool or visible blood) ...Denies fevers ...nausea/vomiting, chest pain ...On presentation EKG showing new complete heart block, patient hypotensive (low blood pressure) and hypoxic (absence of enough oxygen in the tissues to sustain body functions). Delay in evaluation secondary to bed availability, Patient 1 placed on nasal cannula (a device used to deliver supplemental oxygen) and labs ordered by nursing triage prior to patient being roomed ... Physical Exam: Vitals: BP: 88/43 (low), pulse: 46 (low), oxygen saturation: 85 % (low) ...Patient pale, clammy ...bradycardic (low heart rate or pulse) ... Assessment: 1. AV (Atrio-Ventricular- the heart ' s upper and lower chambers) Block, Complete. 2. Acute Respiratory Failure (an inability to maintain adequate oxygenation for tissues) ... 4. Ventricular Tachycardia (when the lower chambers of the heart, beat very quickly) sustained ...5. Cardiac Arrest (sudden, unexpected loss of heart function, breathing, and consciousness) due to unspecified cause 6. Acute Non-ST Elevation Myocardial Infarction (NSTEMI, a type of heart attack that usually happens when the heart ' s need for oxygen cannot be met, it does not have an easily identifiable electrical pattern, like other heart attacks) ...

Re-assess at 9:19 p.m., Cardiology on call contacted ...Patient 1 with pacemaker capturing and BP not improving, recommend patient be placed on dopamine ...Patient started to have nausea ... Patient then found to go into Vtach (Ventricular Tachycardia), Dopamine stopped. Patient 1 given Magnesium ...Patient 1 awake, alert, continued to deny chest pain, troponin 16,986. Heparin drip with bolus ordered but not started before patient altered mental status with loss of consciousness in between patient neuro infarct. After 2nd episode decision to intubate patient for airway protection ... while preparing to intubate patient lost pulses, ACLS protocol started ...Multiple rounds of epinephrine given without ROSC (Return of Spontaneous Circulation, restart of a sustained heart rhythm) ...Time of death called at 10:14 p.m.

During a review of Patient 1 ' s "Progress Note," dated 5/24/2024 at 9:42 p.m., by a Cardiac Physician (MD 3), the Progress Note indicated the following: "I (MD 3) was called with report that pt (Patient 1) is hypotensive and bradycardic with CHB (complete heart block) and he is hypoxic ...In terms of acute cardiac treatment, would support BP (blood pressure) and HR (heart rate) with pressors (medications that raise blood pressure and increase cardiac output) ...Heparin ...recommended for NSEMTI ...His (Patient 1) shock (the body ' s response to a sudden drop in blood pressure) certainly could be MI (myocardial infarction, heart attack, blockage of blood flow to the heart) related and I did recommend transfer to an outside hospital ' s cath lab (catheterization laboratory, where test and procedures can be carried out) tonight emergently if this the primary etiology thought to be occurring ...

During a concurrent interview and record review, on 5/14/2024 at 10:35 a.m., with Assistant Clinical Directors (ACD) 2 & 3, ACD 3 reviewed Patient 1 ' s Triage notes and Medical Screening Exam dated 5/24/2023 and stated the following: Patient 1 walked into the ED on 5/24/2024 at 7:11 p.m., for diarrhea and weakness. At 7:11 p.m., the Intake or Check-In Nurse (RN 1) assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Registered Nurse (RN) 2 triaged Patient 1. Patient 1 ' s blood pressure was 88/43 (low, normal is 120/80), heart rate was 46 (low, normal is 60 - 100), oxygen saturation (percentage of oxygen in the blood) was 85 %, (low, normal is 95 % to 100%)and assigned Patient 1 an ESI Level 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). An EKG was performed for Patient 1 at 7:40 p.m. and shown a physician (MD 1). ACD 3 verified that the EKG did not have MD 1 ' s initials, acknowledging that the EKG had been interpreted, nor that MD 1 wrote any progress notes relating to Patient 1. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). ACD 3 stated that Patient 1 should have been placed in a room at 7:37 p.m., for immediate care, if no beds were available the nurse should have created a bed to place Patient 1 at 7:57 p.m., instead, Charge Nurse (CN) administered oxygen to Patient 1 and placed him (Patient 1) in front of the waiting room, within eyesight of triage area. Patient 1 was placed in a room at 8:35 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m. MD 2 started evaluating Patient 1 at 8:41 p.m., approximately an hour after Patient 1 was assigned an ESI Level of 1, at 7:37 p.m. ACD 3 stated Patient 1 should have been assigned a bed and a physician should have been notified to examine Patient 1 at 7:37 p.m., to assess Patient 1 and provide care.

During an interview on 5/15/2024 at 7:42 a.m. with Registered Nurse (RN) 3, RN 3 stated the following: On 5/24/2023 at 7 p.m., he (RN 3) worked in the ED, as the Emergency Flow Coordinator (EFC) which included duties such as "traffic coordinator" for patients who have been triaged. RN 3 has no patient contact, but looks at the computer screen, checks patient ESI levels, vital signs and decides who should be placed in a room. Patient 1 arrived to the ED at 7:10 p.m. for weakness and diarrhea, an ESI Level of 3 was assessed by RN 1 (Intake /Check-In Nurse). At 7:27 p.m., RN 2 (triage nurse) triaged Patient 1, now complaining of shortness of breath and appeared pale. At 7:29 p.m., Patient 1 ' s BP was 88/43 (low), HR was 46 (low), and oxygen saturation was 85 % (low). Pain was 5 of 10, the location was not documented. At 7:37 p.m., He (RN 3) noticed Patient 1 ' s low blood pressure, pulse and oxygen saturation, and changed Patient 1 ' s ESI level of 2 to ESI Level 1 and notified the Charge Nurse (CN 1) and RN 4 of the ESI level change and inform them to find a room for Patient 1. RN 3 stated that in his (RN 3) opinion Patient 1 should have been assigned an ESI Level 1 at 7:29 p.m. RN 3 stated Patient 1 had an EKG done at 7:40 p.m. RN 3 reviewed the nursing "ED Notes," at 7:57 p.m., and stated CN 1 placed Patient 1 on oxygen and placed within view of triage, but could not say where Patient 1 was placed, could only say that Patient 1 was not in a room. Patient 1 was placed in a room at 8:33 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m., and MD 2 started examining Patient 1 at 8:39 p.m. Patient 1 was moved to a bigger room at 8:57 p.m. RN 3 stated that eventually Patient 1 coded and passed away.

During an interview on 5/15/2024 at 2 p.m. with Emergency Room Physician (MD 1), MD 1 stated the following: He (MD 1) worked in the ED on 5/24/2023 and was the two-star (**) physician between 6 p.m. to 8 p.m. that night. The two-star physicians were required to interpret all EKGs and receive critical labs values for those 2-hours. MD 1 stated he (MD 1) remembers an Emergency Room Assistant (ERA 1) showed him (MD 1) an EKG (for Patient 1) that he (MD 1) interpreted as a Third-degree Heart Block. MD 1 stated he (MD 1) told ERA 1 that Patient 1 needed to be brought to the "back (in a room)" immediately. MD 1 assumed Patient 1 was placed in a room, but he (MD 1) did not follow up with Patient 1.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Department Patient Flow," dated 4/2021, the P&P indicated the following: All patients requesting treatment or emergency care to the ED will have a medical screening examination ...to determine if an emergency medical condition exist ....Triage ...a process to determine order in which individuals will be provided a medical screening examination by a physician ...Emergency Severity Index (ESI) - a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent to 5 (least urgent) based on acuity and resource needs ...All patients presenting to the ED will be initially interviewed by the Intake Registered Nurse (RN). The Intake RN will determine via the interview assessment and process, the presenting complaint of each patient and will assign a triage activity following the ESI ....The Level 1 and Level 2 triage activity patients will be immediately escorted to the treatment area by the ED personnel, and the nurse shall immediately notify an ED physician or the RN staff of any patients that present with a life-threatening emergency ...All other patients will be seen by the triage nurse and have a secondary assessment completed ...

Emergency Severity Index (ESI)

Level 1 = Resuscitation conditions - conditions that are threats to life or limb (or imminent deterioration) requiring immediate aggressive interventions.

Level 2 = Emergent conditions - conditions that multiple resources are a potential threat to life, limb or function, requiring rapid medical interventions or delegated task.

Leve 3 = Urgent conditions - conditions that could potentially progress to a serious problem requiring emergency intervention given chief complaint or injury will determine number of resources needed to determine diagnosis ...

Assessment by RN: Initial assessments will be done an RN. This secondary assessment shall include: ...presenting information ...The triage RN shall transport any patients with a life-threatening emergency directly to the ED treatment area and endorse the care of the patient to the assigned RN.

Attachment A: Emergency Severity Index Algorithm:

A - requires immediate life-saving intervention, arrow point to 1 (Level 1). A. Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic (how blood flows through the blood vessels) intervention ...; and/or any of the following clinical conditions: intubated, apneic (when breathing temporarily stops), pulseless (without a pulse), severe respiratory distress, SPO2 (oxygen saturation) less than 90%, acute mental status changes, or unresponsiveness.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 1/08/2023 indicated the following:

Emergency Medical Condition (EMC) - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and / or symptoms of substance abuse, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual ...in serious jeopardy, serious impairment to bodily functions; or serious dysfunction of any bodily organ or part ...

Medical Screening Examination (MSE) - The process required to determine within reasonable clinical confidence whether an emergency medical condition exist. It is an ongoing process, including monitoring of an individual until the individual is either stabilized or transferred. As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE.

Medical Screening Examinations (MSE). All hospitals...will provide an appropriate MSE to any individual who comes to the ED to determine if an EMC exist. A MSE will be provided: ...The scope of the MSE is tailed to the presenting symptoms and medical history of the individual ...The extent of the necessary examination to determine whether an EMC exists is within the judgment and discretion of the physician ...

2. During a review of Patient 20 ' s Emergency Department Note (ED note, patient assessment, diagnoses and interventions completed by ED physician), dated 6/24/2023, the ED note indicated Patient 20 came to the facility ' s ED with complaint of left sided non radiating chest discomfort. MD 6 evaluated Patient 20 ' s EKG and identified Patient 20 had STEMI. MD 6 ordered to transfer Patient 20 to another facility for higher level of care for cardiac catheterization.

During an interview on 5/15/2024 at 10:27 a.m. with the ED Assistant Clinical Director (ACD) 1, ACD 1 stated facility has STEMI protocol in place for patients who come in with chest pain. ACD 1 stated per STEMI protocol, chest pain patients would receive EKG within 10 minutes from door entry. ACD 1 stated the EKG is then interpreted by a 2-star physician (ED physician assigned to perform EKG interpretation) immediately to screen for STEMI. ACD also stated if STEMI is identified, the facility will transfer patient to STEMI center (hospital specialized in handling STEMI patients) for cardiac catheterization.

During a concurrent interview and record review on 5/15/2024 at 10:43 a.m. with ACD 1, Patient 20 ' s "Patient Care Time Line (ED timeline, document shows the assessment and care flow patients received in ED)," from 6/23/2024 to 6/24/2024 was reviewed. The "ED timeline" indicated the following:

At 11:30 p.m. Patient 20 arrived in ED

At 11:32 p.m. Patient 20 ' s chief complaint was blood pressure problem and chest discomfort. Patient 20 was triaged (sorting of and allocation of treatment to patients) with Emergency Severity Index (ESI, ED triage algorithm that sorts patients into 5 groups from level 1 [most urgent] to level 5 [least urgent]) level 2.

At 11:33 p.m. EKG ordered

At 12:07 a.m. EKG completed

At 12:15 a.m. Vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level): Temperature 98 degrees Fahrenheit (F, unit of measure), blood pressure 158/85 millimeter of mercury (mmHg, unit of measure), heart rate 40 beats per minute (bpm, unit of measures), respiration 20 breath per minute, Pain level 3 out of 10 (pain scale from 0 to 10 with 0 means no pain while 10 means most severe pain) at left chest

At 12:39 a.m. MD 6 completed Medical Screening Examination

At 12:58 a.m. Patient 20 was discharged to another facility

ACD 1 stated Patient 20 ' s EKG was not done within 10 to 12 minutes from door entry and there was no interpretation documented by MD 5 which resulted in delay in MSE and STEMI identification.

During a concurrent interview and record review on 5/15/2024 at 11:25 a.m. with ACD 1, Patient 20 ' s ED note, dated 6/24/2023, the ED note indicated MD 6 interpreted EKG at 12:39 a.m. ACD 1 stated Patient 20 ' s EKG should have been read by MD 5 immediately after when EKG was completed at 12:07 a.m. ACD 1 stated delay EKG interpretation could delay care and treatment.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 4/2023, the P&P indicated, "As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE ... All hospitals operated by [the facility] will provide an appropriate MSE to any individual who comes to the ED to determine if an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity requires immediate medical attention) exists.

Based on interview and record review, the facility failed to provide inter-hospital transfer summary (transfer form, document for transfer with information of reasons for transfer, including risk and benefits of the transfer, and receiving facility information) for one of 20 sampled patients (Patient 15) when Patient 15 was transferred from the facility ' s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) to an acute psychiatric facility (facility which is specialized in treatment patients with mental illnesses).

This deficient practice had the potential to result in physician not evaluating Patient 15 ' s medical condition and indicate the risk and benefits prior transferring Patient 15 to another facility.

Findings:

During a review of Patient 15 ' s "Emergency Provider Notes (ED notes, a formal and complete assessment of the patient and the problem completed by the emergency department physician)," dated 6/20/2023, Patient 15 presented to the facility ' s ED for ingestion of toxic substance. The ED note indicated Patient 15 presented in critical condition with suicidal ideal with immediate/ potential threat at the time of evaluation and had the potential for high morbidity/mortality requiring constant attention.

During a review of Patient 15 ' s "Sign -Out Note (ED physician hand off progress note)," dated 6/20/2023, the sign-out note indicated there was a bed secured at a psychiatric facility, Patient 15 pending transport.

During an interview on 5/14/2024 at 4:03 p.m. with the ED Assistant Clinical Director (ACD) 2, ACD 2 stated physician and nursing staff would complete "Inter-hospital Transfer Summary (transfer form)" for all patients transferring to another facility from ED. ACD 2 stated physician and nursing staff need to complete all 5 sections on the form including:

Section 1: Patient Information

Section 2: Patient Transfer Acknowledgment

Section 3: Physician Certification

Section 4: Accepting Facility and Physician Transfer Information

Section 5: Transfer Assessment

ACD 2 stated the transferring physician would complete "Section 3: Physician Certification" to certify that he or she had examined the patient and determine either the patient was stable or unstable for transfer. ACD 2 stated the transferring physician would also indicate the risks and benefits of transfer in this section.

During an interview on 5/14/2024 at 4:10 p.m. with ACD 2, ACD 2 stated there was no "Interhospital Transfer Summary" form in Patient 15 ' s electronic medical record. ACD 2 stated the transfer form should be kept in Patient 15 ' s electronic medical record. ACD 2 stated there was no other document to show the physician had completed the physician certification for Patient 15.

During a review of the facility ' s policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer," dated 1/2023, the P&P indicated, "It is the policy of [the facility] to comply with the Emergency Medical Treatment and Labor Act (EMTALA) obligations application to hospital with a dedicated emergency department ... Physician Determination to Transfer: after providing a medical examination and treatment withing the capability and capacity of the hospital, the physician may determine that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. The physician must follow the procedures set forth in section Transfer: Obligations of the sending facility ... Transfer: Obligations of the sending facility: the transferring physician will complete the transfer form certifying that:

For unstable patients, the medical benefits of receiving treatment at another facility outweigh the risks to the individual (and, if pregnant, the unborn child) from effecting the transfer, or

For stabilized patients, within reasonable medical probability, the transfer creates no medical hazards to the individual."