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Based on interview and record review, the facility failed to ensure a timely medical screening examination and prevent a delay in treatment for sampled Emergency Department (ED) Patient # 1.The facility failed to :

I. Appropriately place Patient # 1, who arrived by ambulance, prior to triage. Patient # 1 was placed in in the waiting room lobby with unstable vital signs and in a deteriorating condition.

II. Ensure timely triage and medical screening of Patient # 1. Facility discussed and obtained insurance and financial information, as well as a signed acknowledgement of patient financial responsibility prior to triage and medical screening.

lll. Assign a triage acuity level to Patient # 1 to prioritize his care and treatment.

Patient # 1 expired in the facility ED on 12-26-13 at 11:26 p.m., following unsuccessful resuscitation efforts.

Findings include:

TX 000222787

I. Placement in the Waiting Area/Lobby:

Record review on 09-08-15 of the " EMS Patient Care Report" (ambulance run sheet), dated 12-26-13, revealed Patient # 1 was a 32 year old male transported from home to hospital via ambulance. The EMS report documented arrival time of 8:45 p.m. [the hospital records document ambulance arrival at 8:41 p.m.]

Further review of the EMS report read: "...32 year old complaining of swelling in the throat. Pt stated he has been sick for 4 days. The swelling got a lot worse today. Pt stated he went to a clinic earlier today and the swelling has increased since then...pt was transferred over to ER Staff...

Vital signs recorded on the EMS Run Sheet by the Emergency Medical Technician (EMT ) on arrival to facility ( 8:51 p.m.) : "...Pulse 160; body temperature 103 degrees Fahrenheit (F)..." The space allotted for signature of "Hospital Receiving Agent "was signed by Registered Nurse (RN) # 6.

Interview RN # 6

Interview with RN # 6 on 09-09-15 at 1:35 p.m. , he stated "Patient # 1 came by ambulance; walking and talking and in no distress. RN # 6 said he received report from EMS and advised them to place the patient in the waiting room lobby. "He was stable and I called him back to triage as soon as I could."

RN # 6 reviewed the EMS Run sheet for Patient # 1 and acknowledged it was his signature as "Hospital Receiving Agent." RN # 6 said a heart rate of 160 and a body temperature of 103 F were not considered stable vital signs. RN # 6 said "we don't actually sign the EMS report; we sign a small hand-held computer device." RN # 6 said he was certain EMS would have given him a verbal report. He went on to say a patient with a heart rate of 160 would have been taken immediately to a treatment room and not been placed in the lobby.

RN # 6 said he was the Triage Nurse the day Patient # 1 came in ( 12-26-13).Record review of "Clinical Notes-Nurses,"dated 12-26-13, read :" Triage time 21:07 (9:07 p.m.) " by RN # 6. This was 26 minutes after Patient # 1's documented arrival to hospital. RN # 6 said although he documented the triage time as 9:07 p.m.; "he was sure he began his care sooner." RN # 6 said that "during my triage assessment, Patient # 1 began acting differently ; like he had delirium." RN # 6 said he called for help, got a wheelchair and the patient was taken to Trauma Room # 1.

Interview on 09-09-15 at 1:00 p.m. with RN # 5, she was the ED RN who provided care for Patient # 1 on 12-26-13. She stated the care and treatment of Patient # 1 had been reviewed by the ED Manager and staff following Patient # 1's death. RN # 5 said the only change the hospital made was that patients who arrive by ambulance now go straight to triage and not to the waiting room lobby.

Review of Witness Statement, undated, provided by companion of Patient # 1, [she accompanied him to the ED ], read:"...(Patient #1) walked off the ambulance into the ER. The ER was empty except for us..The paramedics told (Patient #1 to sit in a chair in the triage section of the ER, then a paramedic took his vital signs...The paramedics asked one of the nurses where to put (Patient #1) an the nurse told him to take him to the waiting room..."

II. Discussion/Acknowledgement of Financial Responsibilities Prior to Triage & Medical Screening:

Interview on 09-09-15 at 4:10 p.m. with Chief Executive Officer (CEO) # 1 she stated the registration process for walk-in or ambulance: the nurse gets report; the triage nurse makes decision to lobby or to treatment room to register. Financial information is discussed and obtained only after the medical screen. Financial information is not discussed before the medical screen is performed.

Review of the clinical record of Patient # 1 revealed the following timeframes:

12-26-13:

Arrived at hospital by ambulance: 8:41 p.m.

Financial acknowledgement paperwork signed: 8:55 p.m.(prior to triage & medical screen)

Triaged by nursing: 9:07 p.m. (26 minutes after arrival)

Seen by physician 9:23 p.m. (42 minutes after arrival)

Telephone interview on 09-21-15 at 5:15 p.m. with the companion of Patient # 1 , she stated she was with him upon arrival to the ED on 12-26-13. She went on to say after Patient # 1 was placed in the waiting area, a registration clerk came and asked them to complete several papers. " They asked for insurance and at the time Patient # 1 did not have any. The clerk asked for $300. to cover the examination fee. We did not have that much so I was going to have to make arrangements to make payments. I didn't do this because they came with a wheelchair to get Patient # 1. The clerk made it seem we were expected to pay $300. that day."

Continued interview with companion of Patient # 1 she stated she was listed as his"next of kin" and signed all the pre-registration papers at the same time. She said there were several papers she had to initial and sign. Patient # 1 was sitting next to her the entire time she signed the papers. She said "Patient # 1 was unable to sign the papers as he continued to get worse; he had trouble swallowing and breathing. He was shaking and he couldn't talk."

Record review of clinical record of Patient # 1 revealed the following forms were signed or initialed by Patient # 1's companion on his behalf prior to the patient's triage and medical screen:

I."Emergency Medical Statement;"[ form details that patient will receive a medical exam. If it is determined to be non-emergency condition, $300. was required before further medical care is rendered.]:signed 12-26-13 at 8:55 p.m.

II. "Acknowledgement of Responsibility": patient agrees to pay $50. monthly until the Emergency Room & Hospital balances paid in full."

III. Notice of Privacy Practices

IV. Conditions of Admissions

V. Patient Rights & Responsibilities

Review of facility policy titled" Financial Collections for Emergency Department, " review date 2005, read: " ...II. Policy: the hospital should not delay in providing a medical screening examination or necessary stabilizing treatment by inquiring about an individual's ability to pay for care.....Emergency Medical Condition:... a condition in which there is potential for further deterioration if not treated in the foreseeable future... VI. Process Standards...2. A Medical Screening Examination for an ED patient may not be delayed un order to inquire about an individual's ability to pay; inform the patient that he or she must pay for his/her care of they choose to be treated..." "

III. No Assigned Acuity Level: Patient # 1

Further review of "Clinical Notes-Nurses," dated 12-26-13 for Patient # 1 failed to reveal a documented patient acuity level.

Interview with RN # 6 on 09-09-15 at 1:35 p.m. , he stated as the triage nurse, it was his responsibility to assign an acuity level on every patient. He was unable to locate a documented acuity level documented on Patient # 1 on 12-26-13. RN # 6 said she should have documented an acuity level on this patient.

Further review of "Clinical Notes-Nurses, "dated 12-26-13 (9:15 p.m.) read: " Amoxicillin 875-125 mg tablet 2 times daily; last dose was 7:30 -8 p.m. ( today)...recently seen at another facility in office..patient has had fever with chills and sweating ( for 2 days intermittently)...patient has severe sore throat...associated with pain upon swallowing and difficultly swallowing. Patient has moderate hoarseness...swelling if the jaw...severe swelling of the right and left face..."

Review of facility policy titled "Patient Triage and Assessment," review date 12/2007, read: " ...II. Process Standards:...A. Each person presenting to the ED will be triaged within (30) minutes of arrival...B. Each person presenting to the Department will be assessed by an ED RN for classification based on severity of presenting symptoms... C. The following General Classifications are Used in Prioritizing Patients for Medical Screening and Treatment : 1. Emergent: Life Threatening: 1st Priority...2. Urgent, 2nd Priority; ...and..3. Non-Urgent, 3rd priority..."

Emergent is defined in the policy as "A condition requiring immediate medical attention where a delay would be harmful to the patient..."

Interview on 09-08-15 at 11: 15 a.m. with ED Supervisor #3 she stated all ED patients were assigned an acuity level by the Triage Nurse. This acuity level determined the priority and urgency of the medical screening examination.

Telephone interview on 09-21-15 at 5:15 p.m. with the companion of Patient # 1 , she stated she informed the ED nurses and the ED doctor Patient # 1 had taken a dose of Amoxicillin shortly before coming to the ED.

Interview with ED Physician # 8 :

Telephone interview on 09-09-15 at 12:20 p.m. with ED Physician # 8 he stated he remembered Patient # 1 and had reviewed his ED record prior to this interview. He said he was the physician who managed this patient's care on 12-26-13 in the ED. Physician # 8 went on to say the patient presented with 105 degree temperature and initially a very rapid heart rate, which was slowed down by calcium channel blockers. He came to us critically ill.

Physician #8 said " Patient # 1 was very swollen and had a compromised airway. The patient arrested and we had trouble ventilating him. I called anesthesia; we had to trach him. The patient arrested and did not survive."

Physician # 8 said they did everything that could have been done for this patient . He went on to say "this was a very tragic case because Patient # 1 was so young. He came in with advanced sepsis and the mortality rate for this is very high."

Physician # 8 was asked if the case had been peer reviewed. He stated he was sure someone had reviewed it but he had not heard about it. Physician # 8 also said he was not aware of any Autopsy Results for Patient # 1.

Record Review of Patient # 1's Autopsy Report, dated 01-29-14, revealed the autopsy was performed by Assistant Medical Examiner # 13 with the Harris Country Institute of Forensic Sciences on 12-27-13.

"Cause of Death: Anaphylaxis complicating antibiotic therapy for acute pharyngitis"