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Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 26 Emergency Department (ED) records reviewed from 05/11/23 to 03/11/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements Policy," dated 12/20/23, showed a MSE is provided to each patient who comes to the ED. It is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient.

Review of the hospital's policy titled, "Emergency Trauma Center Patient Triage (process of determining the priority of a patient's treatment based on the severity of their condition)," dated 05/02/23, showed patients are given an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients).

Review of Patient #5's medical record, dated 05/21/23, showed:
- At 3:28 PM, he arrived by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with a chief complaint of chest pain that felt like someone was sitting on his chest, non-radiating and denied any cardiac history.
- His vital signs (VS, measurements of the body's most basic functions) were normal.
- The patient was assigned an ESI of two.
- Patient #5's electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) showed a normal rhythm and troponin (a type of blood test that measures whether or not a person is experiencing a heart attack; baseline result was less than six with a normal of less or equal to 15).
- The patient was placed in the waiting room until a treatment room was available.
- At 6:07 PM, Patient #5 approached the triage desk to report that his chest pain had resolved, he wished to leave and stated that he would follow up with cardiology. He signed a refusal of treatment form before he left the hospital at 6:10 PM.

Review of Patient #5's second medical record, dated 05/21/23, showed:
- At 8:01 PM, he arrived in the ED by private vehicle with a chief complaint of chest pain that had returned from earlier and described it as pain in the center of his chest, non-radiating, with intermittent pressure. The patient stated that he had been in earlier in the day for chest pain and left without being seen (LWBS).
- His VS were normal.
- The patient was assigned an ESI of two.
- The cardiac protocol was followed with an EKG which showed bradycardia (slow heart rate) with a heart rate of 57; new laboratory orders for a troponin baseline, repeat in two hours and six hours; complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). His first troponin result came back as seven.
- The triage note showed the patient was in no acute distress and was placed in the waiting room until a treatment room was available. The patient was instructed to return to the triage desk if his symptoms worsened or changed.
- The patient's second troponin result was seven.
- On 05/22/23 at 6:45 AM, the patient returned to the triage desk complaining of increased chest pain. A repeat EKG was performed and again showed bradycardia with a heart rate of 54. The patient was returned to the waiting room.
- At 6:49 AM, it was documented that a concerned individual informed the triage Registered Nurse (RN) that Patient #5 was leaned over in a wheelchair. The patient was taken to a triage room for reassessment. The RN noted the patient was diaphoretic (excessive, abnormal sweating) and pale. The nurse began to draw new blood work and the patient began dry heaving.
- At 6:53 AM, Patient #5 was quickly taken to a treatment room with a cardiac alert. The ED physician was at the bedside. Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was started and epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was given in preparation for defibrillation (a device that controls the heartbeat by applying an electric current to the chest wall or heart).
- At 7:25 AM, Patient #5 became pulseless and despite continued efforts, the patient was pronounced dead; 11 hours and 24 minutes after he arrived.

Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 26 Emergency Department (ED) records reviewed from 05/11/23 to 03/11/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements Policy," dated 12/20/23, showed a MSE is provided to each patient who comes to the ED. It is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient.

Review of the hospital's policy titled, "Emergency Trauma Center Patient Triage (process of determining the priority of a patient's treatment based on the severity of their condition)," dated 05/02/23, showed patients are given an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients).

Review of Patient #5's Ambulance Report, dated 05/21/23, showed at 3:06 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived at the patient's home. He had a chief complaint of chest pain that started at 3:00 PM and it was described as stabbing. The patient reported that the pain was reduced to chest pressure after he took his own nitroglycerin (medication used to prevent chest pain caused by heart disease) and aspirin (blood thinner that can also treat pain, fever, headache and inflammation). The patient was alert and oriented to person, place, time and situation. His vital signs (VS, measurements of the body's most basic functions: body temperature [degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [the number of times the heart beats within a certain time period, usually a minute] and breathing rate) were within normal limits and his electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was documented as normal sinus rhythm. Additional nitroglycerin was given without any relief. The patient arrived in the ED at 3:24 PM in stable condition and care was transferred to ED staff.

Review of Patient #5's medical record, dated 05/21/23, showed:
- At 3:28 PM he arrived by EMS with a chief complaint of chest pain that felt like someone was sitting on his chest, non-radiating and denied any cardiac history.
- The patient had a past medical history of coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), previous heart attack, high blood pressure, stable angina (chest pain caused by low blood flow to the heart), stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), chronic kidney disease (CKD, ongoing, gradual loss of kidney function), and primary liver cancer.
- His vital signs were normal with a BP of 125/73, heart rate of 82 beats per minute, 18 breaths per minute, a temperature of 98.2 degrees and an oxygen saturation (measure of how much oxygen is in blood) of 97 percent without the use of oxygen.
- The patient was given an ESI of two.
- Patient #5's assessment began immediately with an EKG that showed a normal rhythm, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack; baseline result was less than six with a normal of less or equal to 15). Laboratory tests included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) which were all within normal limits. A chest x-ray (test that creates pictures of the structures inside the body-particularly bones) was performed and showed the lungs and cardiac outlines were unremarkable and without pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart).
- The patient was placed in the waiting room until a treatment room was available.
- At 6:07 PM, Patient #5 approached the triage desk to report that his chest pain had resolved, he wished to leave and stated that he would follow up with cardiology. He signed a refusal of treatment form before he left the hospital at 6:10 PM.

Review of Patient #5's second medical record, dated 05/21/23, showed:
- At 8:01 PM he arrived in the ED by private vehicle with a chief complaint of chest pain that had returned from earlier and described it as pain in the center of his chest, non-radiating, with intermittent pressure. The patient stated that he had been in earlier in the day for chest pain and left without being seen (LWBS).
- His vital signs were normal with a BP of 134/73, heart rate of 60 beats per minute, 16 breaths per minute, a temperature of 98.4 degrees and an oxygen saturation of 97 percent without the use of oxygen.
- The patient was given an ESI of two.
- The cardiac protocol was followed with an EKG which showed bradycardia (slow heart rate) with a heart rate of 57; new laboratory orders for a troponin baseline, repeat at two hours and six hours; CBC, and CMP. His first troponin result came back as seven. His CBC showed no abnormalities. The CMP was within normal limits except for sugar that was slightly high at 128 (normal 74-99).
- The triage note showed that the patient was in no acute distress and was placed in the waiting room until a treatment room was available. The patient was instructed to return to the triage desk if his symptoms worsened or changed.
- The patient's second troponin result was seven.
- On 05/22/23 at 6:45 AM, the patient returned to the triage desk complaining of increased chest pain. A repeat EKG was performed and again showed bradycardia with a heart rate of 54. The patient was returned to the waiting room.
- At 6:49 AM, it was documented that a concerned individual informed the triage Registered Nurse (RN) that Patient #5 was leaned over in a wheelchair. The patient was taken to a triage room for reassessment. The RN noted the patient was diaphoretic (excessive, abnormal sweating) and pale. The nurse began to draw new blood work and the patient began dry heaving.
- At 6:53 AM, Patient #5 was quickly taken to a treatment room with a cardiac alert. The patient continued to vomit. When the nurse and Patient Care Technician (PCT) attempted to move the patient to the stretcher, he became unresponsive. The ED physician was at the bedside. The patient was bradycardic, then had ventricular tachycardia (condition in which the lower chambers of the heart [ventricles] beat very quickly). Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was started and epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was given in preparation for defibrillation (a device that controls the heartbeat by applying an electric current to the chest wall or heart).
- At 7:25 AM, Patient #5 became pulseless and despite continued efforts, the patient was pronounced dead; 11 hours and 24 minutes after he arrived.
- The physician's documentation showed that it was thought the event may have been a result of acute coronary syndrome (ACS, any condition brought on by a sudden reduction or blockage of blood flow to the heart) or a pulmonary embolism (PE, blood clot in the lung), which was less likely.

During an interview on 03/13/24 at 12:30 PM, Staff O, ED Physician, stated that he first saw the patient in the ED room when he ran the code (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing). He added that 10 hours and 48 minutes was too long for any patient to have remained in the waiting room, not just a cardiac patient.

During a telephone interview on 03/13/24 at 1:12 PM, Staff N, ED Physician, stated that she was on her way out when the cardiac alert was paged. She stayed to see if she could help with any procedures and did not recall that she was needed. She stated that 10 hours and 48 minutes was too long for this type of patient to have been in the waiting room.

During an interview on 03/12/24 at 3:40 PM, Staff I, ED Medical Director, stated that patients with symptomatic bradycardia would have been brought back sooner. He stated that he would have expected changes in an EKG or troponin results before a cardiac arrest. The reason those tests were performed was to find trends that indicated changes and to guide triage and prioritization of patients. Staff I added that for a patient that had an ESI of two and chest pain, the wait time was too long.

During a telephone interview on 03/12/24 at 4:15 PM, Staff J, ED RN, stated that she was the primary triage nurse. She stated that a patient with a chief complaint of chest pain immediately received an EKG. Patient #5's EKG was normal, therefore, there was no cardiac alert, and the patient was sent back to the waiting room since a treatment room was unavailable. She stated that Patient #5 had been seen in the ED earlier in the day and LWBS after he signed a refusal of treatment form. She stated that when the patient returned to the desk and complained of increased chest pain, he immediately received a repeat EKG. The physician who read the repeat EKG determined there was no cardiac alert and the patient was to remain in the waiting room.

During a telephone interview on 03/12/24 at 4:25 PM, Staff K, ED RN, stated that she was the secondary triage nurse on the evening of 05/21/23 when Patient #5 came in for chest pain. She stated that she had no interaction with the patient until someone in the waiting room yelled out, "He's having a heart attack!" She stated that the patient had his chin to his chest and looked sick. The patient was noted as diaphoretic. She quickly took the patient back to a triage room. The patient woke a little more and said he was going to throw up. She stated that she paged a cardiac alert and immediately took him back to a room. Once in the room, the patient became unresponsive as he was moved to the bed and CPR was started.

During a telephone interview on 03/13/24 at 8:30 AM, Staff L, PCT, stated that she was in the triage area watching video with security related to an earlier incident. She stated that another patient came up and stated that the patient was slumped over in his chair. The patient was taken to a trauma room after he was seen diaphoretic and pale.

During a telephone interview on 03/13/24 at 8:45 AM, Staff M, PCT, stated that she was responsible for performing a second EKG for the patient for a complaint of increased chest pain. She took the EKG back to the ED physician, who read the EKG and determined there was no cardiac alert and the patient was to remain in the ED waiting room.

Review of the hospital's document titled, "Mercy Safety Event Review," dated, 05/25/23, showed Patient #5 first presented on 05/21/23 with a complaint of chest pain. The patient had received an appropriate triage process with an EKG that was normal and laboratory tests that were within normal limits. Although the patient was encouraged to stay to see a physician, the patient LWBS. The patient returned to the hospital with complaints of chest pain, received a repeated EKG that was unchanged. Nursing staff reported that there were multiple challenges with the troponin blood specimen clotting and was rejected. On 05/22/23 at approximately 6:45 AM while in triage, the patient's condition worsened, and he was taken to an exam room as a cardiac alert. The patient became unresponsive, critical care was initiated but was unsuccessful and the patient was pronounced dead at 7:25 AM. The event was classified as a complication of care. The event category was a cardiac complication. The level of harm was noted as moderate and had reached the patient.

Review of the peer-to-peer review completed on 03/01/24, showed Staff I, ED Medical Director, performed the review of Staff O, ED Physician. He saw no concerns with provider care. Staff I pointed out that the reason for a prolonged arrival to room assignment was delayed since the patient had left earlier in the day and arrived hours later.