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Based on interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to complete a medical screening examination in a timely manner for two patients (#1, #3) out of a total of 30 sampled patients reviewed for medical screenings and treatments, resulting in the potential for less than optimal outcomes for 65 patients seeking emergent care at the time of survey. Findings include:

1. The failure to complete a medical screening examination in a timely manner. (See tag A-2406)

Based on interview and record review, the facility failed to ensure a medical screening examination was performed in a timely manner to determine if an emergency medical condition existed for two (#1, #3) out of a total sample of 30 patients resulting in the potential for delay in care and treatment for patient #1 and #3. Findings include:

Record review on 5/24/2022 at 1230, with the Emergency Department (ED) Registered Nurse (Staff J), revealed the patient #1 was 49-year-old female who presented to the ED on 12/5/2021 at 1521 for complaints of bilateral lower leg swelling per nursing triage notes. The patient was coded a "3" on a Emergency Severity Index (ESI) scale, (A five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs).

The patient's vital signs during triage were as follows:
Blood Pressure (B/P) 176/80 Heart Rate (H/R) 80, Respiration (R) 16 on 12/5/2021 at 1521.

Further review of the patient's vital signs per nursing documented the patient's vitals were assessed on the following dates and times.

On 12/5/2021 at 2323, B/P 127/81 HR 75 R 18.
On 12/6/2021 at 0300, B/P 112/91 HR 76 R 16.
On 12/6/2021 at 0820, B/P 161/110 HR 75 R 20.

On 12/6/2021 at 1154 the patient (#1) reported pain at "6" (Scale 0-10) for bilateral lower leg pain. Additionally, nursing staff documented the patient remained in the lobby on 12/6/2021 at 1157 with a complaint of pain, (approximately 20 hours) after arrival to the ED. There was no further evidence in the medical record that documented the patient was being assessed at any other times for her initial complaint of lower leg swelling.

Further record review revealed a medical screening examination was not performed until 12/6/2021 at 1407 (23 hours and 14 minutes after triage). There was no evidence in the medical record that documented the reason for the delay in determining if an emergency medical condition existed for the patient (#1).

Per review of the Resident physician provider note dated 12/6/2021 at 1407, documented the following:
Chief Complaint(s): "My legs are swollen"
History of Present Illness: "This patient comes to the ED presenting with lower extremity swelling pain. She states for the last 2 days that her legs and feet have been swollen. She states it does not happen before. Patient denies history of blood clots. She denies chest pain, shortness of breath. She denies recent surgery, history of cancer or recent travel."

Medical Decision Making: "Of note, this patient was in the lobby for 20 hours prior to her being seen by provider...Patient potentially have a DVT, I do not think that this is heart failure, this also could potentially be dependent edema...I did give the patient 10 mg of Norco for pain orally. We did try to reevaluate her and try to get her to walk again, patient still insist that she is unable to walk, given this we will be getting her lab work and do a cardiac work-up and reevaluating the patient."

Further record review revealed patient #1 was admitted to the facility, diagnosed with bilateral lower extremity deep vein thromboses, and acute kidney injury requiring hemodialysis during hospitalization and post hospitalization.

A phone interview was conducted with the Attending medical doctor Staff M on 5/25/2022 at 1330. He confirmed he saw the patient on 12/6/2021 at 1509 as dated on his "Emergency Department Visit" note. He confirmed he examined the patient as noted. When asked to explain the reason for the delay in performing the medical screening, he replied, "I think all patients should be seen as soon as possible." However, that was not done.

Based on interview and record review, the facility failed to ensure an Electrocardiogram (ECG/EKG) for patient #3 was given to the Emergency Department (ED) medical doctor for review in a timely manner, resulting in the potential for delay in care and treatment for patient #3. Findings include:

On 5/24/2022 at 1500, review of the medical record for patient #3 revealed the patient presented to the Emergency Department (ED) on 3/4/2022 at 2012 for a medical clearance and legal blood draw while in the custody of the police. Review of physician orders dated 3/4/2022 at 2026 for an Electrocardiogram (ECG) Stat (with no delay), for Chest Pain, unit to perform.

Further record review revealed the ECG was performed on 3/4/2022 at 2044 by ED Patient Care Assistant (PCA/Tech) Staff N. However, there was no evidence in the medical record that documented when the ECG was given to the medical doctor and read by the medical doctor.

Review of the initial ED provider treatment note dated 3/4/2022 at 0146 documented the patient reported he was not feeling well and denied chest pain at the time of the evaluation. The patient reported he had a "quantity of alcohol drink" but did not feel intoxicated." He (#3), said he was found outside of his car, and when confronted by the police he got into his car and began to drive away, however he rolled into a parking pole, and they brought him in for further evaluation. The patient reported he did have mild chest pain a few hours earlier but that it is resolved. The patient reported he generally feels ill.

Review of systems included:
Resp: Mild intermittent coughing
Endo: Chills
Extremities: No unusual pain.

Medical Decision Making and Course in Ed included:
"...Patient's tropin (protein level released in the blood 12 hours after the onset of a heart attack), was elevated at 123 (normal range 0.0-0.4 ng/ml). Patient's ECG revealed left bundle branch block. Those findings discussed with Cardiologist and ECG provided to Cardiologist for review, he requested the patient receive medical optimization with heparin, aspirin and Plavix and they would evaluate in the morning."

However, shortly thereafter the patient became diaphoretic, and a repeat EKG revealed marked ST segment changes concerning for complete occlusion. The patient was admitted for an emergent cardiac catheterization, required intubation for acute hypoxic respiratory failure, developed severe cardiogenic shock, acute kidney injury, dialysis, and subsequently was terminally weaned.

During a phone interview on 5/25/2022 at 1445 Staff N explained she did not recall the patient. She confirmed if her name was attached in the medical record, it would have been her who performed the EKG. When further queried regarding the processes for carrying out physician orders for EKG's she said it was her responsibility to print 2 copies one for the nurse and one for the doctor after completing the EKG and give to each. Staff N was asked if anyone (supervisor) had discussed the circumstances of the patient #3 and if she had receiving any re-education she replied "No one had."

A phone interview on 5/25/2022 at 1455 was conducted with ED Staff Nurse O.
She explained she recalled the patient. She said the patient complained of a "headache" and appeared, "extra" (belligerent and gibberish). When asked to explain the process for staff ensuring EKGs were performed and interpreted by the medical doctor in a timely manner she replied, "the ED tech should always take the EKG's to the doctor after completion."

A phone interview was conducted with the ED Medical Director Staff (L), on 5/25/2022 at 1315. She explained she was involved in the reviewing of the circumstances involving patient #3.
According to Staff L, "there were missed opportunities with getting the EKG in front of the ED doctor within minutes of completion." She said, this did not happen in this case.

Review of the facility's "EMTALA" policy, origination date 12/15/2008 and next review date 12/2023, documented as follows:

V. PROCEDURE AND/OR PROVISIONS
A. Detroit Medical Center (DMC) hospitals will provide an appropriate MSE within the capability of Detroit Medical Center (DMC) hospitals to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists.

However, that was not done in a timely manner.

Review of the facility's "Patient Assessment and Documentation", policy with an Effective Date: 02/23/2022 documented:

I. OBJECTIVE
To provide patient assessment and documentation guidelines of nursing care for patients with inpatient status.
II. SCOPE
Registered Nurse (RN), Licensed Practical Nurse (LPN), Patient Care Associate (PCA), Student Nurse
Associate (SNA), Student Nurse Intern (SNI), Student Nurse (SN), Nurse Associate (NA), Patient Support
Associate (PSA), Mental Health Associate (MHA), Mental Health Technician (MHT) and other Health Care
Providers (HCP) within their scope of practice
III. POLICY
A. Documentation responsibilities vary by role, see Attachment 1: DMC Documentation Scope of Practice.
B. The RN documents patient information in the electronic medical record (EMR) except when such documentation is outside of the scope of existing electronic forms or during system downtime time when downtime procedures will be followed.
C. The RN documents admission and on-going and focused assessments, patient/family teaching, plan of care, interventions, and patient response in the medical record. The RN documents all pertinent patient data, including but not limited to, designated required fields.
D. The RN is responsible for patient assessment, data interpretation, determination of patient needs, establishment of nursing intervention priorities, and evaluating effectiveness of the plan of care.
E. The RN integrates information from various assessments and forms, both paper and electronic, to identify patient needs and care priorities. The family and/or significant other are included as a source of information related to assessment and planning of care when appropriate.
F. The RN interacts with patient, family, and significant others to establish goals and formulates plan of care.
G. The RN may delegate data collection tasks to other nursing team members. Delegation of tasks is congruent with their domain of knowledge, training, competency to perform the task, established hospital policies and procedures, and applicable laws and regulations.
H. RNs verify all data documented and co-sign documentation of selected data collected by Licensed Practical Nurses, Student Nurse Associates, Nurse Associates, Patient Care Associates Constant Observers Mental Health Techs, and ED Techs (see Attachment 1).
I. RNs may modify electronic documentation recorded by personnel to whom the RN has delegated data collection. RNs do not modify information documented by another RN, with the exception of the Emergency Department (ED) Triage and Assessment form completed in the ED.