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Based on the review of documentation, interviews, and video of the event, the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's emergency department to determine whether an emergency medical condition (EMC) existed for patient #1 who presented to the emergency department (ED) on 7/3/2022 for the evaluation of an EMC.
Specifically, patient #1 did not received a MSE by a qualified provider to determine an EMC until the patient decompensated in triage and suffered a cardiovascular episode that required resuscitation after arriving via ambulance 50 minutes prior.


Findings included:
a. The Corpus Christi Fire Department (CCFD) EMS run sheet states that on 7/3/2022 patient #1 arrived at the facility and completed a transfer of care at 12:01 am. The EMS run sheet states they were "directed to lobby by charge nurse". The hand off from the CCFD EMT to the facility's nurse or representative was not sign by the facility's staff.


b. Patient #1 record demonstrates that the patient arrived at the facility via EMS at 12:01 AM with complaints of abdominal pain and pain level of 10 out of 10. Upon arrival, Patient #1 was sent to the ED lobby at the direction of a charge nurse, per CCFD EMT documentation. Patient #1 was quick registered at a triage kiosk by a CCFD EMT at 12:18 am. The patient was left in the ED lobby with his wife without a medical screening exam to determine an emergency medical condition until 01:07 AM when he suffered a cardiovascular arrest, and he was seen by a qualified provider.


c. The video review with time stamps of the ED lobby. The timeframe for the video review starts at 11:50 pm on 7/2/2022 through 12:59 AM on 7/3/2022. The video has no audio and it only provided 1 view of the lobby and adjacent areas. The view showed the waiting area, a partial view of the lobby male bathroom entrance, the triage desk, and the entrance to "walk in" patients. A partial view of the ambulance entrance and back hallway behind the triage desk can also be discerned. The video review demonstrated that the patient arrived via ems on 7/2/2022 at 11:57 PM based on the time stamp. An EMS technician is observed wheeling the patient into the ED lobby/waiting room. The EMS technician is seen typing into a waiting room registration kiosk at 11:59 PM by video time stamp. Patient #1 is left with his wife in the lobby. The video shows staff #6 with a patient in the triage area from 12:00 AM to 12:23 AM while the patient sat on a wheelchair in the lobby. Patient #1 is seen growing increasingly restless in the wheelchair and subsequently sliding out of the wheelchair onto the floor at 12:20 AM. Patient #1's wife is seen asking for help while other patients or visitors in the lobby are observed attempting to assist patient #1. Staff #6 is seen entering the lobby and patient #1's wife is observed frantically talking to staff #6. Staff #6 is seen gesturing by pointing the wife to a chair. The nurse stands over the patient who is on his back on the floor with his hands on his stomach, staff #6 points to the wheelchair. Staff #6 does not touch the patient nor assist the patient and departs back to the triage office. Other hospital staff members are seen in the lobby, no staff members are observed attempting to take vital signs or touch the patient. The patient is assisted back onto the wheelchair by Corpus Christi Fire Department EMS staff and a possible patient or visitor. At 12:47 AM patient #1 is taken to the bathroom by his wife. At 12:49 AM the patient is back in the lobby in the wheelchair and is noted to have difficulty holding his head up and appears to not be responding to his wife. At 12:50 AM Patient #1's wife is seen wheeling the patient out of the ED front door to the adjacent ambulance entrance and into the hallway behind triage. Patient #1 appears limp and with his head back in the video.


d. The triage record demonstrates that all the emergency nursing notes were late entries documented between 09:46 AM to 9:59 AM on 7/3/2022. Patient #1's triage was documented as occurring at 12:45 am. Vital signs included a pulse of 118 beats per minute and respirations of 27 per minute. Oxygen saturation at 99% on room air. A blood pressure was not documented. The mode of arrival was documented as "walk in" by staff #6. Patient #1's triage notes states that patient had arrived by ambulance with left lower quadrant abdominal pain. Occurring at 12:51 AM staff #6 documented in free text note; "unable to obtain blood pressure, will continue to attempt." and "Charge nurse notified of patient requiring need for room" and "spouse at bedside". Occurring at 12:56 AM it was documented that patient #1 had "work of effort increasing to breath" and "spouse remains at bedside". Documented as occurring at 12:57 AM "Pt immediately went into respiratory arrest".


e. The provider notes show that the initial greet took place at 01:07 AM. The documentation states " ...called to go to room 1 stat for unresponsive patient." and "Apparently patient came by EMS earlier complaint of abdominal pain and was in the lobby waiting to come back when he became syncopal."


f. Provider interview. Staff #4 stated that he had just finished with a trauma case when he was told that a patient "looked bad" by staff member. He walked into ED room 1 and encountered an unresponsive patient. Staff #4 stated that he was able to rapidly intubate the patient without the use of sedation and cardiac resuscitation started. Staff #4 stated that the resuscitation was successful. Staff #4 asked the nursing staff where did this patient come from? And he was told that the patient had been in the ED lobby for 1 hour. Staff #4 stated he could not understand why the patient had been waiting that long. Staff #4 stated that no one told him that the patient had arrived via ambulance and that the patient had been in the lobby for that long. Staff #4 stated that they have advance practice providers (APP) to assist with medical screening but that they usually leave at 9 pm or midnight. Staff #4 stated that it is difficult for one provider at night to keep track of all the patients being treated as well as those arriving to the triage area. Staff #4 also stated that if he had been notified of the patient's arrival, he could have made a quick assessment and decide on his treatment. Staff #4 stated that one provider for 8 hours from 11PM to 7 am, is very difficult. He added that a surge protocol to call in more staff was developed, yet he stated that it can take hours to have a second provider come in. Staff #4 stated that an APP for nightshift would help to prevent this type of issue.


g. Staff #6 stated that she was assigned to triage on 7/3/2022 from 7PM to 7 AM. Staff #6 stated that it was a busy night without available beds in the department and several EMS ambulances in bound. Staff #6 stated that the triage area was busy as well. Staff #6 stated that she did not have a technician to assist in triage and that the MSE Nurse Practioner had left prior to 12:00 AM. Staff #6 stated that she did not take report from the ambulance that dropped off patient #1. She explained that the charge nurse typically takes report. Staff #6 also stated that the charge nurse makes the decision if a patient is taken to a bed (treatment area) or to the ED lobby. Staff #6 stated that she was unaware that the patient had been taken to the lobby by EMS. Staff #6 stated that she saw the patient on the floor and heard the wife calling for help. Staff #6 stated that she went to the lobby and asked patient #1 "what was wrong?" and "why was he on the floor?". Staff #6 stated that the patient stated that he had nausea and vomiting and that he needed to lay down. Staff #6 stated that she did not assess patient #1 and did not take his vital signs. She also stated that she did not help the patient up from the floor or touch the patient. Staff #6 stated that minutes later and after the patient had been picked up from the floor and back on the wheelchair, the wife notified staff #6 that patient #1 was doing worse. Staff #6 stated she took the patient to triage that she attempted a blood pressure reading on patient #1 and could not get one. She attempted a different machine for the blood pressure without success. Staff #6 informed her charge nurse that the patient needed immediate bed placement then immediately after the patient had respiratory arrest and was taken to room 1, as per her recollection. Staff #6 stated that the patient was successfully resuscitated.


h. Staff #7 interview. Staff #7 stated that she was the charge nurse on 7/3/2022 nightshift (7 PM to 7 AM). She explained that she did not take the report from the CCFD EMS unit that transported patient #1. Staff #6 stated that on that night another CCFD EMT took report and relayed the information to her. Staff #6 stated that this is not the norm or standard. Staff #7 stated that the CCFD EMT informed her that patient #1 had abdominal pain after eating and a blood pressure of 140/80. Staff #7 stated when patient #1 arrived, another CCFD EMT took patient #1 and his wife to the ED lobby. Staff #7 stated that the CCFD EMT informed staff #6, triage nurse, of patient #1's arrival and location. Staff #7 stated that later in the night she was made aware that patient #1 fell in triage but stated that this issue was handled by staff #6, triage nurse. Staff #7 stated that sometime after patient #1's fall in the ED lobby, not sure of the time frame, staff #6 notified her that she needed a bed. Staff #7 stated that "a minute later" staff #6 informed her with great urgency that she needed a room "now". When staff #7 arrived at room 1, that patient was unresponsive, and she participated in the resuscitation efforts. Staff #7 stated that the patient was successfully resuscitated but remained intubated and critical. Staff # stated that the patient was admitted to ICU after the event. Staff #7 explained that APPs leave between 9 PM and 10 PM leaving only one provider from 11 PM to 7 AM on nightshift. Staff #7 also stated that "we live in a constant state of short staffing". Staff #7 stated that she was able to get extra nursing help that night but that it was extremely busy. Staff #7 stated that they had 17 ambulances before 11 PM on that shift. Staff #7 denied completing an incident report or adverse event record for patient #1's fall or decompensation nor for the surge of patients that night. Staff #7 stated that the charge nurses are to document the events and issues of their shift on a charge nurse report that is send to leadership but could not remember if this had been completed. She added "we are not always compliant with the reports". Staff #7 stated that on the day of the event she was the charge nurse with a 4-patient assignment as well as the EMS arrival assessments. She explained that most charge nurses need to take a patient assignment due to staffing shortages. Staff #7 also stated that the staff have not seen their management for over a month. She stated that there is "no leadership presence to assist with their issues".