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Based on interview, record review, policy review and review of video surveillance, the hospital failed to follow its policies and procedures when they did not provide further examination and stabilizing treatment within its capabilities and capacity for one patient (#7), out of 31 sampled case from August 2020 through February 2021 that presented to the Emergency Department (ED) seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital also failed to follow its policies and procedures and did not provide an appropriate medical screening examination within its capabilities and capacity when Patient #7 returned to the ED a third time seeking care for an EMC. The hospital's average monthly ED census over the past six months was 1,996.

Review of the hospital's website showed that Barnes Jewish St Peters Hospital is the only hospital in St. Charles County accredited as a Chest Pain Center by the Society of Cardiovascular Patient Care (SCPC). As a chest pain accredited hospital, Barnes-Jewish St. Peters had the processes in place to reduce the time from onset of symptoms to diagnosis and treatment, treat patients more quickly, and monitor patients to ensure they receive proper and timely treatment. The documentation further specified that several risk factors are controllable and may help prevent a heart attack. Blood pressure, cholesterol and blood glucose levels can provide insight into a patient's risk of heart disease and heart attack.

Review of the hospital's document titled, "Sub-Specialty Emergency Department Call Schedule," dated 07/2020 through 12/2020 and 01/2021 through 06/2021, showed that a Cardiologist was on-call and available to come to the ED 24 hours a day, seven days a week and 365 days a year.

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," showed that individuals who come to the ED and request examination and treatment would receive an appropriate medical screening examination (MSE) provided by qualified medical personnel. When an individual was determined to have an EMC the hospital would provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital.

Review of the hospital's undated document titled, "Departments/Units/Areas/Programs/Services," showed that the hospital had the capability within the Cardiology Department to perform the following:
- Telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen);
- Diagnostic radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) films;
- Computed Tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray);
- Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body).
- Ultrasound (US, a test that uses sound waves to create images of structures within the body);
- Positron Emission Tomography (PET Scan, an imaging test that uses a special dye which is introduced into the body and can be traced);
- Cardiac Catheterization (a procedure where a long thin tube is inserted in a blood vessel and threaded through the blood vessels to the heart to examine how well the heart is working);
- Angioplasty (a procedure to open narrowed or blocked blood vessels that supply blood to the heart);
- Pacemaker (small device that is placed in the chest or abdomen to help control abnormal heart rhythms);
- Cardioversion (a medical procedure to restore the heartbeat to normal rhythm; using either electricity or drugs);
- Trans esophageal Echocardiogram (TEE, a test that produces pictures of the heart); and
- ST-Elevation Myocardial Infarction (STEMI, heart attack) care.

Review of the hospital's undated document titled, "Chest Pain," showed that:
- For patients with normal oxygen saturation and non-diagnostic ECGs, staff were to insert an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream), order a chest x-ray (type of radiation called electromagnetic waves, that creates pictures of the inside of the body), and send blood work including a completed blood count (CBC, a blood test performed to determine overall health including inflammation or infection), basic metabolic panel (BMP, a blood test performed to measure you sugar level, electrolyte and fluid balance and kidney function), and troponin (a type of blood test that indicates heart muscle damage, normal range was less than 0.01).
- Place the patient on a heart monitor.
- Give the patient a 325 milligram (mg, a measure of dosage strength) aspirin (blood thinner that can also treat pain, fever, headache and inflammation) unless the patient is allergic to aspirin.

Review of Patient #7's medical record for 01/08/21 and 01/10/21 showed that the ED staff failed to follow their policy and provide the appropriate treatment necessary to stabilize the patient's EMC prior to discharge. Staff L, ED Physician examined the patient who presented with complaints of chest pain and shortness of breath with exertion for the past week. Patient #7 had multiple comorbidities (the presence of one or more medical diagnoses existing along with a primary condition) such as obesity, high blood pressure, diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing), high cholesterol levels and a family history of myocardial infarction that placed him at high risk for an adverse cardiac event. An electrocardiogram (ECG, test that checks for problems with the electrical activity within the heart) was obtained upon each visit, which was noted to be abnormal. Staff L, consulted with Staff R, On Call Interventional Cardiologist (a branch of physicians that are trained to specifically treat structural heart diseases with the use of catheterization) who recommended the patient be prescribed Ibuprofen (a medication that is used for treating pain, fever, and inflammation) for treatment of Pericarditis (inflammation of the thin saclike membrane surrounding the heart) when he had not reviewed the ECG or examined the patient.
Refer to tag A2407 for further details.

Review of Patient #7's medical record for 01/12/21, showed that staff failed to follow the policy and did not provide the patient with an appropriate medical Screening examination (MSE). At 11:20 AM, the patient presented to the ED with continued complaints of worsening chest pain and shortness of breath. Two ECGs were performed which showed abnormal results. Staff E, RN did not obtain blood work (the diagnostic testing of blood). Patient #7 was placed in the waiting room pending evaluation. Staff L, ED Physician reviewed the ECGs but did not examine the patient or order additional diagnostic testing. At 12:26 PM staff began performing Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) and at 1:23 PM Patient #7 died.
Refer to tag A2406 for further details.






41474

Based on interview, record review, and review of video surveillance, the hospital failed to follow policy and provide within its capability and capacity, a Medical Screening Exam (MSE) for one patient (#7) of 31 Emergency Department (ED) records reviewed from August 2020 through February 2021. 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). The hospital's average monthly ED census over the past six months was 1,996.

Findings included:

1. Review of Patient #7's ED record showed that he was a 39-year-old male with a past medical history of high blood pressure, diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing), epilepsy (a neurological disorder that can cause unpredictable seizures), hyperlipidemia (high level of fat in the blood that can lead to heart disease), obesity, and a family history of heart problems.

Review of Patient #7's medical record showed that he presented to the ED on 01/08/21 at 5:02 PM, seeking care for an emergency medical condition (EMC). The evidence in the medical record showed that Patient #7 complained of chest pain and shortness of breath with exertion that began on 01/01/21. At 7:44 PM, ED Physician L discharged the patient with an un-stabilized EMC. Refer to tag A2407 for details.

Review of a second medical record for Patient #7 showed that he returned to the ED on 01/10/21 at 2:12 PM, complaining of worsening chest pain and shortness of breath on exertion. At 5:17 PM, Staff L, ED Physician, discharged the patient with an un-stabilized EMC. Refer to tag A2407 for details.

Review of a third medical record, along with recorded hospital video surveillance, showed that Patient #7 returned to the ED on 01/12/21 at 11:20 AM, with ongoing chest pain and shortness of breath. The patient was triaged (process of determining the priority of a patient's treatment based on the severity of their condition) and underwent two electrocardiograms (ECG or EKG, test that checks for problems with the electrical activity within the heart) prior to an MSE by Staff L, ED Physician. After each ECG, the patient was returned to the ED waiting room. According to the 11:31 AM machine generated interpretation of the ECG tracing, contained in Patient #7's medical record, showed "moderate T-wave (part of the ECG waveform that represents a crucial stage in the electrical activity within the heart) abnormality, consider inferior ischemia (reduced blood flow to the lower part of the heart), abnormal ECG." Staff L signed the ECG tracing and noted the patient was not having an ST-Elevation Myocardial Infarction (STEMI, heart attack).

Review of the hospital's video surveillance, along with review of Patient #7's third medical record, showed that at approximately 11:42 AM, Staff W, Registrar, wheeled Patient #7 outside the ED and the patient was seen alternating between sitting upright and slumping forward. At 11:43 AM, per video time stamp, the patient's wife arrived and wheeled him back inside the ED. The patient appeared to be in distress, he sat forward with his hand on his forehead. The patient's wife can be seen talking with Staff V, Registrar. Staff B, RN came to the ED waiting room and spoke to the patient's wife. At 11:53, Staff B wheeled Patient #7 back inside the ED. At 12:03 PM, a second ECG was obtained and the machine generated interpretation contained in Patient #7's medical record showed "probable inferior myocardial infarction (a heart attack in the lower part of the heart)." Staff L, ED Physician reviewed the ECG and noted on the ECG tracing that the patient did not have a STEMI. Per hospital video surveillance, at approximately 12:17 PM, Patient #7's wife wheeled him outside the ED. At 12:20 PM, ED staff ran outside the ED doors to the parking lot. At 12:26 PM, staff began Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a persons' breathing or heartbeat has stopped) on Patient #7. Per documentation in the medical record, staff ceased performing CPR and ED Physician L pronounced Patient #7's time of death at 1:23 PM.

During a telephone interview on 02/18/21 at 4:26 PM, Fire Chief X stated that on 01/12/21, he and Patient #7 had just returned to their work office, and he noticed the patient had trouble breathing and seemed to be in pain. The patient was very anxious (feeling fearful or worried intermittently) and when Fire Chief X asked about it, the patient told him he kept having chest pain. He took the patient to the ED where he had to place the patient in a wheelchair, because the patient was weak and could barely walk. He left the patient when hospital staff came to take him into triage.

During an interview on 02/03/21 at 2:33 PM, ED nurse E stated that she triaged Patient #7 on 01/12/21 and she remembered that he was anxious and would hyperventilate (breathe at an abnormally rapid rate). He was tachycardic (increased heart rate, greater than 100 beats per minute), and Patient Care Technician (PCT) N obtained an ECG and took the ECG to the ED physician. She attempted to draw blood for lab tests, but was not successful, so she decided to wait until he was in an examination room in the ED. The patient told her he had been to the ED on two other occasions with the same complaints, and the physician had diagnosed him with pericarditis. She asked the ED physician about placing the patient in an ED examination room, but the physician told her that the patient could go to the waiting room until an examination room came open, so she took him out to the waiting room, and left him in the wheelchair.

During an interview on 02/18/21 at 10:30 AM, Staff W, Registrar, stated that after Patient #7 had been triaged, he asked her to take him outside because he was having trouble breathing, and seemed to be in distress. She pushed the patient outside and left him.

During an interview on 02/09/21 at 10:00 AM, ED Charge Nurse B, stated that the registrar at the front desk notified him that a family member was upset and that he needed to talk to them. The patient's wife told him that the patient's chest pain and breathing were worse than before and no one would help him. The patient looked very anxious, he held his chest and was breathing rapidly, and stated that he could not breathe, so Staff B suggested another ECG be completed. ED Physician L, read the repeat ECG, and told him (ED Charge Nurse B) that the ECG did not indicate a STEMI, so he took the patient back to the waiting room.

During a telephone interview on 02/17/21 at 2:30 PM, Patient #7's wife stated that when she arrived at the hospital she found her husband in a wheelchair sitting outside of the ED doors. He told her he needed air and his chest was hurting. She took him inside and yelled at the women behind the desk that someone needed to do something, that her husband was having a heart attack. The male nurse came out and told her that and ECG was completed on the patient, and it did not show a heart attack. She told him she wanted her husband to be treated as a new patient with a full workup. The nurse told her he would do another ECG, if she wanted that. She told him yes, her husband was hurting worse and the ED physician had missed something. The nurse told her she would need to leave (the ED waiting room) while he took her husband to the back (of the ED). She went to her car and after a few minutes tried twice to call her husband. He did not answer. Her husband called her back and told her that she needed to come get him and take him to another hospital that could help him. She told him she was afraid to put him in the car because he might die. She was afraid she would not be able to help him. He told her that if he stayed where he was, he was going to die anyway. She went inside and found him in a wheelchair in the waiting room. She wheeled him out of the ED to take him to another hospital. She got as far as her car with him, and his eyes rolled back in his head and his legs went under the wheelchair.

The patient presented to the ED at 11:20 AM, in distress, with ongoing symptoms of chest pain and shortness of breath. The hospital failed to provide an appropriate MSE utilizing the ancillary services routinely available to the ED prior to the patient becoming unresponsive approximately one hour later at 12:20 PM.











41474

Based on interview and record review the hospital failed to stabilize one patient (#7) of 31 Emergency Department (ED) records reviewed from August 2020 through February 2021 within the hospital's capacity and capability, when the patient presented to the Emergency Department (ED) seeking care for an Emergency Medical Condition (EMC). This failed practice had the potential to cause harm to all patients who presented to the ED. The hospital's average monthly ED census over the past six months was 1,996.

Findings included:

1. During a telephone interview on 02/17/21 at 2:30 PM, Patient #7's wife stated that the patient had complained of chest pain and shortness of breath (SOB) when he climbed the stairs, which had started around 01/01/21. During the first two visits to the ED (01/08/21 and 01/10/21), the patient complained of chest pain, was clammy, held his chest, and was SOB.

Review of Patient #7's ED record showed that he was a 39-year-old male with a past medical history of high blood pressure, diabetes (a disease that affects how the body produces or uses blood sugar), epilepsy (a neurological disorder that can cause unpredictable seizures), hyperlipidemia (high level of fat in the blood, which can lead to heart disease), and obesity. On 01/08/21 at 5:02 PM, the patient presented to the ED with complaints of chest pain and SOB that increased with physical effort, which began approximately one week prior. The patient described the chest pain as sharp in nature, did not radiate, and improved when he sat forward. His temperature was 98.5, blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) was 144/88, pulse rate (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) was 91 beats per minute, respirations (inhalation and exhalation of air; breathing) were 16 breaths per minute, and his room air oxygen level was 98%. An electrocardiogram (ECG or EKG, test that checks for problems with the electrical activity within the heart) resulted abnormal. ED Physician L marked the ECG as no ST-Elevation Myocardial Infarction (STEMI, heart attack). Blood work obtained included one troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) test, which resulted less than 0.01. He was placed on continuous cardiac monitoring (used to monitor for changes in the hearts rhythm). He had a chest x-ray that showed the lungs were clear, there was no pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart) and no acute cardiopulmonary (relating to the heart and the lungs) disease, an echocardiogram (ECHO, a test that makes images of the heart and surrounding structures) was done at the bedside with no obvious pericardial effusion (a buildup of extra fluid in the space around the heart). At 5:14 PM, Resident Physician Q, assessed the patient and at 7:33 PM, he called Staff R, on-call Interventional Cardiologist (specially trained physician who diagnose and treat complications with the heart through cardiac catheterization [procedure used for diagnosis or treatment of heart conditions, where a long thin tube is inserted in a blood vessel and threaded through the blood vessels to the heart, can be completed to restore blood flow to the heart]), to discuss the patient's condition. Staff R suggested to start high-dose ibuprofen for pericarditis (inflammation of the thin saclike membrane surrounding the heart) and to follow-up with cardiology next week. Patient #7 was discharged to home at 7:44 PM.

During an interview on 02/10/21 at 2:00 PM, Staff R, Interventional Cardiologist (specialized physician who can perform procedures to restore blood flow to the heart), stated that he was on-call on 01/08/21, and that he received a call from the ED concerning the care of Patient #7. Staff R stated that although he had access to the patient's electronic medical record (EMR) from his office and his home, he did not review the patient's history, but knew the patient had a history of diabetes and epilepsy. On the patient's initial visit (01/08/21), he was told that the patient had presented with chest discomfort and SOB. Staff R stated that Staff L, ED Physician, suggested a diagnosis of pericarditis and treatment with ibuprofen, in which he agreed.

During an interview on 02/17/21 at 3:30 PM, Staff U, Interventional Cardiologist, stated that if a patient presented to the ED with co-morbidities (the presence of one or more medical diagnoses existing along with a primary condition) and complaints of chest pain, more than one ECG should have been performed as well as more than one troponin, to determine if there were changes occurring to the patient's heart.

Review of Patient #7's ED record showed that he presented to the ED on 01/10/21 at 2:12 PM (this was his second ED visit within two days), with complaints of chest pain located in the center of his chest. He described the pain as dull and constant and it would become severe at times throughout the day. The pain was worse with exertion and sometimes he would become short of breath. He stated the pain was better when he sat up straight as opposed to when he laid flat. Patient #7 rated his pain as a level two (levels based on scale of 0 to 10 with zero being no pain). He had taken the ibuprofen 600 mg twice the day before and once on 01/10/21. His temperature was 98.6, blood pressure was 120/85, pulse rate was 104 beats per minute, respirations were 15 breaths per minute, and his room air oxygen level was 96%. At 2:24 PM, an ECG resulted abnormal. Staff L, ED Physician, marked the ECG as no STEMI. Blood work obtained included one troponin that resulted less than 0.02 (increased from 01/08/21 visit) and he was placed on continuous cardiac monitoring. At 2:38 PM, he had a chest x-ray which resulted as normal. There was a standing order to give the patient a chewable aspirin (initial treatment for a heart attack), but the patient did not receive the aspirin. At 4:37 PM, ED Physician L called Interventional Cardiologist R to discuss the patient's condition. Staff R recommended a C-reactive protein (CRP, a protein made by the liver) test (CRP, a test that measures the amount of CRP in the blood to detect inflammation either for acute conditions or to monitor chronic conditions) and an erythrocyte sedimentation rate (ESR, a test that indirectly measures the degree of inflammation present in the body), which he would use to follow the patient as an outpatient. He also recommended the medication colchicine (a medication used to treat inflammation). Staff L documented no indication for an ECHO at that time. At 5:05 PM, ibuprofen 800 mg and colchicine 0.6 mg were administered to the patient. Patient #7 was discharged to home at 5:17 PM with instructions to call the cardiology office for an appointment within the next three days.

During an interview on 02/09/21 at 12:30 PM, Staff O, RN, stated that she triaged Patient #7 on 01/10/21, when he presented with chest pain and SOB. When he arrived in the ED, even though he could walk, he used a wheelchair because he was SOB. The patient reported to her, that he came to the ED on 01/08/21, and was given a diagnosis of pericarditis. She performed an ECG on the patient, which was reviewed by ED Physician L, who documented on the ECG that there was no STEMI. Staff O added that the triage nurse ordered the first troponin, but the ED physician had the capability to order a second and third troponin, after he examined the patient.

During interviews on 02/01/21 at 8:50 AM and 02/18/21 at 11:00 AM, ED Physician L, stated that he evaluated Patient #7 on 01/08/21 and 01/10/21. When he reviewed the ECG for 01/10/21, he did not have access to the ECG from 01/08/21 for comparison, although it was a standard practice to review and compare previous ECGs. During the patient's first two visits, he evaluated the patient and consulted the Cardiology Department, which he had access to 24-hours a day, seven days a week. Staff L considered aortic dissection (a tear in the inner layer of the large blood vessel branching off the heart) for the patient's diagnosis, but his symptoms did not fit the picture, and cardiology agreed with the diagnosis of pericarditis and the use of ibuprofen to treat the inflammation. Staff L added that he did not believe inpatient admission would have made a difference for the patient.

During an interview on 02/10/21 at 2:00 PM, Interventional Cardiologist R, stated that on 01/10/21, ED Physician L, called him about Patient #7, who had arrived to the ED with complaints of chest pain and SOB. The ED physician told him the ECG had improved from the first visit (per interview with Staff L, he did not have access to compare the patient's ECG from 01/08/21) and that the troponin was increased to 0.02. Staff R stated that he did not have access to the patient's ECGs in real time, and relied on the ED physician's interpretation. The patient reportedly had not taken the ibuprofen as prescribed, had stable vital signs, and Staff R agreed with Staff L when he wanted to prescribe the patient colchicine for pericarditis and have the patient follow-up with cardiology in the next few days. Staff R stated that when he overread the patient's ECGs for the visits of 01/08/21 and 01/10/21, he said they were abnormal, and that he did not follow-up on the abnormal ECGs, because the patient would have received treatment by the time the overreads were completed.

During an interview on 02/03/21 at 5:05 PM, Staff H, Risk Management Manager, stated that on 02/02/21, Patient #7's case and Staff L's management of the patient was reviewed. It was felt the patient could have been admitted for further diagnostic evaluation.

During an interview on 02/03/21 at 1:30 PM, Medical Director I, confirmed that the Cardiology Department was on call 24 hours a day seven days a week, and that the hospital had the capability and access to Interventional Cardiologists to perform interventional cardiac procedures to include angiograms (a procedure that uses radiology exams to look at blood vessels in your body) and cardiac catheterization. Staff I added that he questioned ED Physician L's interpretation of the ECGs and his diagnosis of pericarditis for Patient #7.

During an interview on 02/04/21 at 9:15 AM, Chief of Cardiology J, stated that it would be very rare for one of the cardiologists to come to the ED to see a patient unless the patient needed a heart catheterization or other procedures. The cardiologists relied on the ED physician to read the ECG, present them an accurate history, and to have reviewed the laboratory tests and any radiology tests. In the review of Patient #7's event, there was an agreement amongst the physician's, that there was a missed diagnosis and an inappropriate interpretation of the ECGs. The first and second time Patient #7 presented to the ED he saw the same ED physician and the same cardiologist was consulted. The patient told Staff L, ED Physician, that he had taken the ibuprofen 600 mg twice on 01/09/21, and once on 01/10/21. This led to physician bias with the need to continue the diagnosis of pericarditis and add the medication colchicine.

During an interview on 02/04/21 at 11:30 AM, Resident ED Physician F, stated that the only way to rule out a cardiac cause of chest pain would be through an ECHO, a Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body), or a cardiac catheterization.

During an interview on 02/17/21 at 8:00 AM, Attending ED Physician P, stated that if a patient presented with chest pain, they should have a troponin performed initially, and then again in four hours to determine if there were changes to the lab value, to know if there were cardiac issues occurring with the patient. If there were no answers to the cause of chest pain, then the patient should be referred to outpatient for further testing.

The hospital failed to provide within its capability, necessary stabilizing treatment for Patient #7. Patient #7 presented to the ED on 01/08/21 and 01/10/21 with complaints of chest pain and SOB. On each visit, he had ECGs that were abnormal. The hospital had the capability and capacity to provide the necessary stabilizing treatment, which included providing aspirin, providing pain medication, a bedside cardiology consult, interventional cardiology procedures, and admission for further diagnostic testing.