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Based on medical record (MR) review, interview, and document review, in 1 of 20 MRs reviewed, a patient (Patient #1) did not receive an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed, therefore Patient #1 did not receive the necessary stabilizing treatment. This could lead to untoward patient outcomes.

Findings include:

-- Review of Patient #1's MR revealed Patient #1 had initially been seen at an urgent care on 1/21/2021 at 11:41 am with the chief complaint of shortness of breath (SOB). Urgent care provider documented, Patient #1 is not in acute distress, he is obese, ill appearing and diaphoretic. Heart rate is normal rate and regular rhythm, normal heart sounds. Pulmonary effort is normal with normal breath sounds. Electrocardiogram (ECG) performed was abnormal. The urgent care provider documented to transfer to other facility, to emergency department (ED).

-- Review of Patient #1's MR revealed on 1/21/2021 at 12:12 pm, Patient #1, a 69-year-old male, presented to the ED with complaint of chest pain, SOB, dizziness, and headache that had started that day. Tightness in his throat began while he was outside starting his snowblower.

Past medical history included high blood pressure (BP), gout, high cholesterol and triglycerides and obstructive sleep apnea. Patient #1 took blood pressure and cardiac medications at home.

He was triaged as a level 2/emergent on the Emergency Severity Index (ESI) (1 being resuscitation and 5 non-urgent). Vital signs (VS) at 12:20 pm were temperature (T) - 97.5, pulse (P) -79, respirations (R) - 16, BP - 138/56, oxygen saturation (SpO2) - 96 percent and pain level - 6 (pain location: back of throat, feels like tightness in throat).

Testing was ordered and completed. Initial blood work showed a slightly elevated white blood cell count and sightly elevated BUN and creatinine. Electrocardiogram was abnormal. Chest x-ray showed no evidence of acute cardiopulmonary disease. COVID test was negative.

At 12:57 pm, nursing started an IV (intravenous). Patient #1 complained of chest pressure. (Not on telemetry or cardiac monitor.) At 1:33 pm, troponin result showed 0.053. (Result range: <0.034 normal, 0.034-0.119 indeterminate, >/= 0.120 abnormal).

Patient #1 was seen by a physician assistant (PA), Staff A, at 2:19 pm (2 hours and 7 minutes after Patient #1 presented to the ED). Documentation reveals: Patient presents with chest pain, SOB, dizziness, headache. Patient is a 69-year-old male who states that this morning his throat was sore when he woke up. He states he went outside to do yard work and he began to feel dizzy and have a mild discomfort in his chest. He states right now he does not feel like himself. He says he has no appetite and has not eaten anything. He took ibuprofen and aspirin at home along with his normal medications. He denies fever and chills. He states he had some sinus congestion which is normal for him. Review of systems (ROS) revealed: positive for activity change, appetite change, congestion, sinus pressure, sore throat, chest tightness and dizziness. Physical exam revealed (in part): patient is not ill-appearing, no throat swelling or drainage, no tonsillar draining or abscess. No swelling of lymph nodes. Heart rate and rhythm are normal, heart murmur is present. Staff A reviewed lab results and test (radiology and medicine) results. Clinical impressions: (Final) Frontal sinusitis, unspecified chronicity, (Final) Pharyngitis, unspecified and (under consideration) chest pain.
Documentation indicates Staff A discussed the patient with other providers.

At 2:29 pm Patient #1's VS were - T - 98.2, P - 72, R - 16, BP - 126/55, SpO2 - 94 percent and at 3:46 pm VS were T - 98.2, P - 78, R - 18, BP - 122/72, SpO2 - 95 percent and pain level = 3 (no location of pain documented). His IV was removed and he was discharged home with diagnosis of sinusitis, pharyngitis and chest pain and was prescribed an antibiotic.

A copy of a death certificate was included in the complaint for Patient #1, dated 1/22/2021 at 3:00 pm. Cause of death was documented as sudden cardiac death, probable cardiac ventricular dysrhythmia due to hypertensive heart disease, obstructive sleep apnea, and hypertriglyceridemia.

-- Review of the hospital's policy and procedure (P&P) titled " Emergency Medical Treatment and Labor Act (EMTALA) Policy," last revised 8/2020, indicated when an individual presents to the Emergency Department or to a location on UHS (United Health Services) hospital property and premises, and a request is made by the individual or on the individual's behalf, or a prudent layperson observer would conclude from the individual's appearance or behavior a need for examination or treatment of a medical condition exists, UHS hospital shall perform a medical screening exam (MSE). An appropriate MSE to determine whether or not an emergency medical condition (EMC) exists must be performed by a qualified medical person (QMP) as defined in this policy. The individual is considered stable for discharge when, within a reasonable clinical confidence, it is determined that the individual has reached the point where his/her care, including diagnostic work-up and/or treatment, could be reasonably performed as an out-patient, or later as an inpatient, provided that the individual is given a plan for appropriate follow-up care with discharge instructions.

-- Review of the hospital's P&P titled "Standard Medical Screening Examination/Emergency Medical Condition," last revised 12/2019, indicated a standard MSE is an examination that should be of sufficient detail to reveal the presence or absence of an EMC. A standard MSE shall also include tests, evaluations, and consultations, as may be determined by the provider to determine whether the patient has or does not have an EMC. An EMC is stabilized for discharge when the provider has determined: the patient has reached the point where further care could be performed on an out-patient basis or later scheduled in-patient basis.

-- The above findings were shared with hospital administration on 11/22/2021 at 10:00 am during the exit conference.