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Based on observation, interview and record review, the facility failed to conspicuously post signs about patient rights under EMTALA (Emergency Medical Treatment and Active Labor Act), when the facility posted signage for at a main entrance to which the facility closed public access. This failure did not ensure patients or the representatives of patients seeking ED care and services received appropriate notification of Federal rights associated with emergency care and services.

Findings:

During an observation and concurrent interview on 3/28/22, at 2:55 p.m., the facility identified two waiting areas for people awaiting ED care and services. Director A stated the facility converted space into a new waiting area specifically for patients with complaints of respiratory symptoms, which was distinct from the other waiting area for patients with other chief complaints. Director A stated the facility's new waiting area was created after closing the main entrance to its ED. At the closed main entrance, the facility's list of patient rights under EMTALA remained posted. The posting was not visible to patients or representatives of patients in the waiting area designated for patients with non-respiratory chief complaints. The posting was not visible upon entry to the ED. Director A verified there was no signage for patient rights other than the signage at the closed entrance. Director A stated the facility posted a second posting indicating patient rights under EMTALA, but at the ambulance bay entrance.

During an interview on 3/28/22 at 3:17 p.m., Manager verified the ED's main entrance door was closed and converted to a waiting area for patients with respiratory complaints in July 2020.

During an interview on 3/30/22 at 1:30 p.m., Director A verified other patients would not see the EMTALA posting unless they were patients with respiratory complaints only, waiting in the converted breezeway of the closed ED main entrance.

Review of the facility's policy and procedure titled "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" approval date 9/21, indicated the signage will be conspicuously posted at hospital entrances and the ED.

Based on observation, interview, and record review, the facility failed to provide an appropriate medical screening examination (MSE) in its Emergency Department (ED) for five of 20 sampled patients (Patients 1, 6, 7, 12, and 15), when the facility did not:

(a) Perform a MSE for Patient 1, who waited almost 6 hours before receiving physician services, was not reassessed with vital signs by nurses after triage, and never received a MSE prior to suffering a significant change of condition;
(b) Perform a MSE for Patients 6, 7, 12, and 15, who were not reassessed with vital signs by nurses after triage and never received a MSE prior to leaving the facility without being see by a physician.

This failure did not comply with facility policy and did not ensure timely stabilization of Patient 1's condition, who lost consciousness and suffered cardiac arrest while awaiting a MSE, and eventually died, and potentially caused adverse outcomes to Patients 6, 7, 12, and 15 from delayed services and treatment for an emergency medical condition.

Findings:

(a) Patient 1

On 3/8/22, the Department received a Complaint from two family members concerning the care their mother (Patient 1) received on 9/3/21 in the facility's ED. In the Complaint, Family Members (FM) claimed Patient 1, an 87-year-old, was "just not feeling right" and short of breath on 9/3/21, so she visited the facility's ED for emergency services. FM indicated a security guard precluded FM from entering the facility's ED with Patient 1. Patient 1 entered the ED and waited for care alone. The Complaint indicated Patient 1 waited five-to-six hours in the waiting room and was never seen by a physician. The Complaint indicated Patient 1 called FM at or around 4:59 p.m. and asked FM to call the ED in effort to help facilitate Patient 1's care. The Complaint indicated Patient 1's was unable to walk to the nurses station for help and Patient 1 could not wait any longer. The Complaint indicated Patient 1 needed assistance to use the bathroom while in the ED, which was not normal for Patient 1, who lived independently. The Complaint indicated Patient 1 was eventually moved from the waiting room to and ED room, but at or around 5:30 p.m. was "found unresponsive" by staff. The Complaint indicated staff initiated CPR (cardiopulmonary resuscitation, chest compressions and breathing assistance) and initiated mechanical ventilation (breathing machine that moves air in and out of the lungs through a tube in the throat). The Complaint indicated, "The idea that she was alone, scared and didn't know what was happening to her breaks my heart."

During an observation and concurrent interview on 3/28/22 at 2:59 p.m., Nurse C was in the triage area of the ED, where the facility assigned an urgency-level for each presenting patient's condition, indicated by an ESI Level (Emergency Severity Index, a five-level emergency department triage algorithm with Level 1 (one) indicating the greatest urgency, Level 2 indicating high risk of deterioration, or signs of a time-critical problem, and Level 3 indicating stable, with multiple types of resources needed to investigate or treat), and the order in which patients should be treated. Nurse C stated if the ED had no beds after a patient was triaged, then the patient would be sent back to the waiting room to wait. When asked how often facility staff reassessed patients in the waiting room based on their ESI Level, Nurse C stated she took vital signs and reassessed patients with an ESI Level 2 every one-to-two hours, but usually every two hours. Nurse C stated she took vital signs and reassessed patients with an ESI Level 3 every two hours. Nurse C stated if a patient had any change on reassessment, she would alert the charge nurse.

During an interview on 3/28/22 at 3:22 p.m., Nurse D stated the triage nurse, the flex care nurse, and the float nurse were responsible reassessing triaged patients awaiting an ED bed in the waiting room. Nurse D stated the assistant nurse manager (ANM) determined who would be assigned to duty at the beginning of each shift. Nurse D stated when a patient was roomed in an ED bed, the doctors were usually in the room with the patient within 15 to 30 minutes. Nurse D stated an ED nurse would be assigned to a patient immediately after the patient was roomed. Nurse D stated the doctors performed a medical screening examination on patients in the main ED or in the flex care area, but not in the waiting room. Nurse D stated when she received a patient assignment in the ED, her goal was to see the new patients within 15 minutes of the patient receiving an ED bed. While initially at the bedside, Nurse D stated she would place the patient on the cardiac and pulse oximetry monitor, and the blood pressure cuff, and would explain her care to the patient. Nurse D stated she rounded on her patients every hour, and when doing so checked the monitors (e.g., the screens that show the patient's heart rhythm and vital signs) and the patient's general appearance, and then updated the patient on the plan of care. For newly-room patients, Nurse D stated whichever staff member roomed a patient placed the patient on the monitors.

During an interview on 3/28/22 at 3:39 p.m., ED Tech E he had assisted patients into the ED and their ED room. When doing so, ED Tech E stated walked the patient to the room, had the patient change into a hospital gown, collected and secured valuables and clothing, placed the patient on the monitor, and after leaving the bedside he updated the assigned nurse on the patient's status. ED Tech E stated that when he put the patient on the monitor, he would put the cardiac leads on the patient, the pulse oximeter (measures oxygen concentration in the blood), and the blood pressure cuff. ED Tech E stated he would "get a fresh set" of vital signs at that point. ED Tech E stated the monitors could be seen in the patient's room and at the desk (where the ED staff were seated). ED Tech E stated if he saw an alarm go off, he told the nurse right away.

During an interview on 3/29/22 at 11:53 a.m., Physician F stated she and Physician G staffed the facility's ED on 9/3/21, at or around the time of Patient 1's ED visit. Physician F stated she reviewed Patient 1's medical record from her ED visit on 9/3/21, including a note written by Physician G. Physician F verified Physician G's note indicated Physician G had not performed a medical screening examination on Patient 1 prior to the patient being found unresponsive. Physician F stated she had entered orders for Patient 1's ED treatment, including a laboratory blood work-up, chest X-ray, and 12-lead electrocardiogram (EKG). Physician F stated she did not examine Patient 1 before entering the orders. Physician F stated she entered the orders after performing a chart review, looking at Patient 1's chief complaint and the triage nurse's note. Physician F verified that after Patient 1 was triaged on 9/3/21, facility staff did not obtain additional vital signs until after 6:20 p.m., after the patient became unconscious and unresponsive. Physician F stated a patient could have an unrecognized change in condition if staff did not reassess the patient or obtain follow-up vital signs from a patient awaiting emergency room services. Physician F believed Patient 1's lab work indicated concern due to the patient's elevated troponin level (e.g., a cardiac enzyme, which typically indicates the presence of a heart attack). When asked what was her expected timeframe for performing the MSE, Physician F stated she expected herself and other physicians to perform an MSE as soon as possible; though, Physician F stated the expectation must be weighed against the ED's census. Physician F stated that patients should be reassessed based on their ESI score, and patients with an ESI Level 2 should be reassessed every two to three hours. Physician F stated the nurse could always increase the frequency of their reassessments based on the nurse's assessment of the severity of a patient's condition.

During an interview on 3/29/22 at 2:30 p.m., with Physician G and Consultant J present, Physician G stated he did not recall the events of 9/3/21 involving Patient 1. Physician G stated read his physician note in Patient 1's medical record, from 9/3/21, and could not offer much more information on interview than what was written in the note. Physician G verified he did not examine Patient 1 before she was found unresponsive. Physician G did not recall the reason why Patient 1 was in an ED room for over an hour without him seeing her. When asked for his goal for how soon he tried to see a new patient, Physician G stated he did not have a goal. Physician G stated he tried to see patients as soon as he could. When asked for his definition of a MSE, Physician G stated an MSE was a clinical process to determine of whether an emergency condition exists. Consultant J stated the EMTALA (Emergency Medical Treatment and Labor Act) policy would have the definition and any further questions could be directed at Physician F, and the interview was terminated.

During an interview on 3/30/22 at 9:17 a.m., Nurse H stated she recalled the events from 9/3/21 involving Patient 1. Nurse H stated 9/3/21 was busy and she remembered feeling overwhelmed. Nurse H stated she did not recall the ED managing any traumas, or recall other significant circumstances that would cause ED staff to re-direct focus away from their assigned patients. Nurse H stated she received Patient 1's assignment and another patient assignment at the same time. Nurse H stated she recalled feeling that ED leadership did not supply enough clinical support that day, and the ED was "inundated" [with patients]. Nurse H recalled she did not observe Patient 1 connected to any monitors when Nurse H entered the patient's room. Upon entry into Patient 1's room, Nurse H stated Patient 1 was in the bathroom. Nurse H stated she recalled Patient 1 vocalized concern and wanted to see the doctor. Nurse H recalled Patient 1 was breathing fast and short of breath. Nurse H stated she had intended to put Patient 1 on the monitor, but had "prioritized the other (new) patient" and did not place the patient on a monitor. When asked if she alerted Physician G that Patient 1 was short of breath, Nurse H stated she did not. Nurse H stated she did not see Patient 1 again before Patient 1 was found unresponsive by Nurse L. Nurse H stated Nurse L found Patient 1 unresponsive during rounds. Nurse H stated at change of shift, Nurse H did not report-off to Patient 1's subsequent nurse (Nurse L) the patient's bedside.

During an interview on 3/30/22 at 9:30 a.m., Nurse K stated she was the triage nurse in the facility's ED on 9/3/21. Nurse K stated she recalled the ED was busy, short-staffed, and actively managing a surge of COVID-19 cases. Nurse K stated she always reassessed patients waiting the lobby for change in status and informed patients during triage to notify her about any worsening symptoms. Nurse K was asked how a patient, alone and unable to ambulate safely, could notify her of worsening symptoms. Nurse K stated her observations of the ED waiting area from the ED triage station would sufficiently recognize these patients. Nurse K stated that if a patient with an ESI Level 2 was waiting in the lobby for a room, she would reassess and retake their vital signs every three hours. Nurse K stated it was the triage nurse's responsibility to retake patients' vital signs. When asked what she would do if she did not have time to reassess the patients waiting in the lobby, Nurse K stated she could escalate to the ANM that she needed additional resources to retake patients' vital signs. Nurse K stated she did not recall asking the ANM for resources on 9/3/21. Nurse K the ANM should know if the ED was busy and needed resources, as the ANM was in charge of "running the board and monitoring the board," indicating the patients awaiting and/or receiving ED care. Nurse K stated she remembered the ED being overwhelmed and hectic on 9/3/21.

During an interview on 3/30/22 at 11:00 a.m., Nurse L stated she recalled Patient 1. Nurse L stated she found Patient 1 unresponsive on 9/3/21. Nurse L stated when she found Patient 1, the patient was not connected to any electronic monitor. Nurse L stated she called a "Code Blue" (e.g., a mass notification to alert all staff that a patient has no heart beat or is not breathing, and requires immediate assistance for resuscitation). Nurse L stated that once the code process started on Patient 1, another nurse took over Patient 1's care. Nurse L stated she was not involved in the code processes or Patient 1's aftercare. Nurse L stated Patient 1 was eventually revived and transfered to the facility's intensive care unit (ICU).

During an interview on 3/30/22 at 11:26 a.m., ANM M stated the facility managed a COVID-19 surge in September 2021, which caused abnormally long waits in the lobby. ANM M stated wait times for some ED patients eclipsed 10-plus hours. ANM M stated whether a patient received a bed in the ED depended on the patient's acuity, as determined by the triage nurse, the ANM, and the ED physician. ANM M stated that on 9/3/21 when Patient 1 waited in the lobby the facility's ED was full. ANM M stated she worked 7:00 a.m. to 7:00 p.m. on 9/3/21, and recalled the ED not being fully-staffed. ANM M stated patients waiting in the lobby were monitored by staff, "ideally," by the triage nurse. ANM M stated on 9/3/21, "the triage nurse had two full lines (of people) out the door" and ANM M stated the facility had no staff available to monitor. ANM M stated the nurse was expected to ask for help when they needed it.

During an interview on 3/30/22 at 1:02 p.m., Director A stated, "with that kind of influx (of patients)" on 9/3/21, he expected the ANM would send additional staff to the ED lobby to reassess the patients awaiting ED room placement. Director A stated it was his expectation for patients to be reassessed with a set of vital signs while they waited for an MSE with the physician. Director A stated a MSE should be done "as soon as possible." Director A stated that if patients were not reassessed while awaiting room placement and MSE, the patients could have a change in condition causing a detrimental outcome. Director A stated he expected staff follow the policy for reassessments, and if the policy indicated a patient with an ESI Level 2 should be reassessed every hour, then he expected staff to reassess the patient every hour. When asked how a patient would let the triage nurse know they were feeling worse if they were alone and could not get up, Director A stated the triage station was positioned so the staff could see the patients in the lobby. Director A stated, "That's why reassessments are so important, so [the triage nurse] can be aware of those changes" to a patient's condition. When asked if the patient's vital signs should be checked if vital signs had not been obtained for five hours, Director A stated, "Yes." Director A verified he expected a nurse to report to the doctor when a patient exhibited labored breathing and shortness of breath. Director A stated the nurses did not need to inform the doctor when a patient was roomed, as doctors were notified automatically.

During an interview on 3/30/22 at 2:11 p.m., Physician F stated a physician must examine the patient to facilitate an MSE, as a nurse was not qualified for the task. Physician F stated Patient 1 was triaged, and received a laboratory blood work-up, an EKG, and chest X-ray, as ordered, but was not examined by a physician.

During an review of Patient 1's medical record the "ED Narrator Timeline," dated 9/3/21, indicated Patient 1 arrived at the ED at 12:37 p.m. The record indicated facility staff obtained a full set of vital signs upon prsentation. The record indicated Patient 1 was triaged with an ESI Level 2 and a chief complaint of "Shortness of breath.," at 12:38 p.m. At 1:17 p.m., Patient 1 had blood drawn for a laboratory work-up, which indicated a troponin level of 0.11 nanograms per milliliter (ng/mL, a unit of measure; normal troponin level is less than 0.04 ng/mL) and a BNP level (brain natriuretic peptide) of 1,092 picograms per milliliter (pg/mL, a unit of measure; normal BNP level is less than 100 pg/mL and elevated levels may indicate the presence of heart failure). At 1:58 p.m., an EKG was performed on Patient 1, which indicated a "left bundle branch block" (e.g., a block in the heart's electrical pathway sometimes associated with heart attack). At 3:04 p.m., Patient 1's chest X-ray images were available. At 5:00 p.m. the record indicated Patient 1 was roomed in the ED. The record indicated an entry by Nurse H: "Breathing pattern: Tachypnea [(shortness of breath)]. Characteristics: Labored; dyspnea [(difficulty breathing)] with speech; shallow. Breath sounds: Abnormal." At 6:05 p.m., Nurse L documented "[Nurse L named] assigned as Registered Nurse." At 6:20 p.m., Nurse H documented, "Code started." At 11:12 p.m., Patient 1 was admitted to the ICU.

During a review of Patient 1's medical record the "History of Present Illness," dated 9/3/21, indicated a note written by Physician G at 11:55 p.m. The record indicated "[Patient 1] is a 88 Y female who presents to the Emergency Department with presentation for [complaints of] shortness of breath this AM. [Patient] had been roomed, per ED RN report [the patient] was ambulating, c/o shortness of breath . . . was not on the monitor however speaking in full sentences . . .. She had been awaiting physician evaluation, had been in room when ED RN noted [Patient 1] was apneic [(not breathing)] and pulseless. CODE BLUE was activated, we contacted [Patient 1's] daughter . . . . I did not get a chance to speak with [Patient 1]."

During a review of Patient 1's medical record a physician note dated 9/4/21, at 6:43 a.m., indicated "Addendum 1:48 am CODE BLUE NOTE: Patient with another CODE BLUE. . . . Per discussion with daughter DNR [Do Not Resuscitate (e.g., allow natural death)] now. Addendum 6:41 AM Late entry note. Spoke with [daughter named] on the phone earlier after she visited her mother in the ICU. . . . will likely pursue comfort measures and withdraw care."

During a review of Patient 1's medical record a critical care progress note, dated 9/4/21, at 11:56 a.m., indicated, "Diagnosis: PEA Arrest (refers to cardiac arrest in which the EKG shows a heart rhythm that should produce a pulse but does not). . . . General Appearance: intubated (tube has been placed down the throat to allow for mechanical ventilation), minimally responsive. . . . "

Review of Patient 1's death note dated 9/4/21 at 4:36 p.m. revealed, "Death pronounced at 1204 9/4/2021. . . . Immediate cause of death: PEA Arrest . . . B. Due to heart failure (a long-term condition in which the heart cannot pump blood well enough to meet the body's needs all the time) . . . . C. Due to hypertension (high blood pressure)."

Review of the ED Log and electronic medical records, dated 9/3/21, revealed the following patients (Patients 3, 4, and 5) arrived in the ED around the same time Patient 1 arrived in the ED:

Patient 3's ED Narrator Timeline indicated Patient 3 arrived at the ED on 9/3/21 at 11:49 a.m. At 11:50 a.m., Patient 3 was triaged at ESI Level 2, with a chief complaint of "Shortness of breath." Patient 3 received an MSE at 4:51 p.m. and at 8:29 p.m. was admitted to the hospital.

Patient 4's ED Narrator Timeline indicated she arrived at the ED on 9/3/21 at 12:15 p.m. At 12:16 p.m. Patient 4 was triaged at ESI Level 3, with a chief complaint of "Abnormal Blood Test" and "Abdominal Pain." Patient 4 received an MSE at 5:05 p.m., and at 11:03 p.m. was discharged home from the ED.

Patient 5's ED Narrator Timeline indicated he arrived at the ED on 9/3/21 at 12:45 p.m. At 12:49 p.m., Patient 5 was triaged at ESI Level 2, with a chief complaint of "Altered Level of Consciousness." Patient 5 received an MSE at 3:51 p.m., and at 6:46 p.m. was discharged home from the ED.

Review of facility's policy and procedure titled "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" approval date 9/21, indicated, "Medical Screening Examination (MSE) means the process required to determine within reasonable clinical confidence whether or not an emergency medical condition exists. It is an ongoing process, including monitoring of the patient until the patient is either stabilized or transferred. A MSE will be provided by a qualified medical provider to the extent of the capacity and capability of the hospital, including the availability of on-call physicians and specialists, and the ancillary services routinely available at the hospital." The policy further indicated, "All individuals presenting to the Emergency Department for medical treatment will be assigned an Emergency Severity Index Scale (ESI) ...The system utilizes five levels of classification, with Level 1 being the most serious and Level 5 being the least serious. The type and level of emergency care that an emergency patient receives is determined by both the patient's condition and the assessment/reassessment of their medical needs by qualified emergency services providers." The policy indicated MSE's, at a minimum, require physical examination of the patient.

(b) Patient 6

During an interview and ED record review with Manager B and Director A on 3/28/22 at 4:41 p.m., Patient 6 arrived in the ED on 10/7/21 at 11:09 a.m. Vital signs were taken at 11:09 a.m. Patient 6 was triaged with an ESI Level 3 11:14 a.m. with a chief complaint of "Dizzy." Per Manager B, the ANM filled out the document "ED Leaving Before Medical Evaluation" which revealed that at 3:38 p.m. and 3:42 p.m., staff looked but could not find Patient 6. Manager B verified that there was no documentation that Patient 6 had been reassessed or had vital signs taken between triage and when staff began looking for Patient 6, a total of 4.5 hours. When queried, Director A stated, "They (ED staff) have to document and reassess (patients) every two hours."

Patient 7

During an interview and ED record review with Manager B and Director A on 3/28/22 at 4:45 p.m., Patient 7 arrived in the ED on 10/8/21 at 3:25 p.m., vital signs were taken at 3:37 p.m., and Patient 7 was triaged an ESI Level 3 at 3:38 p.m. with a chief complaint of "Abdominal Pain." At 7:08 p.m., Patient 7 signed form "ED Leaving Before Medical Evaluation" and wrote, "Waits too long" in section "Reason for leaving." Manager B verified there was no documentation that Patient 7 had been reassessed or had vital signs taken between 3:37 p.m. and 7:08 p.m., approximately 3.5 hours. Manager B and Director A confirmed Patient 7's vital signs should have been reassessed while waiting for a MSE.

Patient 12

During an interview and ED record review with Director A on 3/28/22 at 5 p.m., Patient 12 arrived in the ED on 1/8/22 at 5:03 a.m. for a chief complaint of cough, an ESI triaged at Level 3, Urgent, and vital signs were taken at 5:03 a.m. At 7:55 a.m., Patient 12 signed the form titled "Leaving Before Medical Evaluation/Treatment" Leave Against Medical Advice (AMA) indicating, "Too long of a wait. I've been there about 4 hours and so many people went in front of me." Director A verified the only documented vital sign for Patient 12 was at 5:03 a.m. Director A verified Patient 12 had no reassessment and did not receive an MSE.

Patient 15

During an interview and ED record review with Manager B on 3/29/22 at 2:18 p.m., Patient 15 arrived in the ED on 2/11/22 at 10:08 p.m., for chief complaints of head injury with no loss of consciousness, an ESI triaged at level 3, Urgent. Manager B verified Patient 15's documented vital signs were taken at 2/11/22 at 10:17 p.m. The ED Nurse filled out the form titled "Leaving Before Medical Evaluation/Treatment" Elopement (patient who leaves after nurse initiated a triage) for Patient 15 dated 2/12/22, that indicated the nurse contacted Patient 15 at 2:51 a.m. and at 2:58 a.m. Manager B verified the staff first noted Patient 15 was no longer in the waiting area and tried to call her back was at 2:51 a.m. Manager B verified Patient 15 had no reassessment and did not receive an MSE.

Review of facility's policy and procedure titled "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" approval date 9/21, indicated, "Medical Screening Examination (MSE) means the process required to determine within reasonable clinical confidence whether or not an emergency medical condition exists. It is an ongoing process, including monitoring of the patient until the patient is either stabilized or transferred. A MSE will be provided by a qualified medical provider to the extent of the capacity and capability of the hospital, including the availability of on-call physicians and specialists, and the ancillary services routinely available at the hospital." The policy further indicated, "All individuals presenting to the Emergency Department for medical treatment will be assigned an Emergency Severity Index Scale (ESI) ...The system utilizes five levels of classification, with Level 1 being the most serious and Level 5 being the least serious. The type and level of emergency care that an emergency patient receives is determined by both the patient's condition and the assessment/reassessment of their medical needs by qualified emergency services providers." The policy indicated MSE's, at a minimum, require physical examination of the patient.

Review of facility's policy and procedure titled "ED Assessment and Reassessment" approval date 9/21, indicated, "All patients arriving to the Emergency Department (ED) will have documented vital signs and an assessment related to their complaint and priority assigned to them using the Emergency Severity Index (ESI) Five Level triage system. . . . ESI Level 2: Reassess at least every hour or more frequently as needed per patient condition. ESI Level 3: Reassess at least every two hours or more frequently as needed per patient condition. . . ."


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