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Based on interviews, document reviews, review of video, and review of 22 open and closed medical records, it was determined that there was a delay in performing a medical screening examination for one patient (P1) seen in February, 2019.

P1 was brought the hospital ED via EMS in early February complaining of a two day history of nausea, vomiting, and diarrhea. According to EMS documentation, P1 was alert and oriented and neurologically intact upon arrival at the ED.

The hospital medical record indicated P1 was triaged as an ESI 3 approximately 5 minutes after arrival. Approximately 5 minutes after triage, P1 is seen on the video to slump over to the left side. At the 15 minute mark, the patient is transferred by EMS to a hospital bed in the hall. P1 is clearly minimally responsive and has very little response to noxious stimuli as one of the EMS provider squirted aerosolized saline up P1's nose. Again, no hospital staff assisted or assessed P1.

After the transfer into the hospital bed, the patient was placed back against the wall in the hall, where P1 remained for approx. 25 minutes. P1 started seizing after about 10 minutes. Multiple staff are seen walking past P1 but no assessment is done, and no monitoring or vital signs were checked. P1 had at least three seizures while staff walked past. Following the seizure activity, P1 was not responsive at all. After being in the hall a total of approx. 35 minutes, P1 was taken to a room by a staff person who pulled the back of the stretcher and did not look at or interact with the patient.

According to documentation in the record, P1 continued to exhibit seizure activity and resuscitation efforts started immediately after P1 was placed in the ED room and a Code Blue was called approx. 10 minutes later when P1 lost the heart rate. After an hour of resuscitation efforts, the code was terminated with P1 never regaining a viable heart rhythm.

The investigation confirmed that P1 suffered a delay in the MSE when P1's change in condition was not acted upon by the staff and no physician was notified of P1's condition until the patient was in a room.