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Based on record review, observation and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by failing to ensure that a comprehensive medical screening examination was performed in a timely manner on a patient (Patient #9) who presented to the hospital with complaints of substernal chest pain after it was determined during the triage process that the patient's presenting symptomatolgy included 1) substernal chest pain with a self reported duration of approximately 5 hours and a self reported intensity of 10 on a pain scale of 1-10; 2) a Blood pressure reading of 236/116; and 3) an EKG with diffuse ST elevation. (See findings cited at A2406).

Based on record review, observation and interview, the hospital failed to ensure that a comprehensive medical screening examination was performed in a timely manner on a patient (Patient #9) who presented to the hospital with complaints of substernal chest pain after it was determined during the triage process that the patient's presenting symptomatolgy included 1) substernal chest pain with a self reported duration of approximately 5 hours and a self reported intensity of 10 on a pain scale of 1-10; 2) a Blood pressure reading of 236/116; and 3) an EKG with diffuse ST elevation. The failure to provide a timely comprehensive medical screening examination occurred when Patient #9 was instructed to return to the ED (Emergency Department) waiting room and remain (unmonitored) until an ED room became available. Patient #9 remained in the ED waiting room (unmonitored) until approximately 6:31 p.m. at which time Patient #9 was wheeled back to the triage area by a registered nurse (S9) who was summoned by someone in the waiting room that Patient #9 needed assistance. Findings:

The medical record of Patient #9 was reviewed. This review revealed Patient #9 was a 41 year old female who presented to the ED (Emergency Department) at Our Lady of the Lake Regional Medical Center on 12/05/11 with the mode of arrival documented as "Ambulatory".

Review of the Triage Assessment revealed Patient #9 presented to the ED at Our Lady of the Lake Regional Medical Center on 12/05/11 at 5:49 p.m. Documentation revealed Patient #9's Chief Complaint was "Chest Discomfort: substernal chest pain with abd pain starting 1230-100pm today, denies n\v, +sob, also c\o headache". Documentation revealed Patient #9's vital signs were Blood Pressure of 236/116; Pulse of 103; Respirations of 19; Temp of 98.8; and Pulse Ox of 100%. Documentation revealed Patient #9 was reporting her pain level as 10. Documentation revealed Patient #9 was assigned a triage acuity level of 3. (Our Lady of the Lake Regional Medical Center policy/procedure titled "Triage and Medical Screening Exam (Adult & Pediatric)" documents an acuity level of 3 as "ESI Level 3: Urgent- Patients with injury or illness which require prompt care, but not generally result in severe impairment if untreated immediately").

Review of the ED Record revealed the TIMI Score was assessed by the triage nurse to be "0" on 12/05/11 at 5:58 p.m. (According to hospital documentation, Our Lady of the Lake Regional Medical Center TIMI Score is determined by factoring the following information: One (1) point is given for someone 65 years of age or older; One (1) point is given for the presence of greater than 3 CAD Risk Factors (Family Hx, HTN, High Cholesterol, DM, Active Smoker); One (1) point is given for known CAD (Stenosis > or = to 50%); One (1) point is given for ASA use in past 7 days; One point is given for Recent (last 24 hour) Severe Angina; One (1) point is given for increased Cardiac Enzymes; and One (1) point is given for ST Deviation > or = to 0.05 mV). Further review of the ED Record revealed the patient's history included CVA, TIA, Hyperlipidemia, Hypertension, Acute Renal Problems, and Diabetes Mellitus. In addition, Patient #9 reported substernal chest pain that she rated 10 of 10. (Documentation in the medical record at the time of triage failed to provide evidence to support the TIMI Score of "0" that was assigned to Patient #9 at the time of triage as there was no documentation to 1) indicate that 1 point was given relating to Patient #9's complaints of substernal chest pain since 12:30-1:00, 2) factor and include all risk factors such as the patient's history which included CVA, TIA, Hyperlipidemia, Hypertension, Acute Renal Problems and Diabetes Mellitus with no documentation to indicate whether there was a family history or not in order to determine if greater than 3 risk factors existed as identified on the TIMI Score criteria, and 3) factor not having knowledge of the presence of elevated cardiac enzymes as there was no blood work available at the point of triage when the TIMI Score of "0" was given to Patient #9.

Review of the ED Nurses Notes revealed an entry indicating performed on 12/05/11 at 6:55 p.m. (one hour and six minutes after documented time of initial arrival in triage and one hour and two minutes after the first EKG was done in triage) by S6 (Registered Nurse) which documented "pt laying on the floor in triage 3, states 'I need something for this pain' pts family in triage 3 with patient yelling 'someone do something for her pain' pts family very irate. Explained that we are about to place pt in c7, pts mother at bedside continues to yell, asked to leave, pts mother refuses to leave, security called to assist".

Review of the ED Physician Notes revealed an entry authored by S8 (ED physician) which indicated the service date/time as 12/05/11 at 6:37 p.m. Documentation on this ED physician note included "Time seen: Date & time 12/05/11 18:37:00, Immediately upon arrival. Additional information: MSE (1900) - (name of S4-ED physician)- pt with CP, constant in nature, with EKG c/w pericarditis. Diffuse elevation, PR depression in lead 2. Pt awaiting room in WR, had worsening of pain. No beds available at the time. Pt brought back to triage 3 to get repeat EKG. While in room, pt became agitated and lay down on floor. Family became very upset and security was involved. Repeat EKG was unchanged from #1, still c/w pericarditis. Pt brought back to next available room". Documentation revealed an entry (no time indicated) that read "Patient's mother threw herself on the floor in triage and made a scene and security was called. Her mother was told that she could not come to the bedside due to her behavior. Patient now wants to sign out AMA and go elsewhere". Documentation under the section of Impression and Plan was "Acute Idiopathic Pericarditis".

Review of the medical record revealed the following orders dated 12/05/11 at 6:38 p.m.:
? Cardiac Monitoring Stat
? IV to HL Stat
? Aspirin 325mg, PO, Tablet, Stat
? Basic Metabolic Profile (Chem 7) Stat/Now
? Brain Natriuretic Peptide (BNP) Stat/Now
? CBC (Stat/Now)
? Cardiac Enzymes-No Troponin Stat/Now
? PT (Includes INR) Stat/Now
? PTT Stat/Now
? Troponin Adv Level Stat/Now
? Chest EPA and Lateral Stat/Now
? ECG Stat/Now

Review of the medical record revealed the following:
? No documentation was found in the medical record to indicate that Patient #9 was placed on a cardiac monitor as ordered stat on 12/05/11 at 6:38 p.m. This was confirmed in an interview with the RN Supervisor (S11) on 12/20/11 at 2:35 p.m. S11 reported the documentation of placing the patient on a cardiac monitor should be charted under the Cardiovascular Section of the notes or on a miscellaneous note. S11 reported the documentation could not be found after reviewing Patient #9's medical record.

Review of the laboratory results revealed abnormal values (outside the normal parameters as set by the laboratory) were as follows:
? Chem 7- CO2- 18 mmol/L (normal 22-33); Gluc- 271 mg/dL (normal 70-100); BUN- 37 mg/dL (normal 5-25); Creatinine- 2.86 mg/dL (normal 0.57-1.25)
? CBC- WBC- 14.2 (normal 4.0-11.0); Hct- 36.6% (normal 37.0-47.0); MCV- 73fl (normal 80-100); Plts- 389 (normal 150-375); Lymphs- 44% (normal 15-40);
? CPK- 357 unit/L (normal 29-168); CK MB- 8.7ng/ml (normal 0.1-6.5)
? Troponin Adv Level- 0.90 ng/ml (normal 0.01-0.30)
Imperative Data documented on the lab results for the Troponin Adv level of 0.90 ng/ml revealed "Myocardial damage range greater than 0.30ng/ml".


Review of the medical record revealed two (2) EKG's were done during Patient #9's visit to the ED at Our Lady of the Lake Regional Medical Center on 12/05/11. The first EKG was dated 12/05/11 at 5:53 p.m. The second EKG was dated 12/05/11 at 6:31 p.m. Documentation on the first EKG revealed a handwritten entry (not timed) by the ED physician (S4) that indicated Diffuse ST elevation and Pericarditis verses Repolarization. Documentation on the second EKG revealed a handwritten entry (not timed) by the ED physician (S4) that indicated no change from the first EKG.

Cardiologist over-read of the EKG performed on Patient #9 at Our Lady of the Lake Regional Medical Center on 12/05/11 at 6:31 p.m. revealed the Cardiologist interpreted the EKG as "Diffuse st elevation consider pericarditis or acute injury".

Review of the Nursing Notes revealed Patient #9's vital signs at the time of initial triage (12/05/11 at 5:56 p.m.) were Blood Pressure of 236/116; Pulse of 103; Respirations of 19; Temp of 98.8; and Pulse Ox of 100%. Further review of the record revealed an entry dated 12/05/11 at 5:58 p.m. by S3 (Registered Nurse) which indicated Patient #9's pain level was reported to be 10. Review of the medical record revealed the first reassessment of Patient #9's blood pressure was on 12/05/11 at 7:18 p.m. when the blood pressure was reassessed to be 201/115.

Review of the Nursing Notes revealed an entry dated 12/05/11 at 7:52 p.m. by S10 (Registered Nurse) which indicated the ED physician (S8) was notified of a critical lab value (Troponin of 0.9) and the entry also indicated that Patient #9 left the ED against medical advice.

Review of the Emergency Department Discharge Instructions revealed Patient #9 was assigned to S8 (ED physician) on 12/05/11 at 6:37 p.m. Documentation on the Emergency Department Discharge Instructions under the section "Instructions Enclosed" included "Form-Rejection of Medical Treatment (AMA); Pericarditis-Brief" and "Follow Up" with "name of physician" "within 3 to 5 days". Documentation on the Emergency Department Discharge Instructions under the section of comments included "Return to ED if worse in any way". Documentation revealed S5 was the registered nurse who provided the discharge instructions to Patient #9.

Review of the medical record revealed an entry dated 12/05/11 at 7:43 p.m. by S5 (Registered Nurse) which documented "pt states she wants to leave because her family can not come back. IV d/c. AMA for signed". Further review revealed an entry dated 12/05/11 at 7:47 p.m. by S6 (Registered Nurse) which documented "pt standing at nurses station with family member, states 'I want to leave'".

The medical record relating to Patient #9's visit to Hospital A was reviewed. This review revealed Patient #9 presented to the ED at Hospital A on 12/05/11 with the arrival time documented as 7:54 p.m. Documentation revealed Patient #9's Chief Complaint was "Chest Pain". Documentation revealed an entry under the section of "Cardiac" indicating "Tachycardiac. STEMI PER EKG". Documentation revealed Patient #9 was transported to the Cardiac Cath Lab and the procedure start time for the Cardiac Cath was 12/05/11 at 8:50 p.m.

Observations of the ED (Emergency Department) were made on 12/19/11 between 9:45 a.m. and 10:30 a.m. Observations in the triage staff consisted of an ED physician, a registered nurse, and an EKG technician. S2 (Divisional Director of Regulatory and Infection Prevention) confirmed that an ED physician is assigned to the triage area of the ED (Emergency Department).

S3 (Registered Nurse) was interviewed on 12/19/11 at 1:50 p.m. S3 reported her first contact with Patient #9 was on 12/05/11 at approximately 5:49 p.m. immediately following the initial check-in and the first EKG. S3 reported she was working as the triage nurse at the time. S3 reported that she received the EKG strip and that S4 (ED physician working in triage) saw a st elevation on the strip and felt it was pericarditis. S3 reported Patient #9's blood pressure was 236/116. S3 indicated that Patient #9's complaints included substernal chest pain, shortness of breath, and headache. S3 indicated that she informed S4 (ED physician working in triage) that Patient #9 was hypertensive and that Patient #9 had a history of hypertension. S3 indicated that she informed Patient #9 to return to lobby to wait for ED room to open up. S3 indicated that S9 (ED Registered Nurse) brought Patient #9 back to the triage area with complaints of continued chest pain and a second EKG was done on 12/05/11 at 6:31 p.m. S3 reported that no change from the first EKG was documented on the second EKG by S4 (ED physician working in triage). S3 reported S4 (ED physician working in triage) informed her to find an ED bed for Patient #9 at approximately 6:37 p.m. S3 indicated that she (S3) went to the back (where the ED Rooms are located) and Room C-7 opened up for Patient #9. S3 indicated that as she was returning to the triage rooms, she heard an admissions clerk ask S6 (ED Registered Nurse) for assistance with the family of Patient #9. S3 reported that she was behind S6 (ED Registered Nurse) walking toward triage room 3 when S6 (ED Registered Nurse) opened the door to triage room 3 where Patient #9 was located. S3 indicated that Patient #9 was lying on the floor with no shirt on and that Patient #9's mother and sister were in the room with Patient #9. S3 reported Patient #9's mother approached S6 (ED Registered Nurse) and became physically aggressive with S6. S3 reported that Patient #9's mother grabbed S6's arm and was screaming "help her, she is in pain". S3 indicated that Patient #9's mother and sister were yelling at staff and were interfering with staff's ability to provide treatment to Patient #9 and that security was called for this reason. S3 reported that Patient #9's mother and sister were taken out of the room by deputy sheriffs' after refusing to calm down and allow staff to treat Patient #9.

S4 (ED physician working in triage) was interviewed on 12/19/11 at 2:20 p.m. S4 reported he was working in the triage area at the time Patient #9 presented to the ED on 12/05/11. S4 indicated that two EKG's were performed on Patient #9 in the triage area. S4 indicated the first EKG was at 5:53 p.m. and the second was at 6:31 p.m. S4 reported he reviewed both EKG's and felt the EKG's were consistent with Pericarditis. S4 reviewed the EKG's and reported there was diffuse st elevation and no reciprocal changes and Pericarditis verses Early Repolarization. S4 reported he did not feel the st elevation on the EKG was indicative of a Myocardial Infarction. When asked about the process for triaging patients who present to the ED with complaints of chest pain, S4 indicated the triage includes an EKG and triage assessment on patients who present to the ED with complaints of Chest Pain. When asked about the triage of Patient #9, S4 indicated that he could not recall all of the events relating to Patient #9's triage. S4 indicated the ED was very busy and reported there were no available ED rooms for Patient #9 at the time she presented to the ED. S4 reported he thought he was in another triage room assisting another patient when Patient #9 initially presented for triage. S4 indicated he thought Patient #9's EKG printout from the first EKG was sitting on the desk when he first looked at it and that Patient #9 was in the waiting room when he first read it. S4 reported the triage nurse may have informed him of the patient's complaints of chest pain but he did not recall being informed of the patient's blood pressure reading of 236/116. When asked when he became aware of Patient #9's blood pressure reading of 236/116, S4 reported that he first became aware of the patient's blood pressure reading of 236/116 after the completion of his shift. S4 reported that he logged in to the system from his home and looked at Patient #9's medical record. S4 reported this review was the first time he remembered seeing the patient's blood pressure of 236/116. S4 reported that he informed the triage nurse to find an ED bed for Patient #9 after the completion of the second EKG which was done after Patient #9 returned to the triage area. S4 reported Patient #9 was brought to room C7.

S5 (ED Registered Nurse) was interviewed on 12/19/11 at 2:35 p.m. S5 reported her initial contact with Patient #9 was on 12/05/11 at approximately 6:50 p.m. S5 reported she was the primary nurse caring for Patient #9 while in the ED. S5 reported Patient #9 was awake, alert and oriented. S5 reported Patient #9 was voicing complaints of substernal chest pain and a headache which she rated the pain to be 10 of 10 on the pain scale. S5 reported that she started an IV and collected blood for lab work at approximately 7:18 p.m. S5 indicated that Patient #9 left the hospital's ED AMA (Against Medical Advice) before all treatment could be provided. S5 reported she informed Patient #9 that her blood work was pending and that she had already had her EKG done. S5 reported Patient #9 was insistent on leaving the hospital. S5 reported Patient #9 took her AMA forms and left the hospital with her family or friends stating "we are going to general".

S8 (ED physician) was interviewed on 12/20/11 at 9:40 a.m. S8 indicated that she was Patient #9's attending ED physician. S8 reported that her initial assessment of Patient #9 was when she (Patient #9) was lying in an ED bed in room C7. S8 reported that she reviewed Patient #9's EKG's and examined Patient #9 and felt that Patient #9 had Pericarditis. S8 reported that she was unsure of the exact time of her examination of Patient #9. S8 indicated that the initial orders are dated 12/05/11 at 6:38 p.m. so she thought her examination was sometime around 6:38 p.m. S8 indicated that Patient #9 reported that she wanted to leave the hospital while she (S8) was in the process of completing the medical screening examination and stabilizing treatment. S8 reported that she informed Patient #9 "your still in a lot of pain, let me get you some pain relief". S8 reported that the person with Patient #9 said "we just want to leave". S8 reported that she (S8) then told Patient #9 "your EKG is abnormal, you could die if you leave". S8 reported Patient #9 was insistent on leaving and got out of bed and started walking down hall with IV still attached. S8 reported the nurse took Patient #9's IV out in hall and Patient #9 walked out before signing the AMA forms. S8 indicated that the lab called after Patient #9 had left the hospital to report Patient #9's Troponin level of 0.90. S8 reported she felt Patient #9 was appropriately diagnosed with Pericarditis. S8 indicated that she would have consulted with a Cardiologist had Patient #9 stayed in the hospital and not chosen to leave AMA. S8 indicated that the ED was extremely busy and all rooms were full at the time Patient #9 initially presented to the ED.

S9 (ED Registered Nurse) was interviewed on 12/20/11 at 12:00 noon. S9 indicated that she was floating in the hall and that there were approximately 9 patients holding in the hallway at the time Patient #9 presented to the ED. S9 indicated that all ED rooms were full and the patients holding in the hallway were waiting for an ED room to become available. S9 indicated that she was assisting with the care of the patients holding in the hallway. S9 indicated that patients who require a higher level of monitoring are placed on the hallway when all ED rooms are full. S9 indicated that someone in the waiting room got her attention and told her someone in the waiting room needs help. S9 reported that she saw a lady (Patient #9) in a wheelchair slumped back holding her chest. S9 indicated the lady would not verbally respond when asked what was wrong. S9 reported that she wheeled the lady to the triage area and assisted her to an exam table so that an EKG could be performed. S9 indicated that she had no other involvement in the care provided to Patient #9.

S11(ED Nursing Supervisor) was interviewed on 12/20/11 at 12:45 p.m. When asked about the process for triaging a walk-in patient who presents to the ED with complaints of chest pain, S11 reported an EKG and triage assessment including vital signs would be performed on the patient. S11 indicated the EKG is routinely performed by an EKG technician and the vital signs are routinely obtained by an ER Tech. S11 indicated the nursing assessment is routinely conducted by the registered nurse assigned to triage. S11 indicated the triage nurse should review the EKG and assessment data including vital signs of the patient who presents with chest pain with the ED physician assigned to the triage area. When asked about any hospital approved policies/procedures relating to patients who present to the hospital's ED with chest pain, S11 indicated that he was not aware of a specific hospital approved policy/procedure relating to patients who present to the hospital's ED with chest pain but was aware of a flow-sheet relating to patients who present with chest pain.

Review of the flow-sheet titled "Heart Alert ER: Unknown Heart Alert" revealed (in part) the following in regards to a patient who arrives ambulatory/walk in: Pt asked by triage/hall nurse if they are having ACS Typical/Atypical symptoms>
If yes>Stat EKG>Either Acute MI or Acute MI-NSTEMI
? If Acute MI>Heart Alert paged 901-0443. Enter "ext+911.">Cardiologist notified about patient by ECU MD>CSR calls overhead operator (53333) and asks them to call "Heart Alert ER.">Lab and Quick Reg respond to Heart Alert. House Managers begin looking for an inpatient bed for the patient.>Patient to the Cath Lab with ECU MD
? If Acute MI-NSTEMI>Perform TIMI Score>TIMI Score greater than or equal to 3> If Yes>Notify ER MD and initiate Track 2 of order set. If No>Notify ER MD and initiate Track 3 of order set. (Review of the order set for Track 2 revealed AMI-NSTEMI-Unstable Angina (+Troponin, TIMI > or = to 3, (arrow down) ST or EKG changes) Consult/NotifyCardiologist; Bedrest; NPO except Meds; Vital Signs q 15 minutes; PT/PTT; (check boxes for various medications for the physician to choose). (Review of the order set for Track 3 revealed Chest Pain Observation (No EKG changes, Neg-Troponin, TIMI<3) Consult/Notify Cardiologist; Bedrest with BRP (if pain free); Clear Liquids; Vital Signs q 1 hour until stable then q 4 and PRN pain; Troponin, CK, CK-MB & 12 lead EKG at 2 & 6 hours post initial set; (check boxes for various medications for the physician to choose).
If no>Triaged according to time of arrival/chief complaint/acuity.

Review of the flow-sheet titled "Chest Pain-Non Stemi" revealed (in part) the following in regards to a patient who arrives at the hospital by means other than emergency medical transport: Patient Arrives Self>Triage>Place Pt in Bed>Perform ECG Draw Lab>Physician Reads ECG> Either MD Assesses Pt. OR Initiate AMI Dashboard & Document ECG Read Time & ASA on arrival.

Review of the flow-sheet titled "Chest Pain-Stemi" revealed (in part) the following in regards to a patient who arrives at the hospital by means other than emergency medical transport: Patient Arrives Self>Triage>Place Pt in Bed>Perform ECG Draw Lab>Physician Reads ECG Sees pt.> Either ECG changes to Cath Lab OR Initiate AMI Dashboard & Document ECG Read Time & ASA on arrival.