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Based on review of facility policy, medical record review, and interviews, the facility failed to provide a Medical Screening Examination and failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the Emergency Department (ED) with chest pain of 35 patients reviewed.

The findings included:

Patient #1 presented to the ED on 5/20/2021 at 12:10 AM with intermittent chest pain. An Electrocardiogram (EKG) was performed at 12:17 AM and reviewed by the ED Physician. At 12:32 PM a nursing triage was performed and the patient's chest pain had subsided. The patient was triaged using the Emergency Severity Index (ESI) with a score of a 2 indicating emergent needs. He was triaged back to the ED waiting room. No diagnostic testing was performed for the patient and a Medical Screening Examination (MSE) was not done on the patient. The patient left the ED Against Medical Advice (AMA) at 1:50 AM. On 5/21/2021 at 12:59 PM Patient #1 presented to Hospital B with chest pain where a MSE was performed for the patient and diagnostic testing was performed. The patient was taken to the heart cath lab at 8:59 PM where a 99% occlusion to his Right Coronary Artery (RCA) was found, which required stent placement to the RCA.

Refer to A-2406 and A-2407.

Based on review of facility policy, medical record review, and interviews, the facility failed to provide a Medical Screening Examination for 1 patient (Patient #1) who presented to the Emergency Department (ED) with chest pain of 35 patients reviewed.

The findings included:

Review of the facility's policy titled "EMTALA," (Emergency Medical Treatment and Active Labor Act) last reviewed 11/1//2019, showed "...it is the policy...to provide a MSE [medical screening examination] within its capability to all individuals who present to a DED [dedicated emergency department] for examination or treatment of any medical condition, whether emergent or nonemergent. An examination performed by a Qualified Medical Professional [QMP] to reach with reasonable clinical confidence the point at which it can be determined whether an emergency medical condition does or does not exist..."

Medical record review of the ED Patient Care Timeline dated 5/20/2021 showed Patient #1 presented to the ED at Hospital A at 12:10 AM with a complaint of chest pain and shortness of breath.

Medical record review of an Electrocardiogram (EKG) for Patient #1 done at Hospital A dated 5/20/2021 at 12:17 AM (7 minutes after Patient #1's arrival at the ED) showed the "...Sinus Rhythm [normal rhythm]. First degree AV [atrioventricular] block [abnormal conduction in the AV node] delay, bradycardia [slow heart rate], normal axis [normal conduction direction]..."

Medical record review of an ED Nursing Triage record at Hospital A dated 5/20/2021 at 12:32 AM (22 minutes after arrival at the ED) showed Patient #1 complained of intermittent burning and radiating chest pain and his pain was rated as a 7 (on scale of 1-10 with 10 being the worst pain). His vital signs were as follows: Pulse 57, Respirations 20, Blood Pressure 132/68, and pulse oximetry 95% on room air. His previous medical history showed a history of a previous acute myocardial infarction (heart attack) and a previous cardiac catherization done on 4/6/2019. The patient was triaged as a 2 (indicating emergent needs) on the Emergency Severity Index (ESI). The patient was placed in the ED waiting room after triage to await bed placement in the ED. No further diagnostic testing was ordered.

Medical record review of the ED record at Hospital A dated 5/20/2021 showed the patient was roomed as "off the floor" at 1:50 AM (indicating the patient was not in the ED). The patient had left the facility against medical advice (AMA) and was discharged at 2:00 AM. There was no documentation an AMA form was signed Patient #1.

Review of an office Outpatient visit Cardiology consult dated 5/20/2021 at 3:15 PM showed Patient #1 was evaluated for a history of Coronary Artery Disease (CAD) and a prior history of coronary artery disease with a percutaneous coronary intervention (stent) to his left anterior descending artery in 2019. Further review showed the patient was "...recently seen in the ER [emergency room] last night in Bristol for increasing shortness of breath he has taken 6 nitro [nitroglycerin tablets] in the last 2 weeks with orthopnea [shortness of breath when lying down] and exertional chest discomfort similar to his prior episodes. His EKG demonstrates sinus rhythm poor R wave progression [abnormal conduction in the ventricle] across the anterior leads. I have offered him a catherization and he does not want to proceed at this point will do it next week. I will be placing him on the [schedule] for catherization with my partner next week..." His vital signs were as follows: BP 124/72 and Pulse 57.

Medical record review of an ED Record from Hospital B dated 5/21/2021 at 12:59 PM showed Patient #1 presented to the ED with chest pain and was admitted to the facility and discharged home on 5/23/2021.

Medical record review of the ED Patient Care Timeline at Hospital B dated 5/21/2021 at 1:13 PM showed the following laboratory diagnostic testing was done on Patient #1: Urinalysis, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Troponin 1, Magnesium, and Phosphorus. An EKG and a chest x-ray were ordered.

Medical record review of an EKG done on Patient #1 at Hospital B dated 5/21/2021 at 1:18 PM showed "...Sinus Rhythm with first degree AV Block, no ectopy. ST segments with mild depression [cardiac ischemia] in inferior leads..."

Medical record review of an ED Medical Screening exam at Hospital B dated 5/21/2021 at 1:22 PM showed "...seen in triage for evaluation of chest pain substernal going through to his back radiating down both arms. Patient was seen at [Hospital A] for this 2 days ago. Pain subsided prior to being moved back into the emergency room and patient left. Patient had history of coronary artery disease had 2 stents in the LAD [left anterior descending (artery)]. Patient was seen by [named cardiologist]...yesterday [5/20/2021]. Has outpatient heart catherization scheduled for Monday with. This morning states...has no exercise tolerance without chest pain..."

Medical record review of an ED Nursing Triage note at Hospital B dated 5/21/2021 at 1:24 PM showed "...c/o [complaints of] intermittent chest pain x [times] 2 weeks..."

Medical record review of an ED Provider Note at Hospital B dated 5/21/2021 at 5:24 PM showed "...history of coronary artery disease who reports intermittent chest pain for the past 2 weeks. Also reports dyspnea on exertion. Patient states he saw [cardiologist] yesterday and that he has a heart catherization scheduled for Monday 5/24/2021. States he developed recurrent chest pain this morning and came to the ED. Patient states he took 1 sublingual nitroglycerin this morning which helped his pain a little. Pain is described as heaviness and pressure substernal with numbness in both arms. Patient states pain is 6/10 at this time..." Further review showed "...initial Troponin in the ED is 0.16 EKG is without ST elevation. Patient given Aspirin 324 mg, Heparin [anticoagulant] drip started, Nitroglycerin paste applied. [nurse practitioner] with [named cardiologist group] has evaluated in the ED. Patient reported no relief with Nitroglycerin and Nitroglycerin drip was started. Patient has still not had any relief...patient going to cath lab tonight..."

Medical record review of a Cardiac Cath report dated 5/21/2021 at 8:59 PM showed a left heart catherization (LHC) was performed. The findings showed a 99% occlusion to his Right Coronary Artery (RCA) with multiple significant blockages to adjacent small vessels leading from the RCA. A PTCA (percutaneous transluminal coronary artery angioplasty) and stenting of the RCA was successfully performed.

During an interview on 5/25/2021 at 3:35 PM, the ED Nurse Manager at Hospital A stated Patient #1 presented with chest pain around midnight on 5/20/2021 and an EKG was performed at 12:07 AM. The EKG was reviewed by the ED provider in real time and determined no acute findings on the EKG, so the patient was triaged and sent back to the waiting room.

During a telephone interview on 5/25/2021 at 5:25 PM, Registered Nurse (RN) #1 at Hospital A stated the patient arrived sometime right after midnight with chest pain. An EKG was completed 7 minutes after the patient's arrival and was triaged by the RN. The EKG was taken to the physician immediately after completion where the ED physician reviewed the EKG and found no acute findings. RN #1 started "...the triage nurse had spoken me about the patient and stated the patient's chest pain had subsided at the time of triage. I told her to put the patient in the waiting room...the patient's wife was upset because he was not taken back to a room immediately. They left the ED before we could get the patient back into the room..."

During a telephone interview on 5/25/2021 at 5:30 PM, ED Technician #1 at Hospital A, stated the patient and a female presented to the ED on 5/20/2021 around 12 midnight. ED Technician #1 stated "...the patient had a complaint of chest pain...at 12:07 AM I completed the EKG and took a copy of the EKG to the ED Physician and told the triage nurse. I put the chart in the folder for the triage nurse and the patient went back into the waiting room for the triage nurse to call him back. The female with the patient was very upset...after the patient was triaged, he was sent back to the waiting room where he and the female sat right in front of the registration desk. At one point the female came up to the desk and said they were leaving the ED and stated, 'this is ridiculous.' It all happened so fast that I did not think about getting the patient to sign a AMA form. I told the triage nurse when the patient left..."

During a telephone interview on 5/25/2021 at 6:00 PM, RN #2 at Hospital A stated she performed the ED Nursing Triage for the Patient #1 on 5/20/2021 and the EKG was performed at 12:07 AM, after which the ED physician reviewed the EKG. RN #2 stated "...the patient stated he had chest intermittently for the past 2 weeks and stated the pain was around a 6 or 7. Upon triage he stated his chest pain had subsided. He did have a previous cardiac history which I noted in the triage record. I spoke with the charge nurse and there were no rooms in the ED at that time...she told me to put the patient in the waiting room. I told the patient that we were going to place them back into the waiting room until a bed was available. His wife was upset because he wasn't going straight to a room...a little while after that, the ED tech came and told me the patient and his wife had left and were upset because they had to wait. I was not able to talk to them due they had already left the ED..." RN #1 confirmed no laboratory or radiology diagnostic testing was completed for Patient #1.

During a telephone interview on 5/26/2021 at 10:15 AM, ED Physician #1 at Hospital A stated he had reviewed the patient's EKG on 5/20/2021 and it did not show any acute findings related to an Acute MI. ED Physician #1 stated "...fairly normal EKG...with the findings on the EKG he [Patient #1] did not need any acute interventions and I told them it was ok to place the patient in the waiting room pending an open room..." The physician confirmed he did not see the patient and a MSE was not completed for the patient.

Based on review of facility policy, medical record review, and interviews, the facility failed to provide stabilizing treatment for one patient (Patient #1) who presented to the Emergency Department (ED) with chest pain of 35 patients reviewed.

The findings included:

Review of the facility's policy titled "EMTALA," (Emergency Medical Treatment and Active Labor Act) last reviewed 11/1/2019, showed "...the examination must include all ancillary services routinely available to the ED...in the judgment of the emergency physician or other treating physician are necessary to screen and/or stabilize an individual with an Emergency Medical Condition...A patient will be deemed stabilized if the treating physician attending to the patient in the Emergency Department/hospital had determined, within reasonable clinical confidence, that the emergency medical condition has been resolved..."

Medical record review of the ED Patient Care Timeline for Patient #1 at Hospital A dated 5/20/2021 showed Patient #1 presented at 12:10 AM with a complaint of chest pain and shortness of breath.

Medical record review of an Electrocardiogram (EKG) dated 5/20/2021 at 12:17 AM (7 minutes after Patient #1's arrival at the ED) "...Sinus Rhythm [normal rhythm]. First degree AV [atrioventricular] block [abnormal conduction in the AV node] delay, bradycardia [slow heart rate], normal axis [normal conduction direction]..."

Medical record review of an ED Nursing Triage record at Hospital A for Patient #1 dated 5/20/2021 at 12:32 AM (22 minutes after arrival at the ED) showed the patient complained of intermittent burning and radiating chest pain and his pain was rated as a 7 (on scale of 1-10 with 10 being the worst pain). His vital signs were as follows: Pulse 57, Respirations 20, Blood Pressure 132/68, and pulse oximetry 95% on room air. His previous history showed a history of a previous acute myocardial infarction (heart attack) and a previous cardiac catherization done on 4/6/2019. The patient was triaged as a 2 (indicating emergent needs) on the Emergency Severity Index (ESI). The patient was placed in the ED waiting room after triage to await bed placement in the ED. No further diagnostic testing was ordered.

Medical record review of the ED record at Hospital A dated 5/20/2021 showed Patient #1 was roomed as "off the floor" at 1:50 AM (indicating the patient was not in the ED). The patient had left the facility against medical advice (AMA) and was discharged at 2:00 AM. There was no documentation an AMA form was signed by the patient.

Review of an office Outpatient visit Cardiology consult dated 5/20/2021 at 3:15 PM showed Patient #1 was evaluated for a history of Coronary Artery Disease (CAD) and a prior history of coronary artery disease with a percutaneous coronary intervention (stent) to his left anterior descending artery in 2019. Further review showed the patient was "...recently seen in the ER [emergency room] last night in Bristol for increasing shortness of breath he has taken 6 nitro [nitroglycerin tablets] in the last 2 weeks with orthopnea [shortness of breath when lying down] and exertional chest discomfort similar to his prior episodes.

Medical record review of an ED Record from Hospital B dated 5/21/2021 at 12:59 PM showed the patient presented to the ED with chest pain, was admitted to the facility, and discharged home on 5/23/2021.

Medical record review of an EKG done on Patient #1 at Hospital B dated 5/21/2021 at 1:18 PM showed "...Sinus Rhythm with first degree AV Block, no ectopy. ST segments with mild depression [cardiac ischemia] in inferior leads..."

Medical record review of an ED Medical Screening exam at Hospital B dated 5/21/2021 at 1:22 PM showed "...seen in triage for evaluation of chest pain substernal going through to his back radiating down both arms. Patient was seen at [Hospital A] for this 2 days ago. Pain subsided prior to being moved back into the emergency room and patient left. Patient had history of coronary artery disease had 2 stents in the LAD [left anterior descending (artery)]. Patient was seen by [named cardiologist]...yesterday [5/20/2021]. Has outpatient heart catherization scheduled for Monday with. This morning states...has no exercise tolerance without chest pain..."

Medical record review of an ED Provider Note at Hospital B dated 5/21/2021 at 5:24 PM showed "...history of coronary artery disease who reports intermittent chest pain for the past 2 weeks. Also reports dyspnea on exertion. Patient states he saw [cardiologist] yesterday and that he has a heart catherization scheduled for Monday 5/24/2021. States he developed recurrent chest pain this morning and came to the ED. Patient states he took 1 sublingual nitroglycerin this morning which helped his pain a little. Pain is described as heaviness and pressure substernal with numbness in both arms. Patient states pain is 6/10 at this time..." Further review showed "...initial Troponin in the ED is 0.16 EKG is without ST elevation. Patient given Aspirin 324 mg, Heparin [anticoagulant] drip started, Nitroglycerin paste applied. [nurse practitioner] with [named cardiologist group] has evaluated in the ED. Patient reported no relief with Nitroglycerin and Nitroglycerin drip was started. Patient has still not had any relief...patient going to cath lab tonight..."

Medical record review of a Cardiac Cath report dated 5/21/2021 at 8:59 PM showed a left heart catherization (LHC) was performed. The findings showed a 99% occlusion to his Right Coronary Artery (RCA) with multiple significant blockages to adjacent small vessels leading from the RCA. A PTCA (percutaneous transluminal coronary artery angioplasty) and stenting of the RCA was successfully performed

Medical record review of an Admission History and Physical dated 5/22/2021 at 2:17 AM showed "...s/p [status post] LHC and had a stent to the RCA. He denies chest pain, shortness of breath, nausea, vomiting...impression NSTEMI [non ST elevation myocardial infarction..."

Medical record review of a Discharge Summary at Hospital B dated 5/23/2021 at 12:27 PM showed a LHC was performed on Patient #1 and a stent was placed into the RCA. His chest pain subsided, his clinical condition improved, and he was discharged home.

During an interview on 5/25/2021 at 3:35 PM, the ED Nurse Manager at Hospital A stated Patient #1 presented with chest pain around midnight on 5/20/2021 and an EKG was performed at 12:07 AM. The EKG was reviewed by the ED provider in real time and determined no acute findings on the EKG, so the patient was triaged and sent back to the waiting room.

During a telephone interview on 5/25/2021 at 5:25 PM, Registered Nurse (RN) #1 at Hospital A stated the patient arrived sometime right after midnight with chest pain. An EKG was completed 7 minutes after the patient's arrival and was triaged by the RN. The EKG was taken to the physician immediately after completion where the ED physician reviewed the EKG and found no acute findings. RN #1 started "...the triage nurse had spoken me about the patient and stated the patient's chest pain had subsided at the time of triage. I told her to put the patient in the waiting room...the patient's wife was upset because he was not taken back to a room immediately. They left the ED before we could get the patient back into the room..."

During a telephone interview on 5/25/2021 at 5:30 PM, ED Technician #1 at Hospital A, stated the patient and a female presented to the ED on 5/20/2021 around 12 midnight. ED Technician #1 stated "...the patient had a complaint of chest pain...at 12:07 AM I completed the EKG and took a copy of the EKG to the ED Physician and told the triage nurse. I put the chart in the folder for the triage nurse and the patient went back into the waiting room for the triage nurse to call him back. The female with the patient was very upset...after the patient was triaged, he was sent back to the waiting room where he and the female sat right in front of the registration desk. At one point the female came up to the desk and said they were leaving the ED and stated, 'this is ridiculous.' It all happened so fast that I did not think about getting the patient to sign a AMA form. I told the triage nurse when the patient left..."

During a telephone interview on 5/25/2021 at 6:00 PM, RN #2 at Hospital A stated she performed the ED Nursing Triage for the Patient #1 on 5/20/2021 and the EKG was performed at 12:07 AM, after which the ED physician reviewed the EKG. RN #2 stated "...the patient stated he had chest intermittently for the past 2 weeks and stated the pain was around a 6 or 7. Upon triage he stated his chest pain had subsided. He did have a previous cardiac history which I noted in the triage record. I spoke with the charge nurse and there were no rooms in the ED at that time...she told me to put the patient in the waiting room. I told the patient that we were going to place them back into the waiting room until a bed was available. His wife was upset because he wasn't going straight to a room...a little while after that, the ED tech came and told me the patient and his wife had left and were upset because they had to wait. I was not able to talk to them due they had already left the ED..." RN #1 confirmed no laboratory or radiology diagnostic testing was completed for Patient #1.

During a telephone interview on 5/26/2021 at 10:15 AM, ED Physician #1 at Hospital A stated he had reviewed the patient's EKG on 5/20/2021 and it did not show any acute findings related to an Acute MI. ED Physician #1 stated "...fairly normal EKG...with the findings on the EKG he [Patient #1] did not need any acute interventions and I told them it was ok to place the patient in the waiting room pending an open room..." The physician confirmed he did not see the patient and no laboratory or radiology diagnostic testing was completed on Patient #1.