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Based on interview, observation, and record review the facility was found not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by failing provide an appropriate medical screening exam.

The findings are:

A. The facility failed to provide an appropriate medical screening exam. Refer to 2406.

Based on record review, observation, and interview the hospital failed to provide an appropriate medical screening examination of an ECG (electrocardiogram) within 10 minutes of complaint of chest pain to determine if an emergency medical condition exists for 4 (P (patient)1, P3, P11 and P14) of 21 (P1-P21) patients reviewed. This failed practice may lead to death or harm from a lack of identification of an emergency medical condition for any patient seeking care for chest pain.

The findings are:

A. Record review of hospital policy labeled "EMTALA Medical Screening" Effective Date: 03/05/2021 stated on page 1 under Procedure: Facility Policies, A. General Requirements: ... when an individual ... requests ... an exam or treatment for any medical condition ... the hospital must provide for an appropriate Medical Screening Examination ... to determine whether an emergency medical condition exists .... D. How to Provide a Medical Screening Examination 8. Depending on the patient's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scan [Computed Tomography Scan, imaging technique used to obtaininternal images of the body] and other diagnostic tests and procedures."

B. Record review of hospital policy ED TIP (Emergency Department Treatment Initiated Protocols) for Chest Pain shows: "ECG < (less than) 10 mins (minutes) upon arrival."

C. Record review of P1 face sheet showed that patient arrived in the emergency department on 04/17/2023 at 2035 (8:35 pm) and discharged 04/17/2023 at 2335(11:35 pm), discharge disposition: Expired [deceased].

D. Record review of P1 Patient Care Timeline showed patient arrival complaint at 20:36 (8:36 pm) was foot pain.
a. At 20:53 (8:53 pm) "Chief Complaints Updated: chest pain (pt [patient] mentions generalized chest pain that radiates to left arm x (times) "few days".)"
b. At 2200 (10:00 pm) "Order Performed: ECG".
c. 2201 (10:01 pm) "EKG Initial Interpretation Findings STEM: (ST Elevation Myocardial Infarction. Serious type of Heart Attack): yes"
d. 2238 (10:38 pm) "Send patient to OR/Cath lab [Cardiac catheterization, insertion of a thin flexible tube into the heart to identify where the blockage occurred]"
e. Total elapsed time from complaint of chest pain to ECG was 67 minutes.

E. Record review of P1 "Death Summary" stated Procedure: ... left heart cath ... not performed. Expired on cath table before arterial access [accessing the artery to begin the cardiac cath] could be obtained. Expired at 11:35 pm on 04/17/2023"

F. Record review of P3 face sheet showed that patient arrived in the emergency department on 04/22/2023 at 09:19 (9:19 am) and discharged on 04/22/2023 at 17:30 (5:30 pm). Disposition: Home.

G. Record review of P3 Patient Care Timeline showed patient arrival complaint at 09:19 (9:19 am) was Chest Pain and Shortness of Breath.
a. Record review of P3 ECG completed on 04/22/2023 at 0939 (9:39 am).
b. Total elapsed time from complaint of chest pain to ECG was 20 minutes.

H. Record review of P11 face sheet showed patient arrived in the emergency department on 04/20/2023 at 2345 (11:45 pm) and discharged on 04/23/2023 at 15:35 (3:35 pm). Disposition: Home.

I. Record review of P11 Patient Care Timeline showed patient arrival complaint at 23:46 (11:46 pm) was chest pain.
a. Record review of P11 ECG completed on 04/21/2023 at 00:14 (12:14 am).
b. Total elapsed time from complaint of chest pain to ECG was 28 minutes.

J. Record review of P14 face sheet showed patient arrived in the emergency department on 04/26/2023 at 2325 (11:25 pm) and discharged on 04/27/2023 at 04:13 (4:13 am). Disposition: Home.

K. Record review of P14 Patient Care Timeline showed patient arrival complaint at 23:25 (11:25 pm) was chest pain.
a. Record review of P14 ECG completed on 04/26/2023 at 23:41 (11:41 pm).
b. Total elapsed time from complaint of chest pain to ECG was 16 minutes.

L. During an interview with S8, Charge Registered Nurse, 05/02/2023 at 10:00 am:
a. When asked: Based on facility protocol, what is the time frame that a patient who complains of chest pain should receive an ECG? S8 stated: "10 minutes."
b. When asked: How do you ensure that a patient in P1 situation receives an ECG within 10 minutes? S8 stated: "Ideally, we always leave 1 [triage] bay open to perform EKG's ... at that time all the EKG bays were occupied .... [S13] was fixated on trying to get into bay 1, 2, 4, or 9 [triage bays that have ECG]."
c. When asked: Should [P1] have received and ECG earlier? S8 stated: "Absolutely, It doesn't matter when he complains of it [chest pain], it's still a 10 minute EKG"
d. When asked: Where are the mobile ECG units stored? S8 stated: "They are in our equipment room"

M. During an interview with S21, Charge Nurse, on 05/03/2023 at approximately 10:00 am:
a. When asked: Where are the mobile ECG units stored? S21 stated: "C Pod utility and A Pod in clean utility."
b. When asked: Is that one right there (while pointing to a machine near the nurse station in the front of B Pod)? S21 stated: "Yes, and the other one is in C Pod utility."

N. During an interview with S5, Registered Nurse Director of ED (Emergency Department), and S6, Registered Nurse Assistant Director of ED, on 05/03/2023 at approximately 11 am:
a. When asked: Based on facility protocol, what is the time frame that a patient who complains of chest pain should receive an ECG? P6 stated: "Less than 10 minutes".
b. When asked: Why doesn't every bay in triage have ECG capability? S6 stated: "There was not enough monitoring capability in the hospital for us to do it in every bay ... there is only so many plugs for tele [ECG monitoring], until they [the organization] upgrade the tele."
c. When asked: What are the nurses to do if they do not have a triage bay to do an ECG? S6 stated: "They can take the patient to room 27, 26 or the hallway outside 26, or a mobile unit". These areas are not located in the triage area.
d. When asked: Are those rooms in the triage area? S6 stated: "No they are in a different pod."
e. When asked: Do the mobile units record directly into the patient's chart? S6 stated: "No, they have to be printed, sent to medical records, uploaded and then downloaded into the chart."
f. When asked: Do you think P1 should have received an ECG earlier? S6 stated, "Absolutely."
g. S5 and S6 then confirmed the times for complaint of chest pain to ECG for P1, P3, P11 and P14 and confirmed they were not completed within the 10-minute protocol.

O. During an interview with S22, Triage Nurse, on 05/03/2023 at approximately 10:00 am:
a. When asked: Where are the mobile ECG units located? S22 stated: "In the back of B Pod"

P. During an interview with S13, LPN (Licensed Practical Nurse), on 05/03/2023 at 1:00 pm:
a. When asked: Based on facility protocol, what is the time frame that a patient who complains of chest pain should receive an ECG? S13 stated: "10 minutes."
b. When asked: What was your role regarding P1? S13 stated: "I was summoned to help triage because they were drowning ... I looked up who he [P1] was, typically you would do an EKG (ECG) first, but there were people in all the bays that had an EKG, so I started on the IV [intravenous, a way to admisnter medications and fluid directly into the vein]"
c. When asked: Looking back, would you have done it the same way? S13 stated: "No, I would have verified the chest pain, and taken him to the back or the room that is being used for ambulance [both of these locations are not in the triage area]"
d. When asked: What about the 2 mobile ECG units? S13 stated: "They don't transfer into a patient's chart, I was told those were used as last resort. It would have been too long to get to them ..."
e. When asked: Do you know where the mobile ECG units are stored? S13 stated: "They have rooms they are supposed to be in, but people don't put them back."

Q. During an interview with S23, ED Nurse, on 05/03/2023 at 2:37 pm:
a. When asked: Where are the mobile ECG units located? S23 stated: "Usually in B Pod or C Pod."

R. During an interview with S12, Triage Registered Nurse, on 05/03/2023 at 6:45 pm:
a. When asked: Based on facility protocol, what is the time frame that a patient who complains of chest pain should receive an ECG? S12 stated: "10 minutes".
b. When asked: How many triage bays out of the 9 have ECG capabilities? S12 stated: "I think there is only 3."
c. When asked: Do you think [P1] should have received an ECG sooner? S12 stated: "Yes, of course"

S. During an observation of the Emergency Department triage and pods on 05/03/2023 at approximately 10:00 am, one portable ECG machine was located near the nurse station in the front of B Pod. See finding M. a. for location of second ECG portable machine. C Pod utility and A Pod in clean utility