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Based on medical record review, staff and witness interviews, policy and procedure review, and review of video, the facility failed to provide a medical screening exam (MSE) for 1 of 20 patients (#4) reviewed. The findings were:

Refer to A-2406 for details concerning the facility's failure to re-assess and provide a MSE for one patient (#4) who experienced worsening signs and symptoms while in the waiting room. The resident became unresponsive in the waiting room and staff started cardiopulmonary resuscitation (CPR). Staff discontinued CPR because the patient had do not resuscitate (DNR) directive, and the patient expired.

Based on medical record review, staff and witness interviews, policy and procedure review, and review of video, the facility failed to provide a medical screening exam (MSE) for 1 of 20 patients (#4) reviewed. Resident #4 presented to the emergency room (ER) and was initially triaged, but then experienced worsening signs and symptoms while in the waiting room. The patient was not reassessed nor re-triaged in order to determine the priority to be seen by a provider. The resident became unresponsive in the waiting room and staff started cardiopulmonary resuscitation (CPR). Staff discontinued CPR because the patient had do not resuscitate (DNR) directive, and the patient expired. The findings were:

1. Review of the medical record showed the following:
a. The 82 year old patient arrived on 2/26/24 at 3:06 PM via a nursing home van. The patient's spouse was present.
b. The chief complaint was nausea and vomiting every day for one month. It happened after having COVID and the patient had not been to a GI specialist.
c. Initial vitals taken by the technician (tech) at 3:13 PM were: temperature 36.5 degrees C, oxygen sats 97%, heart rate 121 and blood pressure 83/61.
d. Another blood pressure of 100/62 was documented by the triage registered nurse (RN) at 3:15 PM.
e. The triage RN triaged the patient at 3:17 PM. The Glasgow Coma score was 15 and no actual or suspected pain was documented. The tracking acuity was listed as: ESI 3. [Emergency Severity Index (ESI) is used for triage, from level 1 (most urgent) to level 5 (least urgent).]
f. Review of the CPR form showed the event was recognized at 4:27 PM in the ER waiting room. The arrival time of the physician was 4:29 PM. Efforts were terminated at 4:30 PM due to the DNR form at the bedside.
g. Review of the note by the physician showed the patient presented with approximately one month of nausea and vomiting and complaints of anterior abdominal discomfort. The note showed the patient was "unresponsive pulseless, apneic CPR was initiated immediately. We did identify a DNI DNR form and therefore terminated resuscitation efforts. Time of death 1630." The physician's note showed "...appears older than stated age and chronically poor health...oropharynx with dried blood and coffee-ground emesis."
h. A note dated 2/28/24 showed the chief executive officer (CEO) called the spouse and apologized that s/he had such a traumatic experience in the waiting room and told him/her the facility was going to do an investigation. The spouse stated several times s/he didn't understand why they didn't take [the patient] back to the ER despite the patient's symptoms and him/her expressing concern to staff and other patients expressing concern.
i. The cause of death listed on the death form was cardiac arrest.

2. On 2/29/24 at 1:02 PM a video of the incident on 2/26/24 was reviewed in the presence of the ER Director and the COO (and corporate staff who were on a computer call). The video showed the following:
a. The patient was wheeled to the waiting room following triage at 3:21 PM. The patient was slumped over in the wheelchair (leaning forward with head almost in lap).
b. At 3:32 PM the spouse went to the desk to talk to staff.
c. At 3:34 PM the triage tech brought the patient an emesis bag, then walked away.
d. At 3:35 PM the triage tech swapped out the blanket that was on the patient's lap.
e. At 3:48 PM the spouse talked to the triage tech, and then to a security officer.
f. At 4:13 PM there is a substance on the ground under the resident that appears to be blood. (as the video progresses, the substance spreads out further on the ground).
g. At 4:16 PM a woman from the waiting room goes the desk to talk to staff. At 4:17 PM the spouse and the woman are talking to each other.
h. At 4:19 PM the spouse talked to the triage tech at the desk.
i. About 4:20 PM there is no more movement observed from the patient; his/her arm appears to be limp.
j. At 4:22 PM another woman from the waiting room goes up to the desk to talk to staff.
k. At 4:24 PM a woman from the waiting room goes up the desk.
l. At 4:25 PM a housekeeper comes in, goes over to the patient, and then leaves and talks to the triage tech.
m. At 4:26 PM the triage tech goes to the patient, and then leaves and comes back with the triage RN.
N. At 4:27 PM the triage RN positioned the patient upright and started chest compressions as the tech wheeled him/her back to the ER.

3. During an interview on 2/28/24 at 4:54 PM physician #1 stated the first time she saw the patient on 2/26/24 was after the code was called and she assisted with the resuscitation efforts until the DNR was presented and they stopped efforts. She stated that day in the ER was very busy. She stated she had not heard anything about vomiting or blood regarding that patient.

4. On 2/28/24 at 4:56 PM physician #2 stated nurses triage patients based on acuity from level 1 to 5 and that determines the priority to be seen by the provider.

5. During an interview on 2/29/24 at 9 AM RN #1 stated she was the triage nurse working on 2/26/24. She stated she saw the patient in the triage room and s/he complained of abdominal pain and intermittent vomiting for a month. She stated she re-took the blood pressure after she reviewed the tech's vitals. She stated s/he was awake and coherent. She stated s/he vomited once in the triage room and it was "greenish." She stated the patient was slumped over in the wheelchair and she asked about that, and the patient responded it was more comfortable that way. She stated she took the patient to the waiting room. She stated it was a very hectic day in the ER. She stated techs were supposed to do hourly vitals on everybody in the waiting room. She stated the tech came and got her when the patient was unresponsive. She stated she started CPR while the tech wheeled them back to room 4 in the ER. She further stated after the incident the tech told her the spouse had been bringing up concerns to her and the desk staff. The RN stated nobody had told her about the spouse's concerns and she was not told about the patient vomiting in the waiting room. She stated during the incident in the waiting room she observed the vomit was black.

6. On 2/29/24 at 11:39 AM triage tech #1 stated she was the only triage tech working during that time on 2/26/24. She stated that day was very busy in the ER. She stated she took the initial vitals on the patient and then the RN triaged him/her. She stated techs have been instructed to do vitals about every hour on people in the waiting room. She stated on busy days it is closer to an hour and a half. She stated at one point the patient's spouse approached her and told her the patient had vomited. She stated she gave him/her a new emesis bag and exchanged his/her blanket. She stated it was hard to see the vomit in the emesis bag, but the vomit on the blanket was "yellowish." She stated the spouse came up to her again later and asked how long it would be because she felt the patient was getting worse. She stated she told the spouse she couldn't give her an exact time. She stated a woman in the waiting room came up and told her the patient had thrown up on the floor so she called housekeeping. She stated another person from the waiting room came up and reported the patient had vomited and she told the person housekeeping had been called. She stated the housekeeper then showed up, and then shortly after asked her to look at the patient. She stated she observed the patient and saw blood on the ground. She nudged the patient and called his/her name but the patient was unresponsive. She got the triage nurse who came out and then started CPR. She stated it was a "pool of blood" under the patient, but she couldn't see exactly where the blood was coming from (nose or mouth) because there was so much blood on his/her face. She further stated due to the ER census on 2/26/24 she was unable to complete vital signs on patients in the waiting room hourly and confirmed patient #4 did not have vital signs re-assessed prior to the incident.

7. During an interview on 2/29/24 at 12:20 PM housekeeper #1 stated he was called to clean up vomit in the ER waiting room on 2/26/24. He stated when he arrived he notice the patient was slumped over and it looked like there was blood on the floor. He stated he walked over to the triage tech and asked her to check on the patient. When the triage tech came over she tried to rouse the patient but s/he was unresponsive. She then got the nurse who then started CPR. He stated a woman and her son seemed upset and left the ED. He stated the patient's spouse told him "I told them [s/he] needed to go back."

8. On 2/29/24 at 2:25 PM the ED Director stated the facility followed their process for incidents after the 2/26/24 incident. She stated she was called at home that day and she immediately came in and they started an investigation. She stated she did an in-depth chart review as part of the investigation, staff were interviewed, and she viewed the video. She stated the triage nurse and tech were suspended pending the investigation. She stated she had a couple of concerns. She stated she felt the patient should have been triaged a level 2 and not a 3, based on nausea/vomiting for a month, 82 years old, increased heart rate and a lower blood pressure recorded from the tech. She stated after she watched the video of him in the waiting room, she would have triaged him/her a 1. She also had concerns that staff had not re-assessed the patient after the spouse and other patients in the waiting room brought up concerns. She stated techs were instructed to do hourly vitals on patients because they don't under the ESI levels, but re-assessment should be done per the facility facility, which was based on the ESI levels.

9. During an interview on 2/29/24 at 4:18 PM witness #1 stated she was in the waiting room that day. She stated she observed a patient who was hunched over in the w/c and vomiting. She stated later she sat closer to the patient and noticed blood on the ground. She stated she got up and went to the desk to tell staff, but they cut her off saying they had already called housekeeping. She stated when the housekeeper came, he got staff, who then came over and started CPR right there in the waiting room.

10. Review of the facility's policy "Emergency Department Patient Care," revision date 1/26/22, showed re-assessments were based on the ESI levels. "...ESI 3= documented reassessments every 4 hours...ESI 2= Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care." Further, "...An ESI score will be assigned based upon acuity and resources needed. Patients assigned ESI level 1 & 2 to be given placement priority. These priorities may be modified throughout the patient encounter as diagnostic testing/findings are made available and interventions/treatments are evaluated for effectiveness."

11. Review of the facility's policy "EMTALA- Medical Screening Examination and Stabilization," revision date 11/4/20, showed "...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. An MSE will be conducted to determine whether the Patient has an EMC...The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred."