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Based on document review and interview, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure an appropriate medical screening exam was performed for one (#1) of twenty patients reviewed, from a total sample of twenty, see A 2406.

Based on observation and interview, the facility failed to ensure Emergency Treatment and Labor Act (EMTALA) signs in waiting areas were present and/or likely to be noticed by all individuals that presented to the emergency department resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 6/22/2022 at 1040 during a tour of the Emergency Department (ED) waiting room area it was revealed that the facility failed to have postings of EMTALA signage in the waiting areas of the ED. An EMTALA sign was viewed at the security area located behind a freestanding kiosk which obstructed the view of the sign. Further observation continued in the waiting room area which revealed the lack of signage for EMTALA information.

On 6/22/2022 at 1050 an interview occurred with Staff B, the ED clinical manager. Staff B was queried about the absence of EMTALA postings. Staff B stated he was unaware that the posting of the EMTALA signage was missing and stated that it would immediately be taken care of by posting of the information.

Based on interview and document review the facility failed to complete an appropriate medical screening exam for one (#1) of 20 patients reviewed for treatment and medical screening presenting to the Emergency Department (ED) resulting in the potential to delay care and less than optimal patient outcomes. Findings include:

Document review of the medical record for Patient #1, the patient of concern, was conducted on 6/22/2022 at 1400. Document review revealed the patient was a 72-year-old male who presented to the ED on 5/14/2022 at 0056 via ambulance. According to the ambulance run sheet the patient had complaints of abnormal chest pain. Vitals for the patient according to the ambulance run sheet listed the following:

00:46 Pulse 78, SP02 (oxygen saturation) 95
00:47 Alert, Sitting, Blood Pressure 141/69, Pulse 98, Respiratory rate 18, SP02 97, Temperature 98.0, Pain 0, GCS (Glasgow Coma Scale) 15
00:49 Pulse 84, SP02 97
00:52 Alert, Sitting, Pulse 112, SP02 96
00:52 Blood Pressure 148/50, Pulse 139, SP02 95
The patient's ECG at 00:52 was listed as sinus rhythm.

The narrative portion of the ambulance documentation on 5/14/2022 at 0111, stated the following, " ...were dispatched out for a male that was having chest pain. Crew arrived on scene to find the male in no distress at this time. Patient stated that the pain started around 14-15 minutes ago. Patient stated that he was just in the ER (emergency room) 2 days ago. Patient signed out AMA (Against Medical Advice). Patient was able to walk to the stretcher and was secured with 5-point harness and 2 rails. Patient was moved to the ambulance and secured. Patient was assessed and vitals were taken. Patient stated pain started 15 minutes ago when he was smoking with his family. Patient was stable and all vitals were all within normal range at this time. Patient stated that pain was starting to go away. Patient was transported to (facility), E bridge (notice of arrival) was sent. Patient was monitored with no changes noted at this time. Patient stated that he was feeling better. Patient was taken into the ER and taken to triage. Nurse was given report and signed for the care of the patient. Care was ended by SHSQ4 (ambulance team)."

Further document review of the medical record revealed no vitals were obtained upon entry of the patient to the ED. A medical triage of the patient was absent from the record. The medical record failed to have an ECG (electrocardiogram) being obtained within 5 minutes of the patient's arrival to the ED per the facility's "CP (chest pain) algorithm" for patients presenting to the ED with active chest pain.

The patient's medical record additionally revealed under "Event History" four tasks including fall risk assess, arrive, document home meds, and triage. All four tasks were ordered at 5/14/2022 at 0056. The one completed task of the four tasks listed was "Arrive." The patient's LOS (length of stay) was documented at one hour and ten minutes.

The discharge documentation under the titled document, "ED Disposition Summary," stated the patient was "stable." The "disposition type" listed "left without being seen." The patient was discharged from the facility on 5/14/2022 at 0206. Discharge instructions stating that discharge information had been presented to the patient was dated 5/14/2022 at 0206. The "Patient Education Information" on 5/14/2022 at 0206 stated "Pat (patient) Ed Instructions Reviewed with Patient: Yes - Patient/Guardian/Family Member verbalizes understanding of instructions given and received a copy." The "Event Summary" stated the patient was discharged on 5/14/2022 at 0206.

On 6/23/2022 at 1130 an interview was conducted with the Director of the ED, staff J. Staff J was queried about the presentation of a patient with complaints of chest pain. Staff J stated that protocol for a patient with chest pain would follow the CP algorithm. Staff J was asked to explain the algorithm. Staff J stated an ECG was obtained within five minutes of a patient presenting with chest pain and the ECG would be evaluated by the ED physician. Staff J was also queried if a patient with chest pain would have vitals taken at the time of arrival to the ED. Staff J stated that if the patient was in stable condition that vitals might be obtained at the time of triage. Staff J was then asked if there were any ensuing circumstances that would have delayed patient #1 from receiving an ECG as per protocol or vital signs within an hour of being brought by ambulance to the facility. Staff J stated that four patients in the ED at the time were of high acuity and actively being worked on. Staff J also stated that 28 patients presented to the ED within two hours causing delays in triage for those patients. Staff J stated it was around the time the patient (pt. #1) had arrived in the ED.

An interview occurred on 6/28/2022 at 0930 with staff Q, the triage nurse on 5/14/2022 at 0056. Staff Q was queried if she remembered patient #1 on the morning of 5/14/2022 at 0056. Staff Q stated, "yes ...I know Mr. **** (patient #1)." Staff Q was then asked if she could explain why patient #1 was never triaged. Staff Q explained, "I remember it was very busy in the ED at the time ... (patient #1) was brought into the hallway behind my triage area ...He stated that he was fine and refused to have his vital signs taken when I got to him ...He was there one moment and gone the next." Staff Q was then asked if she had followed the chest pain protocol for the arrival of a patient with chest pain. Staff Q stated, "no ...he refused." Staff Q was then queried if she remembered patient #1 leaving the ED. Staff Q stated, "no ...he was there one moment and gone when I got to him ...I can remember him stating that he was going to call his son to come and get him because it was taking too long ... (patient #1) is impatient and comes to our ED frequently. I do remember trying to convince him that it was in his best interest to stay and be evaluated." Staff Q was then asked if she had documented the patient's refusal to have vital signs taken and an ECG completed. Staff Q stated, "No ...I just thought that clicking 'leaving without being seen' was enough charting." Staff Q was then asked if she knew how long the patient waited to be triaged. Staff Q stated, "It really didn't seem like a long amount of time had passed when I realized he was gone."