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Based on interviews, medical record review, review of the facility's Emergency Department (ED) logbook, facility policies, Medical Staff Bylaws, American Heart Association information, and review of Emergency Medical Services (EMS) records, it was determined the facility failed to provide, within its capabilities, a medical screening examination to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for treatment of an Emergency Medical Condition.

Findings include:

See A2406 and A2407 for findings.

Based on interviews, medical record review, review of the facility's Emergency Department (ED) logbook, facility policies, Medical Staff Bylaws, American Heart Association information, and review of Emergency Medical Services (EMS) records, it was determined the facility failed to provide, within its capabilities, a medical screening examination to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for treatment of an Emergency Medical Condition. Record reviews revealed Patient #1 presented to the facility's ED on 08/27/19 at 7:43 AM with complaints of "muscle spasms mid back." Patient #1 was triaged by Registered Nurse (RN) #2 and then seen by Physician #1 at 8:00 AM, Valium (an anti-anxiety medication) and Toradol (an anti-inflammatory medication) were administered at 8:29 AM, and the patient was discharged home at 9:58 AM with a diagnosis of "other muscle spasm." There was no documented evidence that any diagnostic testing was ordered by Physician #1 in order to determine if the patient had an emergency medical condition.

Interview with Family Member #1 revealed Patient #1 complained of "back pain and nausea" for the next three (3) days and refused to return to the ED because Physician #1 "did not feel anything was wrong with [him/her]." On 08/30/19 at approximately 5:29 PM EMS responded to Patient #1's residence for a "cardiac arrest/death" call and the disposition was listed as "patient dead at scene-no resuscitation attempted (without transport)." At 6:16 PM, Patient #1 and the scene were turned over to the local coroner's office.

The findings include:

Review of the facility policy titled, "Medical Screening, Treatment, Stabilization and Transfer of Patients to Another Facility," dated October 1989 and reviewed July 2017, revealed a physician in the Emergency Department would medically screen patients who presented to the Emergency Department requesting examination and/or treatment. Medical Screening was an ongoing process that required physician evaluation according to the patient's condition. Continued review revealed the patient would be screened by a physician. Within the capability of the Emergency Department using the resources routinely available in the hospital for all individuals with similar symptoms, the medical screening examination was to determine within reasonable clinical confidence whether an emergency medical condition did or did not exist. The medical screening examination was an ongoing process. The record must reflect continued monitoring according to the patient's needs and until the individual was stabilized or appropriately admitted or transferred.

Review of the facility's "Medical Staff Bylaws, Article XVII-Rules, Regulations and Policies," undated, revealed patients coming to the Emergency Department would be provided a medical screening examination beyond initial triaging. Only a physician on staff would provide this screening. Triage was not equivalent to a medical screening examination.

Review of the "American Heart Association Symptoms of Heart Attack in Females," last revised July 2015, revealed the symptoms of a heart attack in females were as follows: Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest. It lasts more than a few minutes, or goes away and comes back. Pain or discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath with or without chest discomfort. Other signs such as breaking out in a cold sweat, nausea, or lightheadedness. As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain.

Review of the ED log dated 08/27/19 to 08/28/19 revealed Patient #1 presented to the ED on 08/27/19 at 7:43 AM with a chief complaint of "back pain." The facility discharged Patient #1 on 08/27/19 at 9:58 AM with a discharge disposition of "home."

Review of the medical record for Patient #1 revealed the facility admitted the patient on 08/27/19 at 7:43 AM. Patient #1 was triaged at 7:44 AM and presented with a chief complaint of "muscle spasms in mid back."

Review of the "Patient Assessment Report" dated 08/27/19 at 7:44 AM revealed an assessment conducted by Registered Nurse (RN) #2 and she documented Patient #1's vital signs as: Temperature - 98, pulse - 77, respirations - 20, blood pressure - 173/89, and oxygen saturation - 95%, with pain rated as "8 out of 10" and commented as "back pain." Continued review of the assessment report revealed RN #2 documented that Patient #1 did not have a "cardiac complaint," a "respiratory complaint," an "abdominal complaint," or a "neuro complaint." RN #2 documented Patient #1's admitting diagnosis as "other muscle spasm" with no height or weight documented. RN #2 documented that Patient #1's pain was "throbbing and aching" and it affected the patient's ability to "rest" or "sleep" and "ability to walk." Further review revealed RN #2 documented that Patient #1 stated "nothing" made the pain better and the patient's pain goal was "0 out of 10" (to have no pain). In addition, RN #2 documented on 08/27/19 at 9:58 AM Patient #1's discharge vital signs as: Temperature - 98.1, pulse - 68, respirations - 20, blood pressure - 139/83, and pain rated as "5 out of 10" with a comment of "back pain," and oxygen saturation as 95%. RN #2 documented that Patient #1 was discharged "home" and discharge mode was "walk on 08/27/19 at 9:58 AM."

Review of the "Patient Care Notes" dated 08/27/19 revealed Patient #1's vital signs with a pain scale documented by RN #2 at 7:44 AM and 9:58 AM. RN #2 documented Pain rated as "8" at 7:44 AM and comment as "NV" (non-verbal); pain documented as "5" at 9:58 AM and comment as "NV."

Interview with RN #2 on 11/19/19 at 1:00 PM revealed the "NV" was an abbreviation for "nonverbal" and it was a default setting in the electronic medical record. RN #2 stated that she failed to go in and change the default setting to "verbal" on the assessment.

Review of the "Clinical View Notes Report" dated 08/27/19 for Patient #1 revealed the patient had no notes.

Review of the "Emergency Provider Record" (EPR) dated 08/27/19 revealed Physician #1 saw Patient #1 at 8:00 AM. Physician #1 documented under the category on the EPR of "History of Present Illness" (HPI) that Patient #1 had pain to upper back and neck pain with the onset/duration of "today." Physician #1 documented that there was no recent injury. Physician #1 did not document the severity of pain or rate Patient #1's pain on a scale from 1-10. Physician #1 documented the quality of Patient #1's pain as dull and similar to prior back pain. Physician #1 did not document any associated symptoms, or what the pain was worsened by or relieved by. Continued review of the record revealed Physician #1 checked that Patient #1's "review of systems" was all systems negative except as marked. There were no systems checked by the physician. Physician #1 documented that Patient #1 had no chronic diseases under past history and on Medications and Allergies he documented "see nurses note" and he checked "nursing assessment reviewed" and "initial vital signs reviewed." Further review of the EPR revealed the category of Physical Exam, where Physician #1 documented Patient #1's general appearance as "appears well" and "alert." Physician #1 also checked that Patient #1 had "normal eye exam" with neck as "normal inspection" and "non-tender," under Respiratory/CVS (cardiovascular system) he checked "chest non-tender" and "heart sounds normal." Physician #1 also checked that Patient #1's abdomen was "non-tender." Physician #1 checked that Patient #1's back was "normal inspection" along with neuro "motor normal," psych "mood/affect normal," skin "color normal, no rash," and extremities were "non-tender, full range of motion," and "no pedal edema." Physician #1 did write across the paper "spasm L (left) trapezoid." Continued review revealed that although Patient #1 was physically assessed by Physician #1, there was no diagnostic testing completed to rule out an emergency medical condition. Further, Physician #1 did not order any diagnostic testing as listed on the EPR, e.g., radiological testing, laboratory testing, and/or electrocardiogram (EKG). Physician #1 failed to complete the "Progress" and the "Clinical Impression" sections on the EPR and documented "Muscle Spasms" with a disposition time of 9:58 AM to home.

Interview with the Chief Nursing Officer (CNO) on 11/18/19 at 2:00 PM revealed the facility did not have nursing order protocols in place. The CNO stated the facility did have assessment sheets for the physician in the ED to utilize to assist them in directing their care and treatment of the patient. The sheets were for things like back pain, abdomen pain, cardiac, etc. The CNO stated the assessment sheets were not all inconclusive and it was up to each individualized physician to determine what diagnostic testing to order once he completed the medical screening exam.

Review of the "Orders History" dated 08/27/19 revealed Physician #1 ordered Diazepam (Valium) INJ (injection) 5 milligrams (mg) on 08/27/19 at 8:16 AM and Ketorolac Tromethamine (Toradol) 15 mg on 08/27/19 at 8:16 AM

Review of the "Interactive Patient Education" revealed Physician #1 prescribed Patient #1 Flexeril 10 mg, take one pill three times a day #10, and Naproxen 500 mg, take one two times a day #10, to take on an outpatient basis.

Interview with RN #2 on 11/18/19 at 12:52 PM revealed that she was the nurse that triaged, assessed, and discharged Patient #1 on 08/27/19. RN #2 stated that as best she could remember Patient #1 presented with "back pain, muscle spasms" and did not indicate any history of cardiac or blood pressure issues. Continued interview with RN #2 revealed that Patient #1's pain level went from "8" to "5" and she reported that decrease to Physician #1. RN #2 stated that Physician #1 determined that was an adequate response to the medications that were administered to Patient #1 and he ordered discharge home for Patient #1. RN #2 stated that she did not recall Patient #1 or the patient's family having any complaints or concerns regarding the care and treatment received in the ED on that day. Further interview with RN #2 revealed that Physician #1 was the type of physician "not to cast as wide a net" when dealing with patients in the ED. RN #2 stated Physician #1 can be "very fast and jumps into things" quickly in the ED. RN #2 stated Physician #1 liked to "get up and get it done" and that he "does not order as many tests to rule out things" as other physicians in the ED in her opinion. In addition, RN #2 stated that she had been trained on the signs and symptoms of a female heart attack and they were "nausea, GI upset, atypical pain such as back pain."

Interview with RN #1 on 11/18/19 at 11:35 AM revealed the ED did not have standing orders or an order set for nursing staff to implement if a cardiac patient presented to the ED. RN #1 stated if a patient presented with a cardiac complaint, nursing staff could obtain an EKG; however, the results had to be shown to the physician in the ED and then the physician must order medications and further testing. RN #1 stated she had been trained on the symptoms of a heart attack in females and it was "shoulder pain, back pain, jaw pain, nausea, crushing chest pain, and stomach pain." Continued interview with RN #1 revealed that Physician #1's "patients either love him or hate him." RN #1 stated if you come to the ED and in Physician #1's opinion are not really an emergency, then he really is not the physician you want to have and those patients do not really like him.

Interview with Physician #1 on 11/19/19 at 1:00 PM revealed he was the physician that provided the medical screening exam and stabilizing treatment to Patient #1 on 08/27/19. Physician #1 stated that Patient #1 was having "muscle spasms in [his/her] trapezoid muscle" and indicated that he/she had a history of that type of back pain previously. Physician #1 stated at no time did he feel there was any clinical indication for further testing to stabilize Patient #1. Physician #1 stated that when he discharged Patient #1, the patient did not indicate any further issues or complaints.

Interview with the Medical Director of the ED on 11/18/19 at 4:00 PM revealed that he had no issues with the quality of the services provided in the ED by Physician #1. The Medical Director stated that he understood there were issues with Physician #1 "rubbing patients the wrong way." The Medical Director stated if you presented to the ED with a complaint such as "abdomen pain for two (2) months then you probably are not going to like [Physician #1]." Continued interview revealed the Medical Director stated the expectation of the facility was for the ED provider to "order the amount of tests to rule in or out a medical condition."

Interview with Family Member #1 on 11/18/19 at 11:51 AM revealed that Patient #1 went to the ED on 08/27/19 with "back pain" with his/her "hard of hearing" spouse. Family Member #1 stated that Patient #1's symptoms never "got better" and over the next three (3) days got worse. Family Member #1 stated that she and other family members attempted to get Patient #1 to return to the ED; however, she stated Patient #1 told her "I'd rather go to a vet's office" than return because Physician #1 did not really think he/she was sick and the facility did not do anything for the patient. Family Member #1 stated Patient #1 expired at home on 08/30/19 and the coroner's report stated Patient #1's cause of death was "cardiac/pulmonary cessation."

Review of the Emergency Medical Services (EMS) record dated 08/30/19 at 5:29 PM revealed EMS was dispatched to Patient #1's residence for "possibly deceased [male/female]." EMS documented upon arrival at the residence that Patient #1 was "located laying face up in the front yard. No CPR [cardio pulmonary resuscitation] was in progress." Continued review of the record revealed "[Patient #1] had no pulse and was not breathing. Pt was very cyanotic and pupils were fixed." EMS documented "Family advised pt. had a hx [history] of hypertension, had recently been seen in the Emergency room for chest pain radiating in to the left shoulder and on this day had been vomiting." Further review of the record revealed EMS was dispatched for call of "cardiac arrest/death" and the disposition was listed as "patient dead at scene-no resuscitation attempted (without transport)." At 6:16 PM Patient #1 and the scene were turned over to the local coroner's office.

Based on interviews, medical record review, review of the facility's Emergency Department (ED) logbook, facility policies, American Heart Association information, and Medical Staff Bylaws and Emergency Medical Services (EMS) record review, it was determined the facility failed to provide stabilizing medical treatment for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for treatment of an Emergency Medical Condition.

Review of the medical record revealed Patient #1 presented to the facility's ED on 08/27/19 at 7:43 AM with complaints of "muscle spasms mid back." Patient #1 was seen by Physician #1 at 8:00 AM and he ordered Valium (an anti-anxiety medication) and Toradol (an anti-inflammatory medication). RN #2 administered the medications at 8:29 AM, and the patient was discharged home at 9:58 AM with a diagnosis of "other muscle spasm." There was no documented evidence that Physician #1 ordered any diagnostic testing in order to provide stabilizing medical treatment to Patient #1.

Per family interview, Patient #1 continued to complain of "back pain and nausea" for the next three (3) days and refused to return to the ED because Physician #1 "did not feel anything was wrong with [him/her.]" On 08/30/19 at approximately 5:29 PM EMS responded to Patient #1's residence for a "cardiac arrest/death" call and the disposition was listed as "patient dead at scene-no resuscitation attempted (without transport)." At 6:16 PM, Patient #1 and the scene were turned over to the local coroner's office.

The findings include:

Review of the facility policy titled, "Medical Screening, Treatment, Stabilization and Transfer of Patients to Another Facility," dated October 1989 and reviewed July 2017, revealed a physician in the Emergency Department would medically screen patients who presented to the Emergency Department requesting examination and/or treatment. Stabilizing treatment consisted of providing medically appropriate treatment within the capabilities of the hospital's emergency department (including those hospital ancillary services routinely available to the emergency department) necessary to assure that no material deterioration of the patient's condition was likely to result from, or occur during, the transfer or discharge of the patient.

Review of the facility's "Medical Staff Bylaws, Article XVII-Rules, Regulations and Policies," undated, revealed patients coming to the Emergency Department would be provided a medical screening examination beyond initial triaging. Only a physician on staff would provide this screening. Triage was not equivalent to a medical screening examination. Continued review revealed an emergency medical condition was defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention would reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Review of the "American Heart Association Symptoms of Heart Attack in Females," last revised July 2015, revealed the symptoms of a heart attack in females were as follows: Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest. It lasts more than a few minutes, or goes away and comes back. Pain or discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath with or without chest discomfort. Other signs such as breaking out in a cold sweat, nausea, or lightheadedness. As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain.

Review of the ED log dated 08/27/19 to 08/28/19 revealed Patient #1 presented to the ED on 08/27/19 at 7:43 AM with a chief complaint of "back pain." The facility discharged Patient #1 on 08/27/19 at 9:58 AM with a discharge disposition of "home."

Review of the medical record for Patient #1 revealed the facility admitted the patient on 08/27/19 at 7:43 AM. Patient #1 was triaged at 7:44 AM and presented with a chief complaint of "muscle spasms in mid back."

Review of the "Patient Assessment Report" dated 08/27/19 at 7:44 AM revealed an assessment conducted by Registered Nurse (RN) #2 and she documented Patient #1's vital signs as: Temperature - 98, pulse - 77, respirations - 20, blood pressure - 173/89, and oxygen saturation of 95% with pain rated as "8 out of 10," and commented as "back pain." Continued review of the assessment report revealed RN #2 documented that Patient #1 did not have a cardiac, respiratory, abdominal, or neuro complaint. RN #2 documented Patient #1's admitting diagnosis as "other muscle spasm" with no height or weight documented. RN #2 documented that Patient #1's pain was throbbing and aching and it affected the patient's ability to "rest, sleep," and "ability to walk." Further review revealed RN #2 documented that Patient #1 stated "nothing" made the pain better and the patient's pain goal was "0 out of 10" (to have no pain). In addition, RN #2 documented on 08/27/19 at 9:58 AM Patient #1's discharge vital signs as: Temperature - 98.1, pulse - 68, respirations - 20, blood pressure - 139/83, pain rated as "5 out of 10," with a comment of "back pain" and oxygen saturation - 95%. RN #2 documented that Patient #1 was discharged "home" and discharge mode was "walk on 08/27/19 at 9:58 AM." RN #2 also documented that Patient #1 was given verbal and written instructions with prescription given and the patient verbalized understanding.

Review of the "Patient Care Notes" dated 08/27/19 revealed Patient #1's vital signs with a pain scale documented by RN #2 at 7:44 AM and 9:58 AM. RN #2 documented Pain rated as "8" at 7:44 AM and comment as "NV"; pain documented as "5" at 9:58 AM and comment as "NV."

Interview with RN #2 on 11/19/19 at 1:00 PM revealed the "NV" was an abbreviation for "nonverbal" and it was a default setting in the electronic medical record. RN #2 stated that she failed to go in and change the default setting to "verbal" on the assessment.

Review of the "Clinical View Notes Report" dated 08/27/19 for Patient #1 revealed the patient had no notes.

Review of the "Emergency Provider Record" (EPR) dated 08/27/19 revealed Physician #1 saw Patient #1 at 8:00 AM. Physician #1 documented under the category on the EPR of "History of Present Illness" (HPI) that Patient #1 had pain to upper back and neck pain with the onset/duration of "today." Physician #1 documented that there was no recent injury. Physician #1 did not document the severity of pain or rate Patient #1's pain on a scale from 1-10. Physician #1 documented the quality of Patient #1's pain as dull and similar to prior back pain. Physician #1 did not document any associated symptoms, or what the pain was worsened by or relieved by. Continued review of the record revealed Physician #1 checked that Patient #1's "review of systems" was all systems negative except as marked. There were no systems checked by the physician. Physician #1 documented that Patient #1 had no chronic diseases under past history and on Medications and Allergies he documented "see nurses note" and he checked "nursing assessment reviewed" and "initial vital signs reviewed." Further review of the EPR revealed the category of Physical Exam, where Physician #1 documented Patient #1's general appearance as "appears well" and "alert." Physician #1 also checked that Patient #1 had "normal eye exam" with neck as "normal inspection" and "non-tender," under Respiratory/CVS (cardiovascular system) he checked "chest non-tender" and "heart sounds normal." Physician #1 also checked that Patient #1's abdomen was "non-tender." Physician #1 checked that Patient #1's back was "normal inspection" along with neuro "motor normal," psych "mood/affect normal," skin "color normal, no rash," and extremities were "non-tender, full range of motion," and "no pedal edema." Physician #1 did write across the paper "spasm L (left) trapezoid." Continued review revealed that although Patient #1 was physically assessed by Physician #1, there was no diagnostic testing completed to rule out an emergency medical condition. Further, Physician #1 did not order any diagnostic testing as listed on the EPR, e.g., radiological testing, laboratory testing, and/or electrocardiogram (EKG). Physician #1 failed to complete the "Progress" and the "Clinical Impression" sections on the EPR and documented "Muscle Spasms" with a disposition time of 9:58 AM to home.

Interview with the Chief Nursing Officer (CNO) on 11/18/19 at 2:00 PM revealed the facility did not have nursing order protocols in place. The CNO stated the facility did have assessment sheets for the physician in the ED to utilize to assist them in directing their care and treatment of the patient. The sheets were for things like back pain, abdomen pain, cardiac, etc. The CNO stated the assessment sheets were not all inconclusive and it was up to each individualized physician to determine what diagnostic testing to order once he completed the medical screening exam.

Review of the "Orders History" dated 08/27/19 revealed Physician #1 ordered Diazepam (Valium) INJ (injection) 5 milligrams (mg) on 08/27/19 at 8:16 AM and Ketorolac Tromethamine (Toradol) 15 mg on 08/27/19 at 8:16 AM

Review of the "Interactive Patient Education" revealed Physician #1 prescribed Patient #1 Flexeril 10 mg, take one pill three times a day #10, and Naproxen 500 mg, take one two times a day #10, to take on an outpatient basis.

Interview with RN #2 on 11/18/19 at 12:52 PM revealed that she was the nurse that triaged, assessed, and discharged Patient #1 on 08/27/19. RN #2 stated that as best she could remember Patient #1 presented with "back pain, muscle spasms" and did not indicate any history of cardiac or blood pressure issues. Continued interview with RN #2 revealed that Patient #1's pain level went from "8" to "5" and she reported that decrease to Physician #1. RN #2 stated that Physician #1 determined that was an adequate response to the medications that were administered to Patient #1 and he ordered discharge home for Patient #1. Further interview with RN #2 revealed that Physician #1 was the type of physician "not to cast as wide a net" when dealing with patients in the ED. RN #2 stated Physician #1 can be "very fast and jumps into things" quickly in the ED. RN #2 stated Physician #1 liked to "get up and get it done" and that he "does not order as many tests to rule out things" as other physicians in the ED in her opinion. In addition, RN #2 stated that she had been trained on the signs and symptoms of a female heart attack and they were "nausea, GI upset, atypical pain such as back pain."

Interview with RN #1 on 11/18/19 at 11:35 AM revealed the ED did not have standing orders or an order set for nursing staff to implement if a cardiac patient presented to the ED. RN #1 stated if a patient presented with a cardiac complaint, nursing staff could obtain an EKG; however, the results had to be shown to the physician in the ED and then the physician must order medications and further testing. RN #1 stated she had been trained on the symptoms of a heart attack in females and it was "shoulder pain, back pain, jaw pain, nausea, crushing chest pain, and stomach pain." Continued interview with RN #1 revealed that Physician #1's "patients either love him or hate him." RN #1 stated if you come to the ED and in Physician #1's opinion are not really an emergency, then he really is not the physician you want to have and those patients do not really like him.

Interview with Physician #1 on 11/19/19 at 1:00 PM revealed he was the physician that provided the medical screening exam and stabilizing treatment to Patient #1 on 08/27/19. Physician #1 stated that Patient #1 was having "muscle spasms in [his/her] trapezoid muscle" and indicated that he/she had a history of that type of back pain previously. Physician #1 stated at no time did he feel there was any clinical indication for further testing to stabilize Patient #1. Physician #1 stated that when he discharged Patient #1, the patient did not indicate any further issues or complaints.

Interview with the Medical Director of the ED on 11/18/19 at 4:00 PM revealed that he had no issues with the quality of the services provided in the ED by Physician #1. The Medical Director stated that he understood there were issues with Physician #1 "rubbing patients the wrong way." The Medical Director stated if you presented to the ED with a complaint such as "abdomen pain for two (2) months then you probably are not going to like [Physician #1]." Continued interview revealed the Medical Director stated the expectation of the facility was for the ED provider to "order the amount of tests to rule in or out a medical condition."

Interview with Family Member #1 on 11/18/19 at 11:51 AM revealed that Patient #1 went to the ED on 08/27/19 with "back pain" with his/her "hard of hearing" spouse. Family Member #1 stated that Patient #1's symptoms never "got better" and over the next three (3) days got worse. Family Member #1 stated that she and other family members attempted to get Patient #1 to return to the ED; however, she stated Patient #1 told her "I'd rather go to a vet's office" than return because Physician #1 did not really think he/she was sick and the facility did not do anything for the patient. Family Member #1 stated Patient #1 expired at home on 08/30/19 and the coroner's report stated Patient #1's cause of death was "cardiac/pulmonary cessation."

Review of the EMS record dated 08/30/19 at 5:29 PM revealed EMS was dispatched to Patient #1's residence for "possibly deceased [male/female]." EMS documented upon arrival at the residence that Patient #1 was "located laying face up in the front yard. No CPR [cardio pulmonary resuscitation] was in progress." Continued review of the record revealed "[Patient #1] had no pulse and was not breathing. Pt was very cyanotic and pupils were fixed." EMS documented "Family advised pt. had a hx [history] of hypertension, had recently been seen in the Emergency room for chest pain radiating in to the left shoulder and on this day had been vomiting." Further review of the record revealed EMS was dispatched for call of "cardiac arrest/death" and the disposition was listed as "patient dead at scene-no resuscitation attempted (without transport)." At 6:16 PM Patient #1 and the scene were turned over to the local coroner's office.