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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to conduct a triage and assessment as required and medical screening examination by the licensed medical practitioner to determine if an emergency medical condition existed. (A-2406)

The Immediate Jeopardy began on 12/11/2022 due to the The Hospital's failure to conduct a triage and assessment as required and medical screening examination by the licensed medical practitioner to determine if an emergency medical condition existed. Subsequently, the patient died while waiting in the waiting area, and was identified on 12/21/2022, at 42 CFR 489.24, Compliance with 489.24-489.20(l). The IJ was announced on 01/05/2023 at 3:30 PM during a meeting with the Vice President of Patient Services, Director of Regulatory, Quality, Risk, Chief Operating Officer, and Emergency Department Manager, and was not removed by the survey exit date of 01/05/2023.

Based on document review, surveillance video review, and interviews, it was determined that for 1 of 20 (Pt. #1) records reviewed for patients seeking care in the Emergency Department (ED), the Hospital failed to conduct a triage and assessment as required and medical screening examination by the licensed medical practitioner to determine if an emergency medical condition existed. Subsequently, the patient died while waiting in the waiting area.

Findings include:

1. On 12/19/2022, the Hospital's policy titled, "Emergency Medical Treatment and Transfer" (revised March 2022) was reviewed and included, "IV. Procedure: i. Triage. Staff shall triage patients and handle cases in the order of medical severity. ii. Medical Screening. All individuals who come for emergency services shall receive an appropriate medical screening examination. A physician must perform the medical screening exam to determine, with a reasonable clinical confidence, whether an Emergency Medical Condition exists."

2. On 12/19/2022, the Hospital's policy titled, "Emergency Department Triage" (revised 7/2021) was reviewed and included, "1. Evaluate all patients upon arrival: 1.1 All patients who present to triage will be assessed by the triage RN ... 2.1 The triage RN ... will document the patient's time of arrival, chief complaint, brief assessment... 3. Assess each patient individually and base triage decisions on critical thinking process including clinical presentation and history ... Categories of needed care: Level 3 Urgent (yellow) Requires greater than 2 resources as defined by Emergency Severity index ... 1. All patients presenting to the ED via ambulance and taken directly into treatment area do not require a "Triage Assessment Sheet." 2. All triage assessments and interventions will be documented in the 'Triage Assessment Sheet' ... Role Responsibilities: The triage nurse is to maintain ongoing communication with the charge nurse to hasten treatment ... serves as liaison to the patient/family providing on going information regarding delays and patient's condition. Patients awaiting definitive care will be reassessed within 2 hours or more frequent if acuity and patient condition requires to assure that any change in patient condition will be detected and the plan for care and urgency modified accordingly."

3. The clinical record of Pt. #1 was reviewed on 12/19/2022. Pt. #1 presented to the Hospital's emergency department (ED) via Chicago Fire Department on 12/11/2022, at 1:57 PM by ambulance. The clinical record included the following:

-The ambulance run sheet dated 12/11/22 at 1:41 PM, included, "Complaint Reported: Difficulty Breathing/Pulmonary Heart rate-70; Respirations-18; Pulse Oximetry-98%; Blood Pressure 126/70 ... Crew was dispatched ... difficulty breathing. Upon arrival crew found (Pt.#1) ambulatory on scene complaining of shortness of breath that started 3 days ago ... has not been feeling better ... patient care and report given to RN in ED ..."

-EMS (emergency medical system) System Telemetry Log Sheet, dated 12/11/22 at 1:44 PM, included, "Chief Complaint: SOB X3 (shortness of breath times 3) days..."

-The Patient Care Timeline dated 12/11/22 at 1:57 PM through 5:56 PM, included the following:
-1:57 PM, Patient (Pt. #1) arrived in ED.
-2:38 PM, Patient brought back from triage (waiting room) after family reported pt (patient) fainting.
-2:38 PM, CPR (cardiopulmonary resuscitation) initiated.
-2:40 PM, Endotracheal tube placed, Epi (epinephrine) given.
-2:42 PM, Pulse check, no pulse. CPR continued.
-3:23 PM, Pt pronounced deceased by MD.

The clinical record indicated that late documentation was completed by E #1 (Triage Nurse) at 4:50 PM, and included the following:
-ED Triage Notes: Pt to ED via EMS with c/o (complaint of) Shortness of breath and couch (sic. cough) after testing positive for the flu and three days ... No active distress noted nor any expressed by pt upon seeing pt and while receiving report from EMS (emergency medical services). Per (EMS) report pt vital signs stable with oxygen of 98% on room air ... Triage Plan: Acuity Destination: Patient Acuity: 3 [urgent] ..."

The clinical record did not indicate that Pt. #1 received a medical screening examination after presenting to the ED via ambulance.

4. On 12/20/2022 at 11:39 AM, the surveillance video of the ED ambulance bay and ED lobby dated 12/11/2022 from 1:53 PM to 2:39 PM, were reviewed with the ED Medical Director (MD#1) and the ED Manager (E #2). The video footage showed the following:
-At 1:53:20 PM, from the ambulance bay Pt. #1 seen arriving via ambulance accompanied by one family member (identified by E #2/ED Manager).
-At 1:57:09 PM, Pt. #1 is noted on a wheelchair being pushed by an EMT into the waiting area. There were no other patients in the waiting room.
-At 2:03:11 PM, a Registrar staff is observed placing an identification band on Pt. #1, two additional family arrived at 2:08 PM.
-At 2:11:47 PM, a family member is observed walking to the triage area and talking to someone (unable to see who the person was).
-At 2:11:47 PM through 2:29:00 PM, Pt. #1 was observed rocking back and forth, with head hanging backwards at times and falling forward, family is observed trying to comfort Pt. #1 and rubbing her legs.
-At 2:32:09 PM, a family member was observed walking quickly to triage area and speaking to someone (unable to see who the person was). The family member returns to Pt. #1 alone.
-At 2:32:40 PM, Pt. #1 is seen slumping forward and the family member runs to triage area for help.
-At 2:33:01 PM, (E #1) is observed walking to Pt. #1 from behind and walks back to triage area.
-At 2:37:51 PM, two Security Officers observed talking to family.
-At 2:38:03 PM, E #1 is observed walking to Pt. #1 from behind and pulling Pt. #1 up in wheelchair, Pt. #1's head was slumped forward and the arms were dangling over the sides of the armrests of wheelchair.
-At 2:38:14 PM, E #1 takes Pt. #1 on the wheelchair into the treatment area.
The video footage did not show staff observing or assessing Pt. #1 from the time Pt. #1 arrived at the waiting room.

5. On 12/19/2022 at 11:20 AM, an interview was conducted with the Emergency Department Medical Director (MD #1). MD #1 stated, "ED patients that come via ambulance are assessed by the Charge Nurse, who will decide if the patient should be roomed or placed in the waiting area. They are seen briefly on arrival for a quick assessment for immediate needs. The EMT's will call in report to us when they are on their way with their vitals and short history of chief complaint. If the patient goes to triage holding area/waiting room, their vitals are assessed by the triage nurse. If there if something of concern, the triage nurse will let the Charge Nurse know and the patient will be roomed and evaluated by the physician. The triage nurse and physicians are responsible for all patients in the ED. The nurses assess vitals; physicians have access to vital signs taken by the triage nurse on the computer. If there is a change the triage nurse can alert the physician. If a patient has a complain of increased SOB, that patient should be reassessed, and vital signs re-checked. Acuity 3 would be considered urgent and require assessment relatively quickly."

6. On 12/20/2022 at 2:20 PM, an interview was conducted with the Triage Nurse (E #1). E #1 stated, "I got the call from EMS with report of a patient (Pt. #1) with sob and tested positive for the flu 3 days prior. The patient came in by ambulance, the usual procedure is that EMS takes the patient to the Charge Nurse to determine if the patient will be roomed or sent to triage area. The Charge Nurse (E #3) made the determination that (Pt. #1) go to triage area. I eyeballed the patient from the triage area, she was in a wheelchair she did not appear to be in distress. Part of triage process is to check vitals and document; I did not check her vital signs. The family was yelling through the window, I do not recall how many times, it was a female. She opened the door and was yelling at me that (Pt. #1) was a 911 patient and why wasn't anyone helping her. When I did check on patient, she was unresponsive, and I brought her back to the department. I tried to wake her up and when I saw she did not respond, and I called for help. Resuscitation measures were initiated and but were not successful."

7. On 12/20/2022 at 2:30 PM, an interview was conducted with the ED Physician (MD #3). MD#3 stated, "I took care of this patient when she was wheeled (by E #1) to the treatment area from the waiting room. She was sitting in a wheelchair right in front of me. I noticed her color wasn't right. I don't know who put her on a gurney, but I noticed she was not breathing. I asked for a pulse ox (oximetry/measures oxygen level) and oxygen, and I called for staff to start CPR." MD #3 stated that the charge nurse will determine if patient goes to the treatment area or waiting room. If patients are in triage waiting area, physicians rely on the triage nurse's assessments or to be notified of change in condition.

8. On 12/20/2022 at 2:53 PM, an interview was conducted with the ED Charge Nurse (E #3). E #3 stated that on 12/11/2022, when (Pt.#1) arrived there were no beds available. E #3 stated that E #1 took the call from EMS when (Pt. #1) was in route. E #3 stated that she was not by the ambulance bay when (Pt. #1) arrived, E #3 was about 5 feet from the patient who was in a wheelchair. E #3 does not recall who determined that the patient was clear for the triage waiting area. E #3 stated that when ambulance patients are taken to the triage area, the triage nurse should check vitals signs and do a quick assessment for immediate needs. E #3 stated that she recalls that some time after the patient arrived, she was brought back into the treatment area by E #1 because it appeared the patient lost consciousness. E#3 stated that they had to put the patient on a bed and start compressions because there was no pulse.