HospitalInspections.org

Based on a review of 25 emergency department (ED) medical records, interviews with staff, observation of care, and review of policies and other pertinent documentation, it was determined that the hospital failed to provide a timely medical screening examination (MSE) for one patient (P1) who presented to the ED in February 2019.

P1 presented to the ED approximately 10 PM complaining of abdominal pain and vomiting. P1 was triaged immediately as a Level 3 emergency severity index (ESI) (moderate intensity with stable vital signs) and sent to the waiting room. P1 was complaining of 10/10 throbbing abdmonial pain and had a slightly rapid heart rate. After approximately 2 hours and 40 minutes, P1 was taken to the rapid assessment part of the ED to obtain blood work and start IV access. P1 remained in the back for approximately 30 minutes while staff tried without success to obtain IV access or draw blood for labs. During this time, P1 did not have a MSE, and the staff neglected to notify the qualified medical personnel (QMP) of the inability to gain IV access. No further vital signs were checked and P1 was taken back to the waiting room at 0110 AM.

According to lobby video, P1 left the ED waiting room around 0300 AM, after another 2 hours. The RN came out to find the patient at 0400 AM but P1 had already left the ED. P1 was later found deceased in P1's vehicle in the parking lot.