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

Findings include:

1. The Hospital failed to: ensure the patient and their presenting complaints were identified on arrival; conduct an assessment and triage; and perform a medical screening examination by the licensed medical practitioner, to determine whether or not an emergency medical condition existed. See A-2406.

The Immediate Jeopardy (IJ) began 2/24/2023 due to the Hospital's failure to conduct a medical screening examination in an appropriate and timely manner to determine if any emergency medical condition existed. Subsequently, the patient was found in the triage bathroom unresponsive and expired on 2/25/2023 at 7:30 PM. The IJ was identified on 3/29/2023, at 42 CFR 489.24 (a) (c). The IJ was announced on 3/29/2023 at 11:30 AM during a meeting with Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer and VP of Quality and was not removed by the survey exit date of 3/29/2023.

Based on surveillance video review, observation, document review and interview, it was determined that for 1 of 20 clinical records (Pt. #1) reviewed for emergency medical services, the Hospital failed to: ensure the patient and their presenting complaints were identified on arrival; conduct an assessment and triage; and perform a medical screening examination by the licensed medical practitioner, to determine whether or not an emergency medical condition existed, as required.

Findings include:

1. On 3/23/2023 at 2:00 PM, the Hospital's video surveillance (on 2/24/2023), from the ER 1 &2 and the ER Triage Room cameras, was reviewed with the Chief Nursing Officer (E #11) and Patient Safety Officer (E #15). The video recording included the following on 2/24/2023 at:

- 11:18:25 PM: Pt. #1 walked into the ED waiting room unaccompanied. Pt. #1 filled out the chief complaint form located on the waiting room's front desk/greeter's desk. No staff was present at the waiting room's desk.
- 11:21:17 PM: Pt. #1 placed the chief complaint form in the box located on the Triage Nurse's door.
- 11:23:42 PM: Pt #1 walked to one of the visitor's bathrooms (located approximately 3 feet) from the Triage Nurse's door.
- 11:27:54 PM: The Triage RN (E #1), came out of the triage room and looked at a form that was placed in the triage door's box. E #1 looked around the waiting room and towards the bathroom door. E #1 did not approach or knock the bathroom door at that time.
- 11:28:06 PM: E #1 returned to the triage room.
- 11:28:12 PM: Pt. #1 walked out of the bathroom.
- 11:28:21 PM: Pt. #1 picked up a drinking can from the area where he was previously seated.
- 11:28:32 PM: Pt. #1 returned to the visitor's bathroom with the drinking can in hand.
- 11:33:26 PM: A Patient Safety Officer (PSO/E #4) entered the waiting room area, approached the bathroom door and then put his ear to the door. E #4 then walked away.
- 11:33:47 PM: Triage RN (E #1) came back out of the triage room. E #4 directed E #1 attention towards the visitor's bathroom door. E #1 did not approach the bathroom.
- 11:34:08 PM: E #1 knocked on the bathroom door once.
- 11:34:17 PM: E #1 went back into the triage room.
- 11:37:18 PM: E #1 came back out of the triage room and glanced around. Two other patients were present in the waiting room at that time.
- 11:42:59 PM: A Patient Safety Officer (E #2), knocked on the visitor's bathroom door and then proceeded to open the door. E #1 came out of the triage room and was near E #2 as he opened the bathroom door.
-11:43:21 PM: Pt. #1 was observed face down on the bathroom floor. The PSO (E #2) nudged Pt. #1 with his foot to check for Pt. #1's responsiveness. Pt. #1 did not have any movement.
- 11:43: 55: Pt. #1 was lifted, pulled up by his coat, and then placed in a sitting position against the door. Pt. #1's head was leaned forward as his back was against the bathroom door. There was no movement noted from Pt. #1.
- 11:44:27 PM: E #1 left the patient unattended. There was no other clinical staff present with the unresponsive patient.
- 11:44:42 PM: E #2 and E #4 (PSO's) left the patient unattended.
- 11:44:58 PM: E #2 and E #4 came back to the waiting room with a wheelchair for Pt. #1. E #1 came back out of the triage room. Pt. #1 remained with no movement. There was no resuscitate measures/emergency interventions initiated at that time.
- 11:46:17 PM: An ED Technician (E #12) came from the back ED area with a transportation cart.
-11:46:25: Pt. #1 was placed on the cart by 3 PSO's (E #2, E #4, and E #13), and the ED Technician (E #12), to transport the patient to the back treatment area (from the waiting room).

2. The Hospital's policy titled, "EMTALA" (reviewed 9/16/2022) was reviewed and indicated, "It is the policy of (the Hospital) that all persons who present to the Emergency Department shall receive an appropriate Medical Screening Examination (MSE) and evaluation within the capabilities of the hospital to determine whether an Emergency Medical Condition (EMC) exists ...Triage - an initial and on-going evaluation of presenting patients by the triage RN or designated RN, to determine the order in which they will be provided a MSE based on the relative severity of their condition. "

3. The Hospital's "Triage policy" (reviewed 9/16/22), was reviewed and indicated, "I. Purpose ...all patients shall be seen by a Triage Nurse upon arrival and assigned a Triage Category based on acuity. II. Triage is a process used to determine the priority of patients' treatment based on severity of their condition. III. Procedure: When a patient presents to the ED, he/she will be directed to the Triage Area. The Triage Nurse will evaluate each patient prior to their registration. Evaluation will consist of vital signs, medical history, medication reconciliation and chief complaint ..."

4, The Hospital's policy titled, "Treatment of the Chest Pain STEMI Patient" (reviewed 9/19/22) was reviewed and indicated, "It is the policy of (the Hospital) Emergency Department to immediately evaluate patients who present with chest pain to identify a patient who is experiencing a possible acute myocardial event ..."

5. As of note, Pt. #1 presented to the ED on 2/24/2023 at 11:18 PM (per video surveillance) for medical evaluation. On 3/23/2023, the clinical record of Pt. #1 was reviewed. Pt #1's registration date was documented as 2/25/2023 with a chief complaint of cardiac emergencies. Past medical history included: schizophrenia, hypertension, hyperlipidemia, diabetes, and heroin abuse. Pt. #1 was found to be unresponsive in the triage bathroom.

-Code Blue Flow Sheet dated 2/24/2023 was reviewed and indicated time of code blue (medical emergency) was called 11:50 PM and time CPR started 11:50 PM; Location of the Code: ED; Present Reason for code: Cardiac" It was an unwitnessed arrest and unknown how long the patient had "been down" The code had a duration from 11:50 PM-11:58 PM (8 minutes). Pt. #1 was orally intubated, IV (intravenous) access obtained and received three rounds of epinephrine (medication used for cardiac emergencies) 1:10,000 1mg (11:50 PM,11:56 PM, and 11:58PM). At 11:58 PM vital sign: blood pressure 96/71, ROSC (return of spontaneous circulation) at 70 (beats per minute).

-Pt. #1's History and Physical, dated 2/25/2023 at 0007 (12:07 AM) documented by MD #1 (ED Physician) included, "Pt (Pt. #1) brought in cardiac arrest. (Pt. #1) brought was found unresponsive in the triage bathroom. Has food substance coming out of mouth and nose. (Pt. #1) not breathing and pulseless. No trauma evident. No other history at this time ...Narcan (medication to reverse opioid overdose) given without any change in clinical situation. ACLS (advance life cardiac support) protocol initiated. 0004 (12:04 AM) Temp, 97.2 (normal 97.8-99.1 Fahrenheit), Pulse 0 (normal 60-100 beats per minute), B/P 0 (normal 90/60-120/80mmg) ...Tube Placement ...equal and bilateral breath sounds ...good oximetry ...connected to ventilator. Portable chest x-ray ordered for placement ...Diagnosis Acute respiratory failure ...Discharge/Disposition: Condition Critical Diagnosis Cardiac Arrest Disposition: Inpatient"

-A nurses note dated 2/25/2023 at 0004 (12:04 AM) by the Triage Nurse (E #1) included, "Patient found in the bathroom unresponsive with a beer and food on the floor no pulse no breathing. Code blue initiated. Transferred into cart and brought to trauma 2. Started CPR (cardiopulmonary resuscitation). At 0004 (12:04 AM) the ED nurse (E #3) documented - "2/24/23 CPR initiated ...2mg Narcan given ...2/25/2023 at 0004 pulse present at 70 BP 96/71 ROSC [return of spontaneous circulation/heart rhythm obtained]. Pt placed on a vent and intubated at 0002 ..." Pt. #1 was transferred to the Critical Care Unit (CCU) on 2/25/2023 at 8:15 AM. At 1800 Pt. #1's mother gives telephone consent for patient to be made DNR (do not resuscitate). Pt #1 was pronounced dead at 7:30 PM.

On 2/25/2023 at 8:02 PM, a physician note included " ...Assessment: Cardiac arrest, Fentanyl (opioid) overdose Time of Death 7:30 PM ..."

6. Two incident reports were created for this event: Event number: 38285 completed by Security and Event Number: 64286 completed by the triage nurse. The reports indicated that Pt. #1 had been in the bathroom "for sometime". Security opened the door and found Pt. #1 face laying on the floor. Unresponsive, no pulse no breathing and was transferred to Trauma 2.

7.An observational tour of the emergency department was conducted with E #7 on 3/24/2023 from approximately 10:45 AM - 11:15 AM. There was a check in area/counter by the ED walk-in entrance, which was staffed with a Registration Technician. E #7 stated that the patients complete the forms (chief complaint forms) if they are able and give the completed form to whoever is working at the desk. There is no set schedule to ensure staff is always at the ED entrance/front desk.

8. E #1 was not available for interview. E #1 was an agency nurse and no longer contracted at the Hospital.

9. On 3/23/2023 at approximately 2:26 PM, and on 3/24/2023 at approximately 10:45 AM the Director of the Emergency Department (E #7) was interviewed. E#7 stated that, "(Pt. #1) had filled out the form and indicated that it was chest pain. During the investigation the video surveillance review it was observed that triage nurse goes to the door of the triage bathroom and walks away. At 11:43 PM the triage bathroom door was forced open. The nurse leaves to call code blue and does not remain with the patient. It was her responsibility to remain with the patient and initiate CPR. I (E #7) was part of the RCA (root cause analysis) and the development of the action plan. ED staff was re-trained on triage policy, triaging chest pain. In addition, ACLS/CPR mock drills will be conducted. We have completed one drill (3/9/2023). There are other items on the action plan that are in progress and waiting for the arrival and/or installation of the parts: code blue button in the triage room, a window to view the triage room. E #7 stated that the patients complete the forms if they are able and give the completed form to whoever is working at the desk. If the patient is unable to complete the form, the staff at the desk will complete the form with the patient. The form included: patient name, address ... reason for visit ..." E #7 stated that when this form has been completed, it is placed in the box located on the triage room door where the Triage Nurse could find it. E #7 stated that staff who are assigned to be at the ED entrance/front desk where patients enter could be Admitting Technicians, the Triage Nurse, Registration staff, or Security. However, E #7 stated that there is no set schedule to ensure staff is always present at the ED entrance/front desk where walk-in patients enter.

10. On 3/27/2023 at approximately 9:00 AM, telephone interview was conducted with E#6 (ED Nurse). E #6 was the Charge Nurse on duty 2/24/2023 night shift. E #6 stated that that the evening of 2/24/2023 was a busy night. E #6 stated, "I received a call that there was a code blue in triage. I directed to bring patient to trauma room 2. When I arrived at the room someone was doing CPR. I didn't hear the 'Code Blue' alarm go off, so I activated it and went to the room to help and assigned staff per ACLS (Advance Cardiac Life Support). There were no issues running the code. E #6 stated that if a patient presents with chest pain an EKG (electrocardiogram) is done right away, and it is shown to the doctor. If ED is full, patients are moved around, and that patient is brought to the back (main ED). When asked on the nurse response when a patient is found unresponsive, E #6 stated that the nurse is to check the patient and ask for help, patient should not be left alone. It is the nurse responsibility to call or yell for help and continue assessment and manage accordingly. E #6 stated that there was a point when a registration clerk was assigned at the front desk at the front desk (approximately a year ago), during nights. Triage RN and security are the ones doing rounds at front desk.

11. On 3/23/2023 at approximately 4:00 PM, the Chief Nursing Officer (E #11) acknowledged that CPR or a "Code Blue" (medical emergency) was not initiated at the time that E #1 found Pt. #1 unresponsive on the bathroom floor. E #11 stated that Pt. #1 should not have been left unattended. E #11 acknowledged that there was no staff assigned or present at the Front desk on that shift (2/24-2/25/23 evening/night shift). On 3/27/2023 at approximately 12:30 PM the Chief Nursing Officer (E #11) stated that it has been an ongoing project with the Security Department and Nursing to ensure staff coverage of the ED front desk. E #1 stated at this time it has been decided that during the day the coverage will be assigned to an ED technician and coverage during the night will be assigned to PSO. The staff will be assigned 12- hour shifts (8:00am to 8:00pm and 8:00 pm to 8:00 am). On 3/28/2023 at 4:10 PM, the Chief Nurse Officer (E #11) was interviewed. E #11 stated that the PSO are non-clinical staff.