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Based on observation, interview, and record review, the facility failed to provide and maintain a safe and sanitary environment for all patients in the facility's Emergency Department resulting in the potential for negative outcomes. Findings include:

Initial tour of facility's Emergency Department (ED) was conducted on 8/6/24 from 1153 untill approximately 1300, with facility's Chief Nursing Officer, Staff C, and Department Nurse Managers, Staff F and Staff G. Approximately at 1214 oxygen tank was observed unsecured at the nurses' station in the pediatric area of the ED. At 1225 two oxygen tanks were observed unsecured in the medication room. Staff F was present during both observations and confirmed the findings. When queried, he stated that staff was busy attending to pediatric patients and did not have a moment to store tanks right away after use.

Facility's Policy Compressed Gas and Oxygen Use was requested and reviewed on 8/7/24. Policy, dated 11/16/22, revealed: Cylinders must be secured at all times so they cannot fall.


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On 8/7/2024 at 1145, during a tour of the facility's resuscitation room in the ED, on the back counter six 50 milliliter bags of 0.9% Sodium Chloride were observed. Each bag did not contain the protective plastic overwrap. Staff C was interviewed at this time and confirmed the findings.

According to the facility's policy "Intravenous Admixture," dated 2/22/2022, the policy indicated that "Expiration dates must be assigned to all fluid bags when they are removed from the protective overwrap packaging provided by the manufacturer, unless the bag is going to be used immediately to prepare a custom admixture. Fluid bags that are less than 100 mLs will be assigned a 15-day expiration date. Fluid bags that are 100 mLs or greater will be assigned a 30-day expiration date."

On 8/7/2024 at 1150, during a tour of the facility's room containing the Computed Tomography (CT) scanner in the Emergency Department, two one-liter bags of 0.9% Sodium Chloride were spiked (administration set attached to the bag) and hanging next to the CT scanner. Each bag did not have any facility-prepared label attached. CT Technician Staff M was asked how long these bags were good for. She replied by pointing to the expiration date on the bag (8/2025).

According to the facility's policy "Medication Administration", dated 7/18/2024, the policy indicated "IV solutions and irrigation bottles (normal saline, sterile water) shall be marked with the expiration date and time. The date/time shall be 24 hours after the product is opened/spiked. Any unused product should be discarded after the noted expiration date/time."

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically, the medical screening exam, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

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A-2406 Failure to provide an appropriate medical screening exam

Based on interview and record review, the facility failed to provide continued monitoring until it was determined whether the individual had an Emergent Medical Condition for one (P-1) out of 20 patients, resulting in delayed treatment and less than optimal outcomes for the patient. Findings include:

On 8/6/2024 at 1515 record review revealed P-1 arrived at the facility on 6/18/2024 at 0322, triage was completed at 0326, EKG (electrocardiogram) was taken at 0331 and reviewed by ED provider. P-1 remained in the waiting room and vitals signs (VS) were re-taken at 0546. P-1 was taken to a room in the ED at 0549 and repeat EKG was completed at 0613 which revealed he was having a STEMI (ST elevation myocardial infarction). P-1 reported 10/10 heavy mid-sternal chest pain, that woke him up at 2300 the evening prior to arrival, left arm pain which radiated to the chest and shortness of breath. VS in triage revealed an elevated blood pressure (BP) of 180/117 and a heart rate of 125.

On 8/6/2024 at 1551 an interview was conducted with the ED Medical Director (Staff D) who reviewed P-1's medical record including the first EKG that was completed in triage. Staff D revealed patients that arrive to the ED by private vehicle with chest pain should have an EKG upon arrival during triage, the ED staff will take the EKG to the ED provider for review. Staff D added the ED provider determines if the patient can wait in the waiting room when all of the ED rooms are full and tells the Registered Nurse (RN) whether the patient needs to be brought back immediately or they are stable to wait. Staff D revealed review of the first EKG for P-1 was not "normal" because it did have ST elevation in V2 (one of the EKG leads or views), but did not warrant a "STEMI" alert activation at that time. Staff D added indicated P-1 was symptomatic based on review of the record, and he should have been brought back for evaluation. When queried whether it was appropriate for P-1 to have waited in the waiting room with his presenting symptoms and the initial EKG findings, Staff D stated "no".

On 8/7/2024 at 0916 an interview was conducted with the triage RN (Staff DD), Staff DD indicated she remembered triaging P-1. Staff DD stated P-1 "did not look ill" and he was not pale, diaphoretic but he was having a lot of chest pain. Staff DD added P-1 had a history of hypertension and his blood pressure was high in triage and assigned an Emergency Severity Index (ESI) of 2 (high risk situation). Staff DD indicated she took the EKG to the ED provider for review and "told him the backstory" regarding P-1 and was told he could wait because there were no rooms available. Staff DD stated she told P-1 to let the staff know if his symptoms changed or worsen, and she did not recall him coming back up to the desk to report changes. When queried if the triage nurse has standing orders available for patients waiting in triage, Staff DD stated "yes, but that is a newer process, and I didn ' t do that" and added she would be using these orders in the future if needed.

On 8/7/2024 at 1015 an interview with the ED Co-Manager (Staff F) was conducted. When queried if nursing has standing orders available for patients waiting in the waiting room, Staff F stated "yes they do, but we need to have staff available to draw the labs and at 0300 we go down in staffing and we were very busy that day". When asked if the standing orders for chest pain would have helped the triage nurse and provider identify the STEMI sooner, Staff DD stated that the elevated troponin of 0.36 would have been a "red flag" and indicated he needed to be treated immediately.

On 8/7/2024 at 1045 an interview was conducted with the ED Educator/Clinical Specialist (Staff EE). She explained that she has been re-educating the ED RN ' s to use standing orders. Staff EE agreed the chest pain standing orders may have helped to identify P-1's need for immediate care.

On 8/7/2024 at 1300 review of facility policy #0703, titled "Responding to Emergencies Hospital Property and Off-Campus Facilities", last reviewed 3/27/2023 revealed on page 6, "Section B. If an individual comes to the Emergency Department: #2. The Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition".