HospitalInspections.org

Based on document review, policy review, medical record review, video review and interviews, the hospital failed to ensure all patients presenting to the hospital's emergency department (ED) were provided an appropriate medical screening exam (MSE) within the hospital's capabilities for 2 of 21 (Patient #1 and 4) in order to determine if an emergency medical condition (EMC) existed.

The findings included:

1. Patient #1 was a 60 year old male transported via emergency medical services (EMS) to Hospital #1's ED on 9/11/2022 at 12:13 PM with complaints of arm pain. EMS vital signs revealed Patient #1 was hypertensive and had abnormal electrocardiogram results. Patient #1 was offloaded to the ED waiting room by EMS at 12:40 PM. There was no documented triage assessment or medical screening exam. The patient left the ED at 3:03 PM, when a random visitor pushed Patient #1 out to the sidewalk to smoke. At 6:54 PM Patient #1 was found unresponsive in a wheelchair on hospital property. Patient #1 was pronounced dead at 7:17 PM by the ED Physician. The hospital failed to initiate and provide an on-going medical screening exam for Patient #1.

2. Patient #4 was a 61 year old female who presented to the ED via private vehicle on 9/10/2022 at 10:36 AM with complaints of chest and left arm pain. Triage was initiated at 10:40 AM with complaints of chest, left arm and right shoulder pain. Patient #4's blood pressure was elevated on triage. The MSE was initiated by NP #1 at 10:42 AM and included an electrocardiogram (ECG), chest X-ray and labs. Patient #4 was returned to the ED waiting room after the MSE was initiated. The ECG resulted at 12:40 PM with normal sinus rhythm, septal infarct age undetermined [patient had possible heart attack in past].." Patient #4 was next called by a nurse on 9/10/2022 at 7:30 PM, 9 hours after presenting at the ED. Patient #4 was called a second and third time by a nurse at 7:42 PM and 8:02 PM. The nurse documented Patient #4 eloped. The hospital failed to adequately monitor and provide an on-going medical screening exam for Patient #4.

The hospital was found not to be in compliance with Federal Regulations at 42 CFR 489.20 and CFR 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A2406

Based on document review, ambulance report, policy review, medical record review, video review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care and treatment for an emergency medical condition (EMC) received an appropriate and on-going medical screening exam (MSE), monitoring and treatment for 2 of 21 (Patient #1 and 4) sampled patients.

The findings included:

1. Review of the Memphis Fire Department (MFD) [Emergency Medical Services (EMS) provider for City of Memphis] offload document dated 1/1/2021, and enforced by the Mayor, revealed, "The MFD is responsible for providing 911 fire and medical services for the citizens of Memphis. MFD currently has 32 ambulances that operate 24 hours a day and up to and additional 8 that operate 12 hours a day (staffing permitted). Delays in transfer of patient care and offloading of patients delivered to designated receiving hospitals by EMS ambulance adversely affects patient care, safety and the availability of ambulances for emergency responses throughout Memphis. It is incumbent upon hospitals and ambulance providers to minimize the time required to transfer patient care and return ambulances to service to ensure optimal patient care, safety, and EMS system integrity. We have established three levels to identify our situational status of ambulance availability.
STATUS GREEN: Greater than 30% of ambulances are available to make 911 calls. This is situation normal. Upon arrival of a patient at the hospital by ambulance the ED medical personnel should make every attempt to offload the patient to a hospital bed or other suitable sitting or reclining device at the earliest possible time not to exceed 30 minutes. EMS personnel will provide a verbal patient report containing any pertinent information necessary for the ongoing care of the patient. Transfer of patient care is completed once the ED medical staff, preferably the ED Charge Nurse, has received a patient report.
STATUS YELLOW: Ambulance availability is 11-30% of the current fleet. A notification is sent to the appropriate EMS supervisors. MEDCOM will be notified and send a Twitter alert stating MFD is on STATUS YELLOW. Thisshould [this should] also serve as a warning to ED staff of a potential upcoming STATUS RED. EMS Supervisors will deploy to hospitals and evaluate current patients in offload for potential transfer to the hospital. This will include evaluation for immediate offload of any patient that can safely be offloaded to the ED. EMS personnel will provide a verbal patient report containing any pertinent information necessary for the ongoing care of the patient. Transfer of patient care is completed once the ED medical staff has received a patient report.
STATUS RED: Ambulance availability is 10% or less. The probability of holding 911 calls is imminent and ongoing. MEDCOM will be notified and send a Twitter alert stating MFD is on STATUS RED. EMS Supervisors will be deployed to the hospitals and offload patients to a hospital stretcher or fire department cot. The EMS Supervisor will notify the ED Charge Nurse of STATUS RED and of our intent to offload patients. Patient demographic sheet will be left with the patient, identifying last vitals, chief complaint any procedures before transfer. Ambulances return to immediate service. SUMMARY OF OFFLOADING PROCEDURE: 1. A verbal report will be provided before offloading. The expectation is that the hospital will offload the patient. EMS will provide a verbal report to the ED Charge Nurse as part of the transfer of the patient. In a Status Yellow or Status Red event, the EMS Lieutenant or Battalion Chief will ensure a verbal report is given to the Charge Nurse or other receiving nurse, on patients offloaded. In addition, a patient demographic sheet will be left with the patient, identifying last vitals, chief complaint any procedures in lieu of verbal report. 2. Patients will be triaged before offloading. The expectation is all arriving patients will be triaged within 30 minutes. If a STATUS YELLOW or RED occurs, the patient has not been triaged, and it has been longer than 30 minutes, the paramedic or EMS Supervisor will verbally report the transfer of the patient to the ED Charge Nurse. MFD will not delay returning ambulances to service during a STATUS RED situation because a patient has not been triaged. 3. MFD cots will be delivered for patients. Many hospitals do not have extra stretchers to offload patients. In these cases, MFD will deliver portable cots to offload patients. The cots will remain in the ED and be logistically managed by MFD. The ultimate responsibility for patient care belongs to the designated receiving hospital once the patient arrives on hospital grounds. Designated receiving hospitals should implement processes for ED medical personnel to immediately provide the appropriate emergency medical care for ill or injured patients upon arrival at the ED by ambulance."

2. Review of the hospital "Triage of Emergency Patients" policy last revised 12/2019 revealed, "POLICY: Triage of patients arriving to the emergency Department (ED) will be conducted by an RN [Registered Nurse]. The triage RN shall verify the data collected by the Emergency Department Technician (EDT) and assign the final triage acuity based upon a five- level triage system known as the Emergency Severity Index (ESI). PURPOSE: Triage ED patients according to the ESI and assign an appropriate acuity level...The triage documentation included name, sex, vital signs, medications, and presenting complaint. The triage assessment will also include a pain assessment and an assessment of level of consciousness....Acuity is determined by the stability of vital signs and potential for life, limb or organ threat based on ESI five level triage system ...the triage nurse may initiate protocols based upon the presenting complaint. The data collection on the presenting complaint and the clinical judgment of the triage nurse will determine the following: Patient condition based on acuity, appropriate treatment designation, the need for immediate medical treatment due to emergent status upon presentation to triage. The Acuity assignments include the following categories: Level 1: Emergent- requires immediate life saving intervention, Level II- High risk situation, is confused, lethargic/disoriented, severe pain/distress, or vitals are in danger zone, Level III- Multiple resources (lab, x-ray, IV, etc.) are required to stabilize the patient, but vitals are not in the danger zone, Level IV- One resource needed to stabilize the patient, Level V- No resources needed to stabilize the patient. Patients will be assigned to available treatment rooms based upon acuity of condition. Emergent patients will be the highest priority and will be take to the treatment area immediately. Levels 2, 3, 4, and 5 will be seen in the appropriate care as condition warrants."

Review of the hospital "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services-EMTALA" policy last revised 3/2021 revealed, "It is the policy of each [Corporate name of Hospital Group] to comply with the Emergency Medical Treatment and Labor Act...Definitions: Capability of a medical facility means that there is physical space, equipment, supplies and specialized services that Hospital provides (e.g., surgery, psychiatry, intensive care, trauma). Capability of the staff means the level of care that the personnel of Hospital can provide within the training and scope of their professional licenses, including on-call coverage. Capacity means the ability of Hospital to accommodate an individual who has been referred for transfer from another facility, and encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as, Hospital's past practices of accommodating additional patients in excess of its occupancy limits to meet its anticipated emergency needs...Emergency medical condition or 'EMC' means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in either: Placing the health of the individual in serious jeopardy, or Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part. Hospital Property means the entire main Hospital campus (including the physical area owned by Hospital that is immediately adjacent to Hospital's main buildings, other areas and structures owned by Hospital that are not attached to Hospital's main buildings but are located within 250 yards of Hospital's main buildings, including parking lots, sidewalks, driveways, and hospital departments...Medical screening examination (MSE) means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage...General EMTALA Requirement: If an individual who is not already a patient presents to the Hospital with an apparent emergency medical condition...and a request is made for (or prudent layperson would believe patient is in apparent need of) treatment, then EMTALA procedures below should be initiated to the extent required by the EMTALA law. Procedures for Individuals Directly Presenting to the Hospital Emergency Department or Labor and Delivery Department: Hospital QMP or trained Labor and Delivery registered nurses should provide a MSE appropriate to the individual's presenting symptoms that is within the capacity and capability of Hospital, to determine whether or not an EMC exists; If the Individual is experiencing an EMC, then Hospital should provide to an individual such further medical examination and treatment as required to stabilize the EMC, within the capability of the Hospital, and/or to arrange for transfer of the individual to another medical facility..."

Review of the hospital "Emergency Department Waiting Room Guidelines" implemented 4/6/2022, revealed, "...Reassessments can be performed by RN, Emergency Department Technician with completed competency and LIP [Licensed Provider] (MD [Medical Doctor], NP [Nurse Practitioner] and PA [Physician Assistant] Vital signs can be performed by: NA [Nurse Assistant], MA [medical assistant], LPN [Licensed Practical Nurse], in addition to RN, EDT [ED Technician] and LIP. The Medical Screening Exam is a process, and continues throughout the visit until the LIP determines the Emergency Medical Condition does not exist...Document focused reassessments and vital signs (BP [blood pressure] HR [heart rate], RR [respiratory rate], Temp if pertinent to presenting complaint SpO2 [oxygen level] and pain level) of patients based on their acuity level...Level 2-vital signs Q [every] 2 hours or more if necessary..."

3. Medical record review for Patient #1 revealed a Prehospital Patient Record (EMS Trip report) dated 9/11/2022 at 11:37 AM. Patient #1 was a 60 year old male and the chief complaint was identified as "left arm pain" and primary impression "weakness". The Emergency Medical Technician (EMT) Summary revealed Unit 27 was dispatched to a patient with complaints of difficulty breathing, with lights and sirens. EMS arrived on scene to a tire shop. Patient #1 was found sitting in front with other guys standing around who reported the patient had not been acting normal. EMS documented the patient was uncooperative and wouldn't answer any questions, but the guys standing there reported Patient #1 had been drinking and was homeless. Patient #1 told EMS he wanted to go to the hospital. Patient #1 was carried to the stretcher without incident. In the back of the unit vitals were taken: blood pressure 185/120, heart rate 143 Oxygen 100% and blood glucose level 158. Patient #1 reported to EMS he had hypertension and admitted to drinking alcohol. 12- lead echocardiogram (ECG) was initiated and transmitted to Hospital #1. When asked was anything hurting, the patient stated his left arm hurt due to him falling on it-when arrived at hospital the patient stated arm not hurting anymore. Review of the ECG results [transmitted to Hospital #1 prior to Patient arrival] dated 9/11/2022 at 12:12 PM revealed, "Abnormal ECG [electrocardiogram a heart monitoring test that measures electrical activity and graphs out heart beats and rhythms] Sinus Tachycardia [irregular heartbeat with faster than normal rhythm] with PVCs [premature ventricular contractions-extra heartbeats that disrupt regular heart rhythm], Possible right atrial abnormality [possible abnormally large right atrium], Left axis deviation [condition when the mean electrical axis of ventricular contraction of the heart lies in the frontal plane direction], Possible infarct- age undetermined [patient had a heart attack at an undetermined time in the past]..." A blood pressure was recorded by EMS at 12:16 PM as 192/173. Patient #1's care was transferred to RN #1 in Hospital #1's ED on 9/11/2022 at 12:40 PM. Patient #1 was placed in waiting room by EMS at approximately 12:41 PM.

Review of the hospital ED records for Patient #1's initial ED visit dated 9/11/2022 revealed he presented at 12:20 PM via EMS. Review of the ED Depart Form dated 9/11/2022 at 4:56 PM and documented by RN #1, revealed the patient left without being seen and was "called x [times] 3 from WR [waiting room] without response." Review of the Clinical Data Flowsheets revealed RN #1 called for Patient #1 at 1:45 PM, 3:29 PM, and 4:00 PM and Patient #1 did not answer/could not be located. Review of the note by NP #1 dated 9/11/2022 and initiated at 1:47 PM revealed, "The patient presents with pt [patient] with hx [history] of ETOH [alcohol] abuse- to ED per EMS and then to WR [waiting room]- uncooperative when calling to triage- He refused to come into triage room- he left ED without telling staff- unable to complete MSE ..."
There was no documented triage or MSE. There was no ECG in Patient #1's certified hospital medical record (that EMS documented transmitting).

4. There was no Prehospital Patient Record (Emergency Medical Services Trip report) for Patient #1's second ED visit on 9/11/2022.

5. Review of Hospital #1's ED records for Patient #1's second ED visit on 9/11/2022 revealed an ED nursing note by RN #2 that documented Patient arrived to ED via EMS after being found unresponsive- EMS stated Patient was found to be in Asystole. Compressions initiated per staff at 7:06 PM, Pulse check at 7:08 PM found to be Asystole, 7:10 PM intravenous access established. 7:11 PM pulse recheck-Asystole, 1 milligram of Epinephrine given at 7:12 PM/compressions resumed,7:25 PM-pulse check Asystole.

The MSE note dated 9/11/2022 and initiated at 7:05 PM revealed Patient #1 was seen by the physician immediately upon arrival. The physician note revealed, "The patient presents in cardiac arrest...Patient was apparently sitting in a wheelchair near the ambulance bay. He was noted to be awake and alert earlier in the evening by staff who were walking by him. About 5 to 10 minutes ago, apparently paramedics near the ambulance bay noticed that he was slumped over in the wheelchair, they [paramedics] could not get a pulse, they hooked him up to the pads and noticed he was in asystole and started compressions. He was then placed on a stretcher and rolled into the ER [emergency room] No other history is immediately available. He was noted to be in asystole, cool and have flies coming out of his mouth when compressions were initiated, all consistent with being down for some time. The onset was unknown. Witnessed arrest unknown. Initial cardiac rhythm Asystole. Pre- arrival treatment cardiopulmonary resuscitation. Preceding symptoms unknown ..Additional history: He did not receive CPR by EMS outside who were prepared to pronounce DOA [dead on arrival] but he was brought in for resus [resuscitation] given he was immediately outside..." The reevaluation by the physician at 7:17 PM revealed Patient #1 was in cardiac standstill on ultrasound, fixed and dilated without sign of life. Patient #1 was pronounced dead at 7:17 PM on 9/11/2022.

6. Review of the video dated 9/11/2022 provided by the Hospital's Director of Security revealed the following: 12:15 PM-Patient #1 can be seen lying on a stretcher transported through the EMS hospital entrance with EMT #1 and EMT #2 12:18 PM- Patient #1 can be seen lying on a stretcher transported through the ED to the triage area by the EMT #1 and EMT #2. 12:19 PM- EMT #2 can be seen walking further into the ED and EMT #1 remained with Patient #1. 12:21 PM- EMT #2 can be seen walking back to the Triage area to stand near Patient #1, EMT #1 can be seen walking down the hallway away from the Triage area. 12:22 PM- RN #1 can be seen approaching Patient #1 and EMT #2, just outside the triage area in the hallway. RN #1 and EMT #2 appear to be talking, and RN #1 points with her left hand/arm down a hallway. RN #1 and EMT #2 can be seen rolling Patient #1 on the stretcher. 12:36 PM- Patient #1 can be seen in the triage hallway lying on a stretcher 12:39 PM-RN #1 can be seen approaching Patient #1 and appears to be talking with Patient #1. 12:40 PM- EMT #1 and EMT#2 can be seen rolling Patient #1 on the stretcher out of the Triage area into the ED waiting room. 12:41 PM- EMT #2 can be seen unstrapping Patient #1 from the EMS stretcher and moving Patient #1's legs off the stretcher. EMT #1 can be seen assisting Patient #1 up by holding Patient #1's left hand. Patient #1 can be seen standing briefly and then goes out of view of the camera. 12:42 PM- EMT #1 can be seen removing the blue protective barrier from the stretcher and rolling the stretcher out of the ED waiting room and few seconds later, EMT #2 is seen walking away from Patient #1. Patient #1 was seated in a bank of chairs in the ED waiting room that was not in view of a camera. 1:46 PM- RN #1 can be seen walking into the ED waiting room to the area where Patient #1 is seated. Patient #1 can not be seen on camera. 1:47 PM- RN #1 can be seen walking away from the area where Patient #1 is seated. 1:48 PM- RN #1 can be seen approaching the area where Patient #1 is seated with what appears to be a gown and some towels. 1:48:32 PM- RN #1 can be seen walking away from Patient #1 back into the triage area. 1:53 PM- Security Guard #1 can be seen rolling Patient #1 in a wheelchair to the front of the ED Waiting room near the registration desk. 1:54 PM- Security Guard #1 walks away from Patient #1 out of view of the camera. 3:02 PM- Patient #1 appears to flag down a white male visitor of the ED. The white male visitor can be seen rolling Patient #1 through the ED waiting room. The white male can be seen talking with Security Guard #2 at the ED walk-in entrance. At 3:03 PM- Security Guard #2 can be seen holding the door open for the white male who rolled Patient #1 out of the ED waiting area, Patient #1 appeared to be talking with Security Guard #2 as he left the waiting room. 3:04 PM- The white male can be seen rolling Patient #1 down the concrete wheelchair ramp outside the ED. 3:05 PM- Patient #1 can be seen on the sidewalk along Eastmoreland Avenue at the end of the wheelchair ramp, sitting in a wheelchair. Patient #1 remains on hospital property. 3:13 PM- a black male can be seen rolling Patient #1 down the sidewalk along Eastmoreland Avenue. 3:19- a black male can be seen rolling Patient #1 further down the sidewalk on Eastmoreland Avenue, Patient #1 remains on hospital property. The black male parked Patient #1 on the sidewalk directly in front of the Shorb parking garage on the sidewalk along Eastmoreland. 3:27 PM- An individual in teal scrubs can be seen rolling Patient #1 further down the sidewalk, past the EMS bay entrance area and past a parked hospital security vehicle, on the sidewalk of Eastmoreland, still on hospital property (identified as the old ED entrance). 4:24 PM the security vehicle can be seen driving into the ambulance bay entrance. At 4:27 the security vehicle can be seen park on the sidewalk near Patient #1. At 4:28 PM the security vehicle enters the Shorb Parking garage. 4:40 PM- the security vehicle can be seen exiting the Shorb parking garage and Security Guard #3 can be seen walking toward the hospital away from the Security vehicle. Patient #1 can be seen making movements through a very grainy blurry video at various times from 3:30 PM through 5:26 PM, it is difficult to see Patient #1 for the video quality (required to zoom in) 6:10 PM- a white car parks on the street directly in front of Patient #1. The driver of the white car can be seen opening the trunk and moving things around. It is unknown if the driver had any interactions with Patient #1. 6:33 PM- the white car is moved. Patient #1 appears to be sitting upright in the wheelchair- the image is very blurry and grainy. 6:46 PM- Patient #1 appears to not be sitting as upright as he was in previous views. 6:51 PM- Patient #1 head appears to be downward in a very blurry grainy camera view. 6:54 PM- EMT #3 appears to be walking away from the blurry figure of Patient #1 and appears to be talking with a bystander wearing a white shirt. EMT #3 appears to throw white gloves away into a trash can, then crosses the street. 6:56 PM- EMT #3 and Paramedic #1 can be seen approaching the blurry figure of Patient #1. 6:57 PM- EMT #3 appears to be connecting a monitor to the patient. 7:00 PM- both EMT #3 and Paramedic #1 are standing near Patient #1 7:03 PM- hospital staff (RN #4 and 5) can be seen running down the sidewalk with a hospital stretcher. The view is too blurry to tell what care is provided to Patient #1 from this camera view. 7:05 PM- Patient #1 is rolled into the EMS hospital entrance on a stretcher. RN #2 can be seen a top Patient #1 on the stretcher doing chest compressions RN #6 is pushing the stretcher and RN #5 is seen pushing the elevator button to transport Patient #1 into the ED treatment area.

7. In a telephone interview on 10/4/2022 at 10:00 AM, EMT #2 verified he transported Patient #1 to hospital #1 on 9/11/2022. EMT #2 stated Patient #1 was initially not cooperating with them and they were getting information from some friends standing around who stated Patient #1 was a heavy drinker. EMT #2 stated he did not recall the primary complaint, but Patient #1 was loaded into the unit, vitals were obtained and a 12 lead ECG was sent to Hospital #1. EMT #2 stated they waited for 10-15 minutes to speak with a nurse. EMT #2 stated Patient #1 was not triaged and the nurse directed them to take Patient #1 to the ED waiting room.

In a telephone interview on 10/4/2022 at 10:18 AM EMT #1 stated Patient #1 was picked up at an abandoned tire shop on 9/11/2022 for complaints of arm pain. EMT #1 verified Patient #1 was transported to Hospital #1's ED. EMT #1 stated he did not recall of Patient #1 was triaged in the ED prior to being offloaded to the ED waiting room by him and his partner.

In an telephone interview on 9/28/2022 at 11:30 AM, RN #1 verified she was the triage nurse on 9/11/2022 when Patient #1 presented via EMS at 12:20 PM. RN #1 stated EMS reported they did not know why they even transported Patient #1 because nothing was wrong with him. RN #1 stated Patient #1 had a swollen left elbow and when she asked Patient #1 about his elbow, he denied any problems with his elbow. RN #1 stated based on the EMT reports, Patient #1 was placed in the ED waiting room by the EMTs. When asked if she took any vital signs or assessed Patient #1 before he was moved to the waiting room, RN #1 stated, "I observed the man [Patient #1] he had grass in his hair ...told me nothing was wrong with his elbow." When asked if the EMT's shared that Patient #1's blood pressure was elevated prior to arrival at the ED or the ECG results or ECG, RN #1 stated she was not informed about the hypertension. RN #1 stated when she approached Patient #1 to initiate triage [documented in medical record as 1:45 PM] he refused to come to the triage room. RN #1 stated Patient #1 had soiled himself and had feces on his clothes and on the arms of the chair he was seated. RN #1 stated she immediately went to get towels and a gown to try to clean Patient #1. RN #1 stated Patient #1 said "No I don't want to do that" and refused to be cleaned up or come to the triage area. RN #1 stated she told Patient #1 she would call him 2 more times for triage but if he continued to refuse care, he would have to leave the ED. RN #1 verified she called for Patient #1 again at 3:29 PM and 4:00 PM. When asked what time Patient #1 left the ED waiting room, RN #1 stated "I have no idea...I never saw him again." When asked where she documented her interactions with Patient #1, his refusal of care/triage/refusal to be cleaned from feces, RN #1 stated, "It was not documented, I didn't have time to document it...I was the only triage nurse..."

In an interview on 9/26/2022 at 3:06 PM, NP #1 verified she was working on 9/11/2022 when Patient #1 presented to the ED via EMS. NP #1 stated she was assigned the triage area and would initiate MSE by beginning orders and initiating the initial assessment of patients. NP #1 stated she was standing in the triage area behind a glass window when Patient #1 was brought into the ED by EMS. NP #1 stated she started her note because she anticipated performing an MSE after triage for Patient #1. NP #1 verified Patient #1 did not come into triage area, but instead was offloaded into the ED waiting room by EMS based on their report to the RN #1. When asked how it was determined Patient #1 could be offloaded to the waiting room, NP #1 stated "That's not my call to make whether a patient can go into waiting room...based on what EMS said." NP #1 stated she later documented that Patient #1 refused to come back to triage. NP #1 stated, "RN #1 told me he was refusing to come back into triage room...he had soiled himself...I never really saw him..."

In an email correspondence on 10/5/2022 at 8:24 AM, the surveyor requested the hospital protocol for EMS transmitting ECG results and hospital staff reviewing the results. The Senior Director of Quality responded with an email that stated,"We don't have a written protocol for this process. EKGs transmitted for patients with complaints of chest pain/STEMI [heart attack] are received by the charge nurse and taken to the ED physician for review. The physician initials it and it is placed in the medical record. In this case [Patient #1], the EKG was not received."

In a telephone interview on 10/6/2022 at 10:00 AM, RN #6 verified she was the charge nurse when Patient #1 presented the first time on 9/11/2022 via EMS. RN #6 stated she did not receive a ECG for Patient #1. RN #6 stated sometimes the ECG do not transmit from EMS. RN #6 stated she did not recall Patient #1. When the surveyor read Patient #'1 ECG results from 9/11/2022, RN #6 verified if had she received them, she would have shared with a provider based on the patient pulse rate and other indicators.


In a telephone interview on 9/28/2022 at 1:50 PM Security Guard #1 verified he was working the ED entrance, near the metal detector as security on 9/11/2022. Security Guard #1 stated he was alerted by other patients that there was an odor in the waiting room. Security Guard #1 stated when he approached Patient #1, seated near the Family room, Patient #1 had defecated on himself. Security Guard #1 stated he called for environmental services to clean the area and he and another Security Guard helped Patient #1 to a wheelchair. Security Guard #1 stated he moved Patient #1 up near the registration area, closer to the nursing triage area, in case he needed assistance.

In a telephone interview on 9/28/2022 at 1:43 PM, Security Guard #2 stated she recalled seeing Patient #1 being rolled out of the ED on 9/11/2022 by another male. Security Guard #2 stated the male rolling the wheelchair asked where he could take Patient #1 outside to smoke. Security Guard #2 stated she told them they would have to go down past the steps or wheelchair ramp to smoke because the hospital was a nonsmoking campus.

In an interview on 9/28/2022 at 2:31 PM, Security Guard #3 stated he saw Patient #1 seated in a wheelchair on the sidewalk of Eastmoreland Avenue (just past where his security vehicle was parked) on 9/11/2022 at approximately 4:30 PM. Security Guard #3 stated he was getting in the Security patrol vehicle to make his rounds of the parking garage and Patient #1 told him he was thirsty. Security Guard #1 stated he drove his security vehicle to the EMS bay area and got two cups filled with water for Patient #1. Security Guard #3 stated he took the water to Patient #1, Patient #1 drank the water and when asked if he need anything else, Patient #1 stated he did not. Security Guard #3 stated he then got in his vehicle, drove his rounds of the Shorb parking garage and returned to park the Security vehicle. He stated Patient #1 was still seated in the wheelchair and was in no distress. Security Guard #3 stated he then went to another area of the hospital to make rounds and did not see Patient #1 again.

In a telephone interview on 10/4/2022 at 9:33 AM, Paramedic #1 stated he was working the Unit 6 MFD EMS on 9/11/2022. Paramedic #1 stated he and his partner had driven out of the ambulance bay at Hospital #1, onto Eastmoreland Avenue, to complete their documentation because the bay can get crowded with units. Paramedic #1 stated a bystander got their attention, as they were sitting in their unit, and alerted them that Patient #1 appeared to be deceased. Paramedic #1 stated when he and his partner approached Patient #1 he was in a wheelchair on the sidewalk, pulseless and breathless with flies swarming. Paramedic #1 stated,"it was very disturbing sight." He stated the cardiac monitor was connected to the patient and Patient #1 was in Asystole, therefore no care was provided by himself or his partner. Paramedic #1 verified Hospital #1 nursing staff did initiate compressions when they arrived at Patient #1.

In a telephone interview on 10/4/2022 at 10:11 AM, EMT #3 verified he was working in Unit 6 MFD EMS on 9/11/2022. EMT #3 stated he was the driver and had pulled the unit on Eastmoreland Avenue to complete their documentation for the previous call. EMT #3 stated a bystander flagged him down to ask if he would check on Patient #1. EMT #3 stated he initially approached Patient #1 and noted he was not responsive. EMT #3 then went to get his partner, Paramedic #1 and the heart monitor. EMT #3 stated there was no activity on the monitor and Patient #1 was already deceased. When asked how Hospital #1 staff were alerted by their unit, he stated Paramedic #1 called another Paramedic (unable to identify for interview) who was in the ED proper, who reported it to the nursing staff.

In a telephone interview on 9/28/2022 at 12:00 PM RN #4 stated she was coming on shift at 7:00 PM and was assigned the hallway. RN #4 stated a Fire Unit medic reported there was a dead man in a wheelchair outside. RN #4 stated the unit that found the patient did not radio into the hospital, they told another unit who reported it to the ED staff. RN #4 stated she also had an Orientee assigned to her that shift. RN #4 stated she and another nurse (RN #5) and the Orientee, got a stretcher and went outside. RN #4 stated she found Patient #1 in a wheelchair with a life pack (a portable monitor) on (via EMS). RN #4 stated EMS was not performing CPR for Patient #1. RN #4 stated she and RN #5 along with EMS got Patient #1 on the stretcher and she straddled Patient #1 and began chest compressions, while RN #5 and the Orientee wheeled the stretcher back into the ED. RN #4 stated a physician assisted once they were in the ED and she continued to perform compressions for 2 more rounds and then was relieved by another staff member.

In a telephone interview on 9/29/2022 at 8:00 AM, RN #2 verified she was working 7PM- 7 AM when Patient #1 was brought into the ED nonresponsive. RN #2 stated she assisted by documenting the care provided by the 5-6 team members who were in Room 25 trying to resuscitate Patient #1.

In a telephone interview on 9/29/2022 at 9:12 AM, RN #5 verified she was working as a 7PM- 7AM Charge Nurse in the ED on 9/11/2022. RN #5 stated they were alerted at the start of her shift by a EMS worker, that another EMS unit had found a man in a wheelchair non-responsive on Eastmoreland. RN #5 stated