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Based on observation, interview, and record review, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of twenty sampled patients (Patient 19), when Patient 19 presented to the Emergency Department (ED, provides immediate medical care to patients with acute, life-threatening illness and injuries) complaining of chest pain and an EKG was not performed within 10 minutes of ED arrival.

This deficient practice resulted in Patient 19 not having a medical screening examination (MSE) to determine whether an emergency medical condition existed, such as a myocardial infarction (heart attack, blockage of blood flow to the heart muscle) or other cardiovascular related problems, upon arrival to the ED complaining of chest pain.

Findings:

During a review of Patient 19's "Face Sheet," dated 3/17/2025, the Face Sheet indicated Patient 19 walked in to the Emergency Department at 12:40 a.m. for chest pain with neck pain.

During a review of Patient 19's "Conditions of Admission (COA)," dated 3/17/2025, the COA indicated form was signed by Patient 19 on 3/17/2025 at 12:40 a.m.

During a review of Patient 19's "View Existing Collection Notes," dated 3/17/2025 and timed at 12:50 a.m., the Notes indicated Patient 19 was eligible for public health insurance.

During concurrent observation and interview on 7/8/2025 at 01:34 p.m. with the Triage Nurse (TRN) from the Emergency Department, the TRN stated that patients enter the Emergency Department and present to the Check-In window with the Triage nurse, who documents in a "Walk-In Triage Log" patients' arrival time, name, complaint, oxygen level, heart rate, respiration rate, allergies, pain level, notes, and nurse initials, then the triage nurse sends the patients to the registration desk to register with the admitting department. TRN stated after patients register, the patient's name will appear in the triage's nurse computer and the triage nurse will call the patient to place the identification wristband on the patient and complete the triage process, which includes assigning a priority level, a full vital signs (VS, temperature, blood pressure, heart rate/minute, oxygen level, respiratory rate, and pain), EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) for patients who complaint of chest pain, and a past medical history is collected by an Emergency Medical Technician, located right next door to the triage nurse at the Check-In window.

During a concurrent interview and record review on 7/10/2025 at 10:37 a.m. with the Registered Nurse of Emergency Department (RNED) 1, RNED 1 stated Patient 19 presented to the ED on 3/17/2025 at 12:40 a.m. for chest pain with neck pain. Patient 19 registered at the Registration window. RNED 1 also stated Patient 19 was called in the waiting room by Registered Nurse of Emergency Department (RNED) 2 at 01:13 a.m., 01:35 a.m., and 01:44 a.m. with no response. RNED 1 stated Patient 19 waited for 33 minutes to be called for triage (a preliminary assessment in order to determine the urgency of a patient's need for treatment and nature of treatment required) and verified an EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) had not been completed prior to Patient 19's registration. RNED 1 stated that there were no records of interventions or treatment such as, EKG, triage, or MSE, being done for the Patient 19 because Patient 19 left without been seen.

During a concurrent interview on 7/10/2025 at 11:22 a.m. with the Emergency Department Clinical Supervisor (EDCS), EDCS stated patients presenting to the ED with complaint of chest pain will be provided with EKG (a non-invasive test that records the electrical activity of the heart) immediately. A physician interprets the EKG to determine a patients' priority level. In addition, standard orders are placed, and patients are placed in a room immediately. EDCS stated Patient 19's EKG was not performed for Patient 19 upon arrival to the ED. In addition, Patient 19 was not triaged, nor did Patient 19 receive a medical screening exam.

During a concurrent interview and record review on 7/10/2025 at 1:45 p.m. with the Medical Director of the Emergency Department (MDED), the MDED stated that standardized procedures for patients presenting to the ED with complaints of chest pain will require an immediate EKG and interpretation by a physician to help determine whether an emergency medical condition exists. Patients are immediately expediated for STEMI (a severe type of heart attack characterized by a complete blockage of a major coronary artery) order set and blood work. MDED stated the failure to complete the standardized procedures for Patient 19 had the potential for myocardial infarction (MI, heart attack) and/or cardiac catheterization (a procedure where a thin, flexible tube [catheter] is inserted into a blood vessel and guided to the heart to diagnose and treat certain heart conditions).

During a review of the facility's policy and procedure (P&P) titled, "RN Standardized Procedures: Emergency Department," dated 3/2025, the P&P indicated the following. Patients presenting to the emergency department (ED) receive timely high-quality care. Therefore, a Registered Nurse (RN) in the ED may begin evaluation and care of patients using standardized procedures that are withing their scope of practice. Section 7. Procedure 7.2 The Emergency Department Standardized Procedure for specific patient conditions indicated Patients presenting with symptom (s) and or complaint (s) with Chest pain and are greater than or 40 years old or known cardiac history; the standardized procedure order sets to include: Labs, including, Troponin (indicate heart muscle damage). Nursing orders include to activate a facility STEMI order set, Cardiac Monitor, Start IV (Saline Lock). Cardiology, a 12-lead EKG, to show to MD immediately. Imaging includes a Chest x-ray.

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Examination" dated 9/2023, the P&P indicated "to provide a medical screening examination with the facility's capability by an Emergency Physician for all individuals presenting to the Emergency Department without regard for their ability to pay. To determine the existence of an emergency medical condition. To provide medical screening, examination, emergency services and care as indicated to stabilize the medical condition of the patient ...if it is determined that the individual has an emergency medical condition, the Emergency Department will provide the individual, within the capabilities of the Hospital, with such further medical examination and treatment, as required, to stabilize the medical condition ...5. Without Delay: The Emergency Department will not delay the provision of a medical screening examination, further medical examination and stabilizing treatment, or appropriate transfer of an individual with an emergency medical condition in order to inquire about the individual's method of payment or insurance status."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain," dated 9/2023, the P&P indicated "it is the policy of [facility's name] to attempt to reduce the morbidity and mortality associated with patients presenting to the Emergency Department with chest pain or other cardiovascular related problems. Qualified personnel accomplish this through rapid assessment, intervention and treatment of these symptoms without delay for financial or any other reason. Patients presenting to the Emergency Department with symptoms/signs suggestive of acute coronary syndrome or cardiac event will be immediately triaged and will receive an EKG within 10 minutes of arrival to the emergency department (ED) ...The RN will order an EKG if EKG shows signs of STEMI/NSTEMI, acute ischemia, then patient is to be placed in bed immediately. ED physician initiates Code STEMI as indicated by the EKG."

Based on observation, interview, and record review, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of twenty sampled patients (Patient 19), when Patient 19 presented to the Emergency Department (ED, provides immediate medical care to patients with acute, life-threatening illness and injuries) complaining of chest pain and an EKG was not performed within 10 minutes of ED arrival.


This deficient practice resulted in Patient 19 not having a medical screening examination (MSE) to determine whether an emergency medical condition existed, such as a myocardial infarction (heart attack, blockage of blood flow to the heart muscle) or other cardiovascular related problems, upon arrival to the ED complaining of chest pain.

Findings:

During a review of Patient 19's "Face Sheet," dated 3/17/2025, the Face Sheet indicated Patient 19 walked in to the Emergency Department at 12:40 a.m. for chest pain with neck pain.

During a review of Patient 19's "Conditions of Admission (COA)," dated 3/17/2025, the COA indicated form was signed by Patient 19 on 3/17/2025 at 12:40 a.m.

During a review of Patient 19's "View Existing Collection Notes," dated 3/17/2025 and timed at 12:50 a.m., the Notes indicated Patient 19 was eligible for public health insurance.

During concurrent observation and interview on 7/8/2025 at 01:34 p.m. with the Triage Nurse (TRN) from the Emergency Department, the TRN stated that patients enter the Emergency Department and present to the Check-In window with the Triage nurse, who documents in a "Walk-In Triage Log" patients' arrival time, name, complaint, oxygen level, heart rate, respiration rate, allergies, pain level, notes, and nurse initials, then the triage nurse sends the patients to the registration desk to register with the admitting department. TRN stated after patients register, the patient's name will appear in the triage's nurse computer and the triage nurse will call the patient to place the identification wristband on the patient and complete the triage process, which includes assigning a priority level, a full vital signs (VS, temperature, blood pressure, heart rate/minute, oxygen level, respiratory rate, and pain), EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) for patients who complaint of chest pain, and a past medical history is collected by an Emergency Medical Technician, located right next door to the triage nurse at the Check-In window.

During a concurrent interview and record review on 7/10/2025 at 10:37 a.m. with the Registered Nurse of Emergency Department (RNED) 1, RNED 1 stated Patient 19 presented to the ED on 3/17/2025 at 12:40 a.m. for chest pain with neck pain. Patient 19 registered at the Registration window. RNED 1 also stated Patient 19 was called in the waiting room by Registered Nurse of Emergency Department (RNED) 2 at 01:13 a.m., 01:35 a.m., and 01:44 a.m. with no response. RNED 1 stated Patient 19 waited for 33 minutes to be called for triage (a preliminary assessment in order to determine the urgency of a patient's need for treatment and nature of treatment required) and verified an EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) had not been completed prior to Patient 19's registration. RNED 1 stated that there were no records of interventions or treatment such as, EKG, triage, or MSE, being done for the Patient 19 because Patient 19 left without been seen.

During a concurrent interview on 7/10/2025 at 11:22 a.m. with the Emergency Department Clinical Supervisor (EDCS), EDCS stated patients presenting to the ED with complaint of chest pain will be provided with EKG (a non-invasive test that records the electrical activity of the heart) immediately. A physician interprets the EKG to determine a patients' priority level. In addition, standard orders are placed, and patients are placed in a room immediately. EDCS stated Patient 19's EKG was not performed for Patient 19 upon arrival to the ED. In addition, Patient 19 was not triaged, nor did Patient 19 receive a medical screening exam.

During a concurrent interview and record review on 7/10/2025 at 1:45 p.m. with the Medical Director of the Emergency Department (MDED), the MDED stated that standardized procedures for patients presenting to the ED with complaints of chest pain will require an immediate EKG and interpretation by a physician to help determine whether an emergency medical condition exists. Patients are immediately expediated for STEMI (a severe type of heart attack characterized by a complete blockage of a major coronary artery) order set and blood work. MDED stated the failure to complete the standardized procedures for Patient 19 had the potential for myocardial infarction (MI, heart attack) and/or cardiac catheterization (a procedure where a thin, flexible tube [catheter] is inserted into a blood vessel and guided to the heart to diagnose and treat certain heart conditions).

During a review of the facility's policy and procedure (P&P) titled, "RN Standardized Procedures: Emergency Department," dated 3/2025, the P&P indicated the following. Patients presenting to the emergency department (ED) receive timely high-quality care. Therefore, a Registered Nurse (RN) in the ED may begin evaluation and care of patients using standardized procedures that are withing their scope of practice. Section 7. Procedure 7.2 The Emergency Department Standardized Procedure for specific patient conditions indicated Patients presenting with symptom (s) and or complaint (s) with Chest pain and are greater than or 40 years old or known cardiac history; the standardized procedure order sets to include: Labs, including, Troponin (indicate heart muscle damage). Nursing orders include to activate a facility STEMI order set, Cardiac Monitor, Start IV (Saline Lock). Cardiology, a 12-lead EKG, to show to MD immediately. Imaging includes a Chest x-ray.

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Examination" dated 9/2023, the P&P indicated "to provide a medical screening examination with the facility's capability by an Emergency Physician for all individuals presenting to the Emergency Department without regard for their ability to pay. To determine the existence of an emergency medical condition. To provide medical screening, examination, emergency services and care as indicated to stabilize the medical condition of the patient ...if it is determined that the individual has an emergency medical condition, the Emergency Department will provide the individual, within the capabilities of the Hospital, with such further medical examination and treatment, as required, to stabilize the medical condition ...5. Without Delay: The Emergency Department will not delay the provision of a medical screening examination, further medical examination and stabilizing treatment, or appropriate transfer of an individual with an emergency medical condition in order to inquire about the individual's method of payment or insurance status."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain," dated 9/2023, the P&P indicated "it is the policy of [facility's name] to attempt to reduce the morbidity and mortality associated with patients presenting to the Emergency Department with chest pain or other cardiovascular related problems. Qualified personnel accomplish this through rapid assessment, intervention and treatment of these symptoms without delay for financial or any other reason. Patients presenting to the Emergency Department with symptoms/signs suggestive of acute coronary syndrome or cardiac event will be immediately triaged and will receive an EKG within 10 minutes of arrival to the emergency department (ED) ...The RN will order an EKG if EKG shows signs of STEMI/NSTEMI, acute ischemia, then patient is to be placed in bed immediately. ED physician initiates Code STEMI as indicated by the EKG."