HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a timely medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 10 sampled patients (Patient #3).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital failed to ensure a timely medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 10 sampled patients (Patient #3).

The findings included:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA) Compliance" policy, effective 10/26/2018, revealed "...PROCEDURE: Medical Screening Examination (MSE): 1. Any individual that presents on hospital property and requests....examination or treatment for a medical condition....will be provided a MSE to determine if an emergent medical condition exists. 2. The MSE will be performed within the capability and capacity of the hospital, including ancillary services, resources routinely available... ."

1 Review of a closed DED medial record on 07/27/2021 for Patient #3 revealed an 87- year-old female that presented to the DED on 06/28/2021 at 1548 with a chief complaint of shortness of breath. Review of the EKG (electrocardiogram - test that measures electrical activity of heart) performed at 1556 revealed "Interpretation: Sinus Rhythm Left axis deviation Right bundle branch block Left ventricular hypertrophy with repolarization abnormality (Rin a VL) Inferior infarct, age undetermined Anterior infarct, age undetermined Abnormal ECG (same as EKG) No significant change since 06/03/2021. Review of vital signs documented at 1556 revealed a temperature (T) of 97.7 degrees Fahrenheit; pulse (P) 110; respirations (R) 18; blood pressure (BP) 153/85; and oxygen saturation of 98%. Review of the Triage Note dated 06/28/2021 at 1609 [21 minutes after arrival] revealed "Patient arrives to ED (emergency department) with complaints of worsening of her SOB (shortness of breath) today while doing physical therapy at home. Patient states she was SOB when she woke up this morning. Pt on 2 L (liters of oxygen) at all times now on 3.5 L for O2 (oxygen) > 94%. Patient states her O2 dropped to 90% while doing PT (physical therapy) today. NAD (no acute distress) in triage." Review of the Physician orders revealed at 1614 an order for "Pulse oximetry, continuous; If O2 Sat < 94% administer O2 at 2 liters/minute via nasal cannula; Basic metabolic panel; CBC (complete blood count); ED EKG; Chest 2 view" x-ray. Review revealed at 1615 Patient #3 was assigned an ESI acuity of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review revealed Patient #3 was transferred from the ED triage room to the ED waiting room at 1628. The chest x-ray performed at 1643 revealed "IMPRESSION: No active cardiopulmonary disease. Aortic Atherosclerosis (build up in the arteries). The CBC resulted at 1717 with a normal result except for "RBC (red blood cells) 3.70 (Ref [reference] Range: 3.87-5.11); Hemoglobin: 11.2 (Ref Range: 12.0-15.0); and Platelets: 131 (Ref Range: 150.0-400.0)." The BMP resulted at 1718 with a normal results except for " CO2 (carbon dioxide) 18 (Ref Range: 22-32); Glucose, Bld (blood): 219 (Ref Range: 70-99 [Glucose reference range applies only to samples taken after fasting for at least 8 hours); and Anion gap: 20 (Ref Range: 5-15)." Review of the vital signs at 1924 (3 hours 28 minutes since last set of vital signs) revealed a P 97; R 20; BP 133/81; and oxygen saturation of 100% on 3 L/min via nasal cannula. Review of the vital signs at 2232 (3 hours and 8 minutes since last vital signs ) revealed a P 87; R: 18; BP 129/69; and oxygen saturation of 99% with "Oxygen Therapy: O2 Device: nasal cannula". Review of the vital signs on 06/29/2021 at 0242 (4 hours 10 minutes) revealed a T of 98 degrees Fahrenheit; P 85; R 16; BP 131/67; and oxygen saturation of 99%. Review of the vital signs at 0615 (3 hours and 33 minutes since last vital) revealed a T of 97.7 degrees Fahrenheit; P 93; R 16; BP 126/66; and oxygen saturation of 100% on Room Air. Review of the hourly rounding on 06/29/2021 at 0728 revealed "Assessment: Alert; Patient comfortable; Intervention: Delay explained to pt (patient)/other; Pain Assessment: 0-10; Pain Score: 0-No pain." Review of the vital signs at 0729 (1 hour and 14 minutes since last vital signs) revealed a T of 98.2 degrees Fahrenheit; P 105; R 16; BP 136/104; and oxygen saturation of 100% on 2 L/min oxygen via nasal cannula. Review of the Nurses Note at 0729 revealed "Brought back into triage for re-eval. Pt is alert. Daughter with pt. Remains on oxygen. States she feels better. Just sleepy." Review revealed Patient #3 was transferred from the ED triage room back to the ED waiting room at 0730. Review of the CBG (capillary blood glucose) monitoring resulted at 0733 revealed "Glucose-Capillary: 61 (Ref Range: 70-99 [Glucose reference range applies only to samples taken after fasting for at least 8 hours]). Review revealed Patient #3 was transferred to an exam room in the ED at 0740. Review of Physician Assistant (PA) #1's medical screening examination dated 06/29/2021 at 0749 (16 hours and 01 minutes since arrival to ED) recorded the patient presented "to the ED (emergency department) with her daughter for evaluation of dyspnea (difficult or labored breathing) since yesterday AM. Per patient's daughter the patient was getting dressed yesterday morning & (and) seemed to have some increased dyspnea with wheezing on her 2L via NC (nasal cannula), therefore they increased her oxygen to 3.5 L & gave her a breathing treatment which seemed to help some. Later in the day her oxygen dropped to 90% on 3.5L, her physical therapist came to the house and she seemed to have some increased work of breathing with her exercise which prompted ED visit." Review of the Physician Assistant (PA)'s note recorded the patient had "Respiratory: Positive for cough and shortness of breath; Cardiovascular: Negative for chest pain and leg swelling ... Gastrointestinal: Positive for diarrhea ... Physical Exam: Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales. Comments: Poor air movement ...tachycardic into the 120's and with SPO2 of 100% on her baseline 2 L via nasal cannula ... On initial evaluation of the patient after a 15-hour wait in the lobby patient has been able to be titrated back down to her 2 L via nasal cannula baseline oxygen requirement - she is saturating well on this without signs of respiratory distress. She has somewhat poor air movement but no obvious admission to his (sic) lung sounds. Chest x-ray does not show findings of pneumonia or fluid overload. Her BMP is notable for an anion gap acidosis, this may be dehydration related given her diarrhea yesterday current tachycardia and dry mucous membranes, therefore will give 500 cc of fluid, will avoid aggressive fluid resuscitation in patient with EF (ejection fraction) of 30 to 35% ... 1003 Patient with increased dyspnea, mild diaphoresis noted, difficult to discern rhythm A. fib (atrial fibrillation - irregular fast heart rate) versus sinus tachycardia (regular fast heart rate), repeat EKG does not meet STEMI criteria, troponin is elevated at 101. Will give 324 of aspirin and give 10 mg (milligrams) of IV Cardizem with plan for reassessment. Lungs remain without obvious adventitious sounds ... 1125 RE-EVAL: Patient initially symptomatically improved S/p (status post) Cardizem (medication), however upon return from CT (computerized tomography - special x-rays that produce detailed pictures of inside the body to include organs, blood vessels, and tissue) dyspnea mildly returned with wheezing. On re-exam mild expiratory wheezing noted throughout - Albuterol inhaler w/ (with) spacer & steroids ordered. CTA (computerized tomography angiogram - special x-ray using a special dye to produce pictures of blood vessels and tissues in the body): Negative for PE (pulmonary embolism - blood clot in the lung). Emphysema (respiratory disease) noted. Findings suggested of mild pulmonary edema, cardiomegaly (enlarged heart) & CAD (coronary artery disease - heart disease) noted ... Suspect sxs (symptoms) multifactorial - CHF (congestive heart failure - heart disease where heart doesn't pump blood well), COPD ( chronic obstructive pulmonary disease - respiratory disease), & afib (atrial fibrillation) related, requiring 3 L, plan for admission for further management & trending of troponins ..." Review of Physician orders revealed at 0826 PA #17 ordered Troponin I; Brain natriuretic peptide (BNP); CT Angio Chest PE W (with) or WO (without) contrast; sodium chloride 0.9% bolus 500 mL (milliliters). Review of the vital signs at 0830 revealed ECG Heart Rate: 130; R 29; and BP 155/92. Review of the vital signs at 0938 revealed P 128; R 17; BP 156/95; and oxygen saturation of 100%. Review of the vital signs at 0945 revealed P 78; ECG Heart Rate: 104; R 28; BP 154/78; and oxygen saturation of 99%. Review of the EKG performed at 0956 revealed Sinus tachycardia; Ventricular premature complex; RBBB (right bundle branch block) and LAFB (left anterior fascicular block - failure of electrical conduction in left anterior fascicle [part of the left ventricle in the heart]); LVH (left ventricle hypertrophy [enlargement]with secondary repolarization abnormality (abnormal EKG). Review of the Nurse note dated 06/29/2021 at 0956 revealed "Family call staff to room because pt was cold and clammy and SJOB (sic)". Review of the vital signs at 1000 revealed P 103; ECG Heart Rate: 113; R 37; BP 173/83; and oxygen saturation of 99%. Review of the CBG monitoring resulted at 1001 revealed "Glucose-Capillary: 145 (Ref Range: 70-99 [Glucose reference range applies only to samples taken after fasting for at least 8 hours]). Review of the Troponin I resulted at 1004 revealed "Troponin I (High Sensitivity): 101 (Ref Range: < 18 [CRITICAL RESULT CALLED TO, READ BACK BY AND VERIFIED WITH (RN #19's name). Review of the electronic medical administration report revealed Patient #3 was administered a sodium chloride 0.9% bolus of 500 mL via peripheral iv (intravenous) at 1005; a Chewable aspirin tablet 324 mg (milligrams) at 1011; and diltiazem injection 10 mg via peripheral IV at 1012. Review revealed at 1031 another dose of diltiazem 10 mg injection was administered via peripheral IV. Review of the BNP resulted at 1049 with an abnormal result of "B Natriuretic Peptide: 2,658.9 (Ref Range: 0.0-100.0). Review of the CT Angio Chest PE W/ or WO Contrast resulted at 1124 revealed "Impression: 1. Negative examination for pulmonary embolism. 2. Emphysema. 3. Mild, diffuse interlobular septal thickening, suggestive of mild pulmonary edema. 4. Cardiomegaly and coronary artery disease. 5. Aortic Atherosclerosis." Review of the Physician's Orders revealed an order was placed at 1128 for "Inpatient consult to Cardiology ..." Review of the vital signs at 1132 revealed P 95; ECG Heart Rate: 81; R 19; BP 122/98; and oxygen saturation of 92%. Review of the electronic medical record revealed Patient #3 was given potassium chloride 20 mEq (milliequivalent) tablet at 1145; AeroChamber Plus Flo-Vu at 1200; albuterol inhaler 2 puffs at 1130; lasix 20 mg injection via peripheral IV at 1145, and Solu-Medrol 125/2mL injection via peripheral IV at 1130. Review revealed an order was placed at 1152, for a consult to the hospitalist for admission. Review revealed at 1152 the ED Disposition was set to admit. Review of the vital signs at 1215 revealed P 95; ECG Heart Rate: 96; R 19; BP 139/75; and oxygen saturation of 93%. Review of the Nurse note dated 06/29/2021 at 1351 revealed "Increased oxygen need noted. 98% on 4 L previously, now 91% on 6L. Accesory (sic) muscle use, HR (heart rate) trending from 80s to 100s with more frequent PVCs (premature ventricular contractions - extra heartbeats) also noted. Respiratory reassessed. Wheezing worse despite Lasix given at 1200. Review of the Physician Attestation note signed by MD (Medical Doctor) #2 on 06/29/2021 at 1432 revealed "Attestation: Medical screening examination/treatment/procedures(s) were conducted as a shared visit with non-physician practitioner(s) and myself ... Patient is an 87-year-old female with history of CHF, coronary artery disease, COPD, and dementia (loss of memory and social skills that interferes with daily functioning). She presents today for evaluation of shortness of breath ... This has worsened since yesterday. On exam, vitals are stable and she is afebrile. Oxygen saturations in the lower 90s. Heart is irregularly irregular. Lungs with bilateral rhonchi. Abdomen soft, nontender. Extremities are without edema. Work-up initiated including cardiac markers, BNP, EKG, and chest x-ray. Her BNP was significantly elevated and troponin was 101. Chest x-ray inconclusive. CT scan of the chest was obtained to rule out PE. This was negative for PE, but did have findings consistent with mild pulmonary edema. IV Lasix given and patient to be admitted to the hospitalist service for further treatment. Review revealed a final diagnosis of "Atrial fibrillation with rapid ventricular response; COPD exacerbation; Acute congestive heart failure, unspecified heart failure type." Review of the Physician orders revealed an "Admit to Inpatient (patient's expected length of stay will be greater than 2 midnights or inpatient only procedure)" was ordered on 06/29/2021 at 1221 by MD #18 the admitting physician. Review of Physician orders revealed at 1232 a "Do not attempt resuscitation (DNR)" order was entered. Review of the vital signs at 1315 revealed P 96; ECG Heart Rate: 100; R 19; and BP 143/62. Review of the electronic medical administration record revealed Patient #3 received Lovenox 30 mg subcutaneous injection at 1324. Review of the Nurses note at 1351 revealed "ED Notes Addendum: Increased oxygen need noted. 98% on 4L previously, now 91% on 5L. Accesory (sic) muscle use, HR trending from 80s to 100s with more frequent PVCs also noted. Respiratory reassessed. Wheezing worse despite lasix given at 1200. (MD #20 name) returned page, orders provided to give 1600 duoneb early and 20 mg lasix IV, would also like cardiology paged for this pt to be seen. Unable to draw ordered labs from IV or straight stick x 2, phlebotomy consulted." Review of the electronic medical administration record revealed at 1400 Patient #3 received Lasix 20 mg injection via peripheral IV. Review of the vital signs at 1400 revealed P 97; ECG Heart Rate: 100; R 20; BP 134/63; and oxygen saturation of 92%. Review of the electronic medical administration record revealed at 1413 Patient #3 received Duoneb 0.5-2.5 mg/3mL via nebulizer. Review of the nurses note at 1421 revealed "Spoke with cardiology (sic) about condition change, no new orders at this time, will be rounding on pt later." Review of the vital signs at 1437 revealed P 76; ECG Heart Rate: 103; R 23; and oxygen saturation of 94%. Review of the Nurses respiratory assessment at 1438 revealed "Respiratory (WDL [within defined limits]): Exceptions to WDL; Bilateral Breath Sounds: Expiratory wheezes; Inspiratory wheezes; L (left) Breath Sounds: Expiratory wheezes; Inspiratory wheezes; R (right) Breath Sounds: Inspiratory wheezes; Expiratory wheezes; Respiratory Pattern: Labored; Shallow; Accessory muscle use; Retractions; Regular; Chest Assessment: Chest expansion symmetrical; O2 Device: Nasal Cannula; O2 Flow Rate (L/min): 6 L/min." The CBC resulted 06/29/2021 at 1440 with a normal result except for "WBC (white blood cell): 22.4 (Ref Range: 4.0-10.5); RBC (red blood cells) 3.81 (Ref [reference] Range: 3.87-5.11); Hemoglobin: 11.70 (Ref Range: 12.0-15.0); MCV (mean corpuscular volume): 105.0 (Ref Range: 80.0-100.0); and MCHC (mean corpuscular hemoglobin concentration) 29.3 (Ref Range: 30.0-36.0)." The Magnesium resulted at 1514 revealed "Magnesium: 1.6 (Ref Range: 1.7-2.4), the Comprehensive metabolic panel resulted at 1514 revealed a normal result except for "Glucose, Bld: 344 (Ref Range: 70-99 [Glucose reference range applies only to samples taken after fasting fr at least 8 hours]; BUN: 30 (Ref Range: 8-23); AST: 42 (Ref Range: 15-41); ALT: 52 (Ref Range: 0-44); and GFR cal non AF Amer: 57 (Ref Range: > 60), and the Troponin I resulted at 1514 revealed "Troponin I (High Sensitivity): 73 (Ref Range: < 48). Review of the SARS Coronavirus 2 by RT PCR resulted at 1527 revealed "Negative (Ref Range: Negative)". Review of the vital signs at 1549 revealed P 89; ECG Heart Rate: 114; R 21; and oxygen saturation of 91%. Review of Physician orders revealed at 1645 an order placed for "Consult to palliative care". The Digoxin level resulted at 1801 revealed "Digoxin Level: 0.5 (Ref Range: 0.8-2.0) and the TSH revealed a normal lab value. )". Review of the vital signs at 1943 revealed a rectal T: 93.9 degrees Fahrenheit. Review of Nurse Technician note at 1943 revealed "Placed pt on bear hugger due to rectal temp". Review of the electronic medical administration record revealed at 1948 Patient #3 received Lotensin 10 mg tablet at 1948, Digoxin 0.0625 mg tablet at 1949, aspirin EC 81 mg tablet at 1950, Flomax 0.4 mg capsule at 1950, Coreg 6.25 mg tablet at 1951, Namenda 10 mg tablet at 1951, Lipitor 10 mg tablet at 1953, vitamin B-12 1,000 mcg (micrograms) tablet at1953, Lasix 20 mg injection via peripheral IV at 1954, Dulera 200-5 mcg/act inhaler 2 puffs at 1955 and Lasix 20 mg injection via peripheral IV at 1958. Review of the vital signs at 2000 revealed P 94; ECG Heart Rate 89; R 21; BP 117/74; and oxygen saturation of 91%. Review of the electronic medical administration record revealed at 2004 Patient #3 received Incruse Ellipta 62.5 mcg/inh 1 puff at 2004 and Duoneb 0.5-2.5 mg/3 mL,: nebulizer at 2014. Review of the Respiratory Therapy Protocol Assessment at 2015 revealed " ... Breath Sounds: Moderate expiratry (sic) wheezes, moderatley (sic) decreased bibasilar rales .... O2 Requirements/Pulse Ox Sat (%): Nasal cannula 1-6 LPM (liters per minute) or SpO2 88%-92% ... Dyspnea: Dyspnea on exertion ...)". Review of the vital signs at 2030 revealed P 96; ECG Heart Rate: 98; R 34; BP 110/67 and oxygen saturation of 93%. Review of the vital signs at 2045 revealed P 92; ECG Heart Rate: 94; R 20; BP 109/90 and oxygen saturation of 93%. Review of Physician orders revealed at 2102 orders were placed for blood cultures and to apply the warming blanket. Review of the Nurse note at 2114 revealed "Warming blanket applied at 2045 per pt rectal temp 93.9 F. Paged MD, received new orders. Rectal 94.0F at this time." Review of the ED Timeline revealed Patient #3 was transferred to the inpatient unit at 2143. Review revealed Patient #3 expired at 2225.


Telephone interview on 07/28/2021 at 0915 with Registered Nurse (RN) #21 revealed if a patient has dementia in their history can have one family member with them. Interview revealed Patient #3 was triaged at a level 2 and should be the first one back. Interview revealed level 2's wait 30 minutes to 1 hour at the most. Interview revealed the triage nurse does not see the patient anymore after they are triaged, the sort nurse, the nurse that sits out front, is alerted and watches for the labs to come back and monitors the vital signs. Interview revealed RN #21 was aware of the continuous pulse oximetry order that was ordered while Patient #3 was in the waiting room. Interview revealed the order is for when the patient is in a room in the ED. Interview revealed the "sort tech (technician) documents the vital signs and alerts the "sort nurse" of any concerns.

Telephone interview on 07/28/2021 at 1000 with NT (Nurse Technician) #22 revealed he was assigned the position of "sort tech" in the waiting room. Interview revealed the sort tech assists patients in the waiting room, assist them to the bathroom, perform patients' vital signs, and assist patients from their car into the ED. Interview revealed NT #22 does not remember Patient #3 nor the night Patient #3 presented to the ED. Interview revealed for patients that have an acuity level 2 should have their vital signs every 30 minutes. Interview revealed determining if the vital signs get taken every 30 minutes depends on the night and how heavy the patient load is. Interview revealed often elderly patients need assistance and for the most part it is doable. Interview revealed patients are not supposed to eat or drink in the waiting room in case they need a procedure. Interview revealed if a patient is diabetic and sugar is low, the staff can provide juice. Interview revealed the staff only check the blood sugars if the patient request it to be checked, came in with symptoms of abnormal sugar, or develops symptoms of abnormal sugar.

Telephone interview on 07/28/2021 at 1035 with RN # 23 revealed she was the charge nurse on nights. Interview revealed as charge nurse she would not know a patient in the lobby was on oxygen "unless someone tells me". Interview revealed if the patient's oxygen needed to be increased someone would generally tell the charge nurse. Interview revealed the night shift providers may go out to see if they can see patients and send them home, however it is hard when there are so many patients. Interview revealed "during the day, the whole ER (emergency room) runs except yellow zone, holding zone with 8-10 patients there." Interview revealed at 11 PM (2300) there was "no staff to keep the green zone open, so only about 40 beds , so if holding 29 patients that is almost our entire department." Interview revealed the charge nurse generally goes to see the patients but does not perform rounding on patients who are in the lobby. Interview revealed the staff get a pulse oximetry when vital signs are checked, it is "not continuous" in the lobby. Interview revealed if a patient is a level 2 the vital signs were checked every 30 minutes. Interview revealed the charge nurse can call ED leadership or call the house coverage person but there is "not much they can do." Interview revealed some nights they have to hold an entire emergency department number of patients.

Telephone interview on 07/28/2021 at 1130 with PA #17 revealed she remembered Patient #3 well. Interview revealed PA #17 saw Patient #3 with her supervising physician (MD #18). Interview revealed Patient #3 was an 87-year-old female with multiple co-morbidities on 2L oxygen. Interview revealed Patient #3 was having worsening shortness of breath and requiring increased oxygen at home. Interview revealed Patient #3's blood sugar was low in the waiting room and staff gave her a sandwich. Interview revealed when PA #17 saw Patient #3 she was back down to her baseline oxygen of 2L. Interview revealed Patient #3 looked ok, did not see significant work of breathing on initial assessment. Interview revealed PA #17 would not have considered Patient #3 "critically ill" on her first evaluation. Interview revealed Patient #3 was tachycardic. Interview revealed PA #17 discussed Patient #3 with MD #18. Interview revealed they discussed the CBC was baseline, the BMP showed Patient #3's anion gap of 20 which you "typically think acidosis" and she had "some diarrhea and looked a little dry." Interview revealed PA #17 ordered a small amount of fluids for patient # 3. Interview revealed Patient #3's heart rate kept increasing and PA #17 ordered Cardizem. Interview revealed initially as the nurse started to push the Cardizem in through the IV, and the IV infiltrated. Interview revealed the heart rate did not change so PA #17 gave another dose of Cardizem. Interview revealed the PA ordered a CT scan to look for pulmonary embolism, talked with cardiology about Patient #3 and informed the cardiologist, going to admit Patient #3. Interview revealed whenever the nurse notified the provider that Patient #3 was feeling worse, PA #17 adjusted the medication. Interview revealed "once admit to hospitalist, they basically manage the patient after that." Interview revealed Patient #3 was in the waiting room for about 16 hours. Interview revealed PA #17 could not say if the wait created negative consequences for Patient #3. Interview revealed "don't know, initial presentation looked ok, no one benefits from delay." Interview revealed the wait times are a "hard problem." Interview revealed "primarily not having beds to move admitted patients" to and they have to "stay in the ED", which "limits beds in the ED."

Interview on 07/28/2021 at 1230 with RN #19 revealed she remembered Patient #3. Interview revealed RN #19 was not aware of the wait time, the "daughter mentioned it." Interview revealed RN #19 knows Patient #3 was on oxygen, "just not sure the amount". Interview revealed RN #19 did her assessment based on symptom of shortness of breath Patient #3's daughter said she presented with. Interview revealed RN #19 started Patient #3's peripheral IV and remembered she was a "hard stick". Interview revealed the IV infiltrated and another nurse's attempts to restart it was unsuccessful. Interview revealed toward the end of the day Patient #3's heart rate was up, and she was more sweaty. Interview revealed the PA and the MD were in to see the patient and ordered Lasix. Interview revealed Patient #3 "went out for some test." Interview revealed "the daughter called me in an said she was off oxygen." Interview revealed when RN #19 got in the room Patient #3 was "hooked up at the wall" with the oxygen. Interview revealed RN #19's assignment to care for Patient #3 was about 4 hours before she was changed to a different assignment.

Interview on 07/28/2021 at 1405 with NT #24 revealed he did not remember Patient #3. Interview revealed NT #24 reviewed Patient #3's medical record. Interview revealed "if acuity 2 but appears stable a lower acuity patient may go back. Typically, 4's try to put in the hallways and other areas to be seen as will discharge sooner." Interview revealed NT #24 "would not think took off oxygen, probably just accidentally clicked wrong button." Interview revealed a patient with acuity level 2, the goal should be every 30-minute vital signs. Interview revealed "we have long wait times all the times." Interview revealed "six hours verses fifteen hours for patients seems like a long time, regardless being able to move people upstairs is a big issue. Getting beds is the challenge and started having this about a year and half ago around COVID" time. Interview revealed NT #24 has not done continuous pulse oximetry in the ED waiting room.

Interview on 07/28/2021 at 1430 with MD #18 revealed Patient #3 was an elderly patient with COPD and CHF. Interview revealed MD #18 went and saw Patient #3 relatively early. Interview revealed Patient #3's oxygen saturations seemed ok and she was a little tachycardic. Interview revealed MD #18 gave Patient #3 a little fluid and added on labs as it began to look more like CHF. Interview revealed both the Troponin and the BNP were elevated so MD #18 gave Patient #3 Lasix. Interview revealed Patient #3 was on oxygen when MD #18 saw Patient #3. Interview revealed Patient #3 "did not seem critically ill, she was eating a sandwich, smiling talking with her daughter." Interview revealed she was slightly confused about details, but she could have conversations. Interview revealed the last time MD #18 checked on Patient #3 her oxygen saturations looked fine and they got the hospitalist involved for the admission. Interview revealed MD #18 did not know if the delay did any harm to Patient #3. "Don't think it did any favors." Interview revealed Patient #3's vital signs were stable, and nothing made MD #18 think Patient #3 should have been brought back immediately. Interview revealed if the vital signs had been unstable Patient #3 would have been brought back immediately. Interview revealed holding admissions and holding behavioral health patients backs up the ED. Interview revealed the wait time problem "seems like this is a healthcare universal problem."

Telephone interview on 07/28/2021 at 1510 with RN #25 revealed she remembered Patient #3. Interview revealed RN #25 noticed the oxygen tank on the bed was empty and she put a new tank on the bed. Interview revealed Patient #3 was already hooked up to the wall oxygen at this time. Interview revealed RN #25 was not aware of a time that Patient #3 was without oxygen. Interview revealed Patient #3's daughter left to go home around 8-9 pm. Interview revealed prior to moving Patient #3 to the inpatient unit she had a change in condition. Interview revealed a rectal temperature was checked and Patient #3 was colder. Interview revealed RN #25 put a bair hugger on Patient #3. Interview revealed transporting Patient #3 to the inpatient unit was delayed due the inpatient unit had to obtain a bair hugger. Interview revealed Patient #3 did not want the bair hugger on as she "felt hot". Interview revealed Patient #3 could answer questions but was "definitely weaker." Interview revealed "vital signs had been checked, not so much with temperatures." Interview revealed "temperature was not something focused on". Interview revealed Patient #3 had been offered warm blankets and she would refuse them so was not thinking of low temperature. Interview revealed when Patient #3 was moved to the floor there was "nothing different there was a palliative consult" and "she didn't look the way we would want her to, but no big change." Interview revealed RN #25 remembered saying good-bye to Patient #3 and she was lethargic, but she spoke. Interview revealed RN #25 heard Patient #1 had passed away from the Chaplain the next day but was not a big surprise based on Patient #3's heart and breathing.

Telephone interview on 07/28/2021 at 1642 with MD #20 revealed she remembered Patient #3. Interview revealed Patient #3 was pleasant and was having to use accessary muscles with breathing. Interview revealed MD #20 knew Patient #3 was a DNR (Do Not Resuscitate) and wanted her to be comfortable. Interview revealed when MD #20 examined Patient #3, her vital signs were stable, and she did not complain of anything. Interview revealed MD #20 did not receive a page about Patient #3's temperature being low. Interview revealed MD #20 was on call 1200 (noon) till 2000. Interview revealed if MD #20 had known about the low temperature she would have done some labs to include blood cultures, started the sepsis protocol, possibly started antibiotics, and called PCCM (pulmonary critical care medicine). Interview revealed "apparently when she went upstairs she was very short of breath." Interview revealed MD #20 was surprised when Patient #3 died. Interview revealed Patient #3 was "literally smiling" and MD #20 "did not expect it". Interview revealed MD #20 thinks she covered everything, did a cardiology consult, COPD, and I don't think we missed anything."

In summary, it was hospital policy to reassess vital signs every 30 minutes for patients who are assigned an ESI level of 2. This did not occur. The patient also had significant delays in her management with medications, reassessment by a qualified medical provider, and placement in an emergency department bed.