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Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff followed the CAH's policies to ensure that 1 of 20 patients reviewed (Patient #1) who presented to the ED with an emergency medical condition (EMC) received an appropriate medical screening examination (MSE). Failure to provide an appropriate MSE at the CAH's ED resulted in Patient #1 waiting for more than 1 hour without receiving an appropriate MSE to rule out a EMC delayed Patient #1 from receiving appropriate care, which potentially resulted in Patient #1's death. The administrative staff identified an average of 523 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "EMTALA Transfers," approved 11/20, revealed in part, " ...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."

2. Review of the policy "ED Triage," approved 12/21, revealed in part, " ...provide a rapid and brief focused assessment to make a determination of acuity level to identify those patients that present to our ED that need immediate care and cannot wait to be seen and those that are safe to wait for medical evaluation and treatment."

"Triage means to sort and classify patients according to type and urgency of their conditions for the purpose of determining medical treatment priorities."

"Emergency Severity Index (ESI): this is a five-level (1-5) standardized triage scale and acuity system.

ESI level-1- requires immediate life-saving intervention
ESI level-2- is a high risk situation, an emergent condition
ESI level-3 are predicted to require two or more resources, urgent condition
ESI level-4 are predicted to require one resource, less urgent condition
ESI level-5 are predicted to require no resources, non-urgent condition"

" ...Triage RN will ...obtain VS (vital signs), chief complaint and associated symptoms to make a determination of their ESI level and the need to be roomed immediately or if they are safe to wait in the WR (waiting room). Assess and document allergies, PMH (past medical history), PSH (past social history)."

" ...Triage RN is responsible for rounding on patients that have been triaged but are in the WR awaiting a room to be available."

3. Review of the policy "Medical Staff Rules and Regulations," approved 10/21, revealed in part, " ...Physician on call must respond within a reasonable time when requested to see a patient for emergency stabilization. As a general guideline "reasonable response time" is defined as thirty (30) minutes."

4. During an interview on 9/6/22 at 1:15 PM with Emergency Medical Technician (EMT) B revealed, Patient #1 was picked up from a Skilled Nursing Facility (SNF) on 8/22/22 with a chief complaint of abdominal pain level of a 10 out of 10 (with 0 being no pain and 10 being the worst pain imaginable). Patient #1 described it as pain she had never experienced before and had a history of stomach ulcers. EMT B called report to Registered Nurse (RN) A explaining that an IV (intravenous catheter) for fluids was not started, Electrocardiogram (EKG records the electrical signal from the heart to check for different heart conditions), nor pain medication administered because this is outside the scope for an EMT and the Paramedic that was riding with EMT B refused to provide these medical services.

5. During an interview on 9/6/22 at 11:40 AM with RN A revealed, when the ambulance arrived at the critical access hospital (CAH) at 9:34 PM, RN A informed the EMT B that the ED staff did not have a bed available for Patient #1. RN A did not triage Patient #1, but instead transferred Patient #1 from the ambulance cot to a wheelchair and placed Patient #1 in the Emergency Department's waiting room until a room was cleaned.

6. During review of video footage Patient #1 arrived by ambulance at approximately 9:34 PM. Patient #1 was ambulated from ambulance cot to wheelchair and wheeled to ED's waiting room. Approximately 5 minutes later Patient #1 was retrieved from waiting area and taken to ED room #7. At approximately 9:45 PM, RN A and House Supervisor (HS) D triaged Patient #1. Then after approximately 8 minutes, RN A and HS D left Patient #1 room and closed ED room #7's door. No one entered ED room #7 until shortly before 10:49 PM, in which Laboratory Technician E found Patient #1 unresponsive. Patient #1 pronounced dead at 10:49 PM on 8/22/22.

7. Review of Patient #1's medical record lacked an appropriate Medical Screening Examination.

Please refer to C2406 for additional information.

Based on document review and staff interviews, the administrative staff failed to ensure the critical access hospital's (CAH's) ED staff provided 1 of 20 emergency patients reviewed (Patient #1) with an appropriate medical screening examination (MSE) after presenting to the Emergency Department (ED) by ambulance seeking medical care. Failure to provide an appropriate MSE at the CAH's ED resulted in Patient #1 waiting for more than 1 hour without receiving an appropriate MSE to rule out an emergency medical condition (EMC) delayed Patient #1 from receiving appropriate care, which potentially resulted in Patient #1's death. The administrative staff identified an average of 523 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed that EMS Prehospital Care Report showed Patient #1 was picked up from the residential nursing facility on 8/22/22 at 9:20 PM by the hospital owned/operated ambulance for abdominal pain and pain down Patient #1's left arm. When EMS arrived, Patient #1 was lying on their bed with nursing staff at side. Patient #1 stated "this is the worst pain I've ever had in my stomach". Also, telling EMS the pain is different than what they experienced before, and they didn't know how to describe it.

Patient #1 stated their pain was excruciating, to the point they could not stand it any longer but it had subsided when EMS arrived. Patient #1 reported a history of bleeding stomach ulcers. Vital signs were pulse rate of 132 (60-90 normal), respirations 20, blood pressure 138/78 (120/80 Normal), and oxygen 98% on room air. Patient #1 was normally on 1 liter of oxygen with a nasal canal.

EMT B and Paramedic H, CAH employees, transferred Patient #1 by stretcher into the CAH owned and operated ambulance. EMT B documented that Paramedic H asked if anything was needed and EMT B documented that Patient #1 needed more intervention than what an EMT could perform and that "this request was ignored and the patient was transported as basic life support (meaning without cardiac monitoring or administration of medications). The report indicated Paramedic H drove the ambulance and EMT B was the primary care giver during transport. The EMT documented the patient was observed to be wincing in pain during transport and complained of nausea. Upon arrival to the ED, report was provided and care was transferred to RN A. Patient #1 was then taken to the ED waiting room due to a "full ER".

2. During an interview on 9/6/22 at 1:15 PM with EMT B revealed, Patient #1 was complaining of abdominal pain level of a 10 out of 10. Patient #1 described it as pain she had never experienced before and had a history of stomach ulcers. EMT B called report to RN A explained to RN A that an IV (intravenous catheter) for fluids was not started, EKG nor pain medication administered because this was outside the scope for an EMT and Paramedic H that was driving with EMT B refused to provide these medical services. Once EMT B arrived at the CAH, EMT B was met by RN A and provided an update to Patient #1's condition then proceeded to track down Physician C to inform him that EKG, IV, nor pain medication was given to Patient #1 due to Paramedic H refusal and communicated to Physician C these services should have been provided based on Patient #1's symptoms.

3. During an interview on 9/6/22 at 11:40 AM RN A revealed, when the ambulance arrived at the CAH at 9:34 PM, RN A informed the EMT B that the ED staff did not have a bed available for Patient #1. RN A did not triage Patient #1, but instead transferred the patient from the ambulance cot to a wheelchair and placed Patient #1 in the Emergency Department's waiting room until a room was cleaned. RN A verified Patient #1 was classified as an ESI level-3 (Stable and should be seen urgently by a physician (within 30 minutes), often require laboratory and radiology testing, and medication) because abdominal pain patients require more than one resource such as lab and x-ray. RN A stated she felt the patient did not exhibit signs or symptoms of a patient requiring emergent need to be seen.

4. Review of the CAH's video footage of Patient #1's arrival to the ED on 8/22/22 revealed the following:

-At 9:35 PM Patient #1 arrived to the ED via Ambulance
-Patient #1 was able to transfer to wheelchair using her walker.
-Patient #1 was immediately wheel chaired into the waiting room by RN A.
-Patient #1's wheelchair was parked with brakes locked. No other person was present in waiting room.
-Registration staff helping another patient to checkout but was unable to see Patient #1 due to privacy boards around registration desk.
-Patient #1 is noted to put her head in her hands, lean over, and hold her abdomen area multiple times while in the waiting room.
-3 CAH staff members walked by Patient #1.
-Approximately 5 minutes later, Patient #1 was then wheeled to ED room #7 by RN A.
-RN A and Patient #1 were met by House Supervisor (HS) D in ED room #7.

5. Review of Patient #1's ED medical record showed the patient's vital signs at 9:45 PM were as follows:
Temperature- 99.1 F
Respirations - 20
Pulse-71
Blood Pressure- 151/79
Oxygen- 94% on 1-liter nasal canal (NC)
Pain Level- 10 (1-10 scale)

At 9:51 PM a second set of vital signs were as follows:

Pulse- 92
Blood Pressure- 151/67
Oxygen- 94% on 1-liter NC

6. During an interview on 8/31/22 at 1:00 PM RN A revealed Patient #1 was not triaged right away when they arrived because all rooms were in use. RN A received a verbal report from EMT B and based the Patient's ESI level assessment on the patient's appearance and ability to ambulate to wheelchair. RN A then moved Patient #1 back to ED room #7 once a room was cleaned. RN A acknowledged documentation for patients are written on a Triage Worksheet and then transcribed into the electronic medical records (EMR) later when they are able. In the meantime, the Triage Worksheet is placed on a clipboard by the nurse's station for staff to look at prior to the information being entered into the EMR.

7. Review of the CAH's 8/22/22 video footage at 9:42 PM revealed that approximately 8 minutes later at 9:50 PM, RN A and HS D departed from ED room #7 and closed the door.

Approximately 1 hour later at 10:47 PM, Lab Tech E arrived to draw blood and found Patient #1 unresponsive.

Lab Tech E exited ED room #7 and walked down hall to notify RN A and Physician C.

Approximately 2 minutes later at 10:49 PM, RN A and Physician C entered Patient #1's room.

8. During an interview on 9/6/22 at 4:15 PM with House Supervisor (HS) D revealed, Patient #1 was placed in ED room #7 and hooked to a blood pressure monitor. HS D acknowledged the blood pressure monitors in ED rooms # 6 and 7 cannot be viewed from the nurse's station computer. These machines can only be set to record vital signs in the room. HS D stated only one set of vital signs were collected at the time of triage and the machine was set to record another set in one hour.

9. During an interview on 8/31/22 at 6:50 AM Physician C revealed, when the ED is busy the providers will order labs and x-rays before assessing the patient. Physician C stated that they try to see the patient before doing anything else and if the patient is critical, we will see them right away. Physician C stated the ED nurse will usually let me know if I need to see a patient right away.

When asked about using ED room # 7, located in the speciality clinic, as an overflow room for an ED patient, Physician C stated they try not to use them because there is no equipment and the ED staff can't see the patient.

10. Review of Patient #1 medical record revealed Patient #1 was triaged on 8/22/22 between 9:45 PM and 10:00 PM by RN A and HS D with no medical interventions performed during that time.

11. Documentation in Patient #1's medical record revealed at approximately 10:45 PM Lab Tech E found Patient #1 unresponsive and notified RN A and Physician C. At 10:49 PM, Physician C documented they pronounced Patient #1 deceased.

12. During an interview on 8/30/22 at 9:29 AM with RN I from RCF A, Patient #1 lived independently in RCF level of care. Nursing staff assisted Patient #1 with medications, housekeeping, and laundry.

13. During an interview on 8/30/22 at 1:14 PM with CMA F from RCF A revealed, Patient #1 placed their call light on shortly after supper voicing complaints of stomach pain. Patient #1 requested a nurse to come check their vitals. Around 8:00PM, Patient #1 request a 7UP. At 8:45 PM, Patient #1 asked to go to the hospital and by ambulance.

14. During an interview on 8/30/22 at 1:00 PM with LPN G from RCF A revealed, Patient #1 had complained of stomach pain that evening. Patient #1 had tried 7UP but around 8:45 PM, Patient #1 asked to go to the hospital and by ambulance. Patient #1 left around 9:30 PM. Around 10:30 PM to 10:45 PM, the CAH had called the RCF asking for Patient #1's IPOST, shortly after that we learned Patient #1 had passed away. LPN G called the CAH ED to ask what happened and HS D said Patient #1 passed away and they didn't know what happened.

15. The evidence in the medical record showed that the CAH staff failed to provide Patient #1 with a medical screening examination after Patient #1 presented to the CAH owned/operated ambulance and the ED with abnormal vital signs, complaining of new onset of severe pain Patient #1 rated a 10 out of 10, and was unlike any pain Patient #1 had experienced in the past.