HospitalInspections.org

Based on facility policy review, medical record review, video footage review, electronic central log review, Facility's Corrective Action Plan reviews, and interviews conducted, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's ED (Emergency Department), including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 (Patient #15) of 20 patients reviewed. On 12/21/2024 at 12:23 AM, Patient #15 presented to the hospital's ED with presenting signs and symptoms complaining of chest pain then placed in the hospital's ED waiting room. At 12:50 AM, Patient #15 is slumped over in wheelchair and male accompanied with patient went to the registration desk asking for help. Patient #15 was pronounced dead on 12/21/24 at 01:33 AM.

Refer to Tag -A2406

Based on facility policy review, medical record review, video footage review, electronic central log, review, Facility's Corrective Action Plan reviews, and interviews conducted, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 (Patient #15) of 20 patients reviewed. Patient #15 presented to the hospital's ED with presenting signs and symptoms complaining of chest pain, checked in at the registration desk on 12/21/2024 at 12: 23 AM, and then placed in the hospital's ED waiting room. At 12:50 AM, patient slumped over in wheelchair male accompanied with patient went to the registration desk asking for help. Patient #15 was pronounced dead on 12/21/2024 at 01:33 AM.

Findings included:

The facility's policy titled, "EMTALA-Medical Screening Examination and Stabilization" EFFECTIVE DATE:11/1/24. The Policy revealed in part, A hospital must provide an appropriate MSE (Medical Screening Examination) with the capability of the hospital's emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists ...3. Extent of the MSE ...a. Determine if an EMC exists ...Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP (Qualified Medical Personnel). b. Definition of MSE ...The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC."

Review of the Electronic Central Log dated 12/21/24 at 12:23 AM, revealed Patient #15's reason for the ED visit was listed as "CHEST PAIN."


Review of Part 1 of the video footage (no audio) of the ED lobby dated 12/21/2024, revealed Patient #15 walked into ED (Emergency Department) on 12/21 /2024 at 12:23 AM. After the patient checked in at the registration desk, the patient (Accompanied by a male) was placed in a wheelchair by a PCT (Patient Care technician) and placed in an area of the ED lobby/waiting area.

Review of Part 2 of the video footage (no audio) dated 12/21/2024 revealed the following for Patient #15 in the ED waiting area:

12:30 AM- seen leaning forward and placed his right hand on the left side of his chest, was also seen to be restless.
12:33 AM- family member went up to the registration desk and was given an emesis bag (bag for handling vomiting episodes) by the registrar. Family member gives emesis bag to the patient; patient leaned forward with emesis bag in his hand; sat up facial grimacing s and clenching teeth.
12:35 AM- family member was seen going to speak with an individual staff member; family member was seen at the vending machine and brought bottled water to the patient.
12:37 AM- the patient gave the family member used emesis bag; family member was seen throwing the emesis bag in the trash. The registration clerk was seen giving the family member a new emesis bag for the patient.
12:38 AM- the patient was seen drinking water.
12:41 AM- pt seen to be restless, bent over in wheelchair using his right hand rubbing the left side of his abdomen and chest.
12:46 AM-12:48 AM- pt seen having right hand on the left side of chest, and clinching his fist, restless and very uncomfortable.
12:50 AM- face pale in color, and now slumped over in wheelchair, family member went to registration desk asking for help. (definite change in the patient's condition) Male RN (Registered Nurse) came to assist and is seen checking on the patient.
12:52 AM- another staff member came attempting to assist with moving the patient from the waiting room but had some difficulty pushing the wheelchair. That team member leaves and Patient #15 is still slumped over to the left side and pale in color. A female staff member then comes to assist with moving the patient. She raised Patient #15 legs and wheelchair moved easily towards a stretcher that was brought out. Multiple staff members came out from the main ER to assist with transferring the patient onto the stretcher. The patient was taken to a room in the ED to be evaluated.


Patient #15's medical record was reviewed. Review of the physician's order dated 12/21/24 at 12:28 A.M., revealed that an EKG (a painless test that measures the electrical activity of the heart) was ordered, 5 minutes after the patient's arrival to the hospital's ED. Review of the Emergency Provider Report dated 12/21/24 at 12:31 A.M., "Free Text MDM (Medical Decision Making) Notes: Callout made to waiting area and EKG with no response or location of patient. Will return to waiting area to try and locate patient." Documentation by the ED physician dated 12/21/24 at 1:39 A.M. revealed in part, "HPI (history of present illness) -Cardiac Arrest ...Patient ...male who presents to the emergency department for evaluation with a chief complaint of chest pain. Limited history available upon initial arrival, however, notified that patient became unresponsive without a pulse in the waiting area. CPR was initiated and patient was rapidly transferred to ER room with CPR in progress. Further history was obtained from son-in-law and daughter arrived at the bedside and states that patient had been complaining of chest pain throughout the day and had an episode of emesis prior to arrival patient also experienced a syncopal (temporary loss of consciousness, usually followed by a rapid and complete recovery) episode prior to arrival." Further review revealed in part, "Discussed with family regarding poor prognosis given prolonged downtown with over 30 minutes of resuscitation efforts with no return of spontaneous circulation and resuscitation efforts were ultimately ceased. Time of death was called at 1:33 a.m."

There was an inappropriate delay between Patient #15's arrival to the ED, and provision of the medical screening examination as evidence by failing to triage the patient, no vital signs and EKG were performed. There was a delay in placing the patient on a cardiac monitor and performing a physical examination. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to provide a medical screening examination appropriate to the patients presenting signs and symptoms and the capacity and capability of the hospital as stated in the facility's policy.

During an interview on 01/08/2025 at 10:06 AM with Staff G/ Patient Safety Manager, she stated based on the timeline from the medical record review, we discovered the areas for improvement include the EKG and vital signs should have been completed on arrival, someone should have responded to complete the EKG when ordered, "Due to competing priorities in the main emergency room, the importance of the EKG and the vital signs was not prioritized appropriately".

During an interview on 01/08/2025 11:53 AM with Staff H/VP Emergency Services, she stated the protocol and standard is when a patient checks in with chest pain, an EKG and vital signs are taken within 10 minutes of arrival. It was an extremely busy night with very high acuity level patients, and we were also holding 22 admission patients in the main ED. When the patient checked in, we did not have an open bed to place him in and when the PCT went to perform his EKG, the PCT got a phone call to come to the back (main ED) to help with another patient. So, the EKG was never done.

On 01/16/2025 at 11:15 AM, 01/17/2025 at 16:20 PM, and on 01/20/2025 at 10:00 AM, an interview was attempted via phone call with the ED Medical Director and voicemail left each time, no phone call back.

The facility completed their Corrective Action Plan (CAP) on 01/03/2025. Review of the CAP included additional RN role assigned to the waiting room and education on the role and responsibilities, role and responsibilities to staff assigned to perform EKG's and vital signs in the waiting room, reimplementing Zones 1, 2, 3 (Zone 1 patients that have checked in but have not been triaged, Zone 2 after a patient has been triaged, and Zone 3 patients who are stable and waiting for discharge) for patient identification and location in the waiting room and surge scenarios are conducted daily with the ER Director and/or Managers. Employees were required to acknowledge education with a sign in sheet.

On 01/09/2025, evidence of the above was verified by review of the education sign in sheets, interviews conducted with the staff of the ED and tour of the Emergency Room waiting room. The plan of correction was found to be in place and 100% completed. Education provided included "Care of the Patient Presenting with Chest Pain in the ED", "ED Waiting Room Zones and Process for Patient Flow", "Process for Internal Activation for Code Blue", ED Waiting Room: Roles and Responsibilities of RN assigned to the Waiting Room and EKG PCT and Policy's included Assessment/Reassessment, ED Patient Standards of Care and Code Blue.