The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SOUTHERN REGIONAL MEDICAL CENTER 11 UPPER RIVERDALE ROAD, SW RIVERDALE, GA 30274 June 25, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of medical records, Policies and Procedures, emergency room logs, Facility time sheets, Patient Care Reports, Emergency Department Communication Report, Autopsy Report, Bureau Investigation Report, staff interviews and Paramedic interviews it was determined that the facility failed to provide an appropriate medical screening examination as evidenced by an inappropriately long delay based on the individual's clinical presentation between the individual's arrival and the provision of an appropriate medical screening examination for 1 (#4) of 20 sampled patients. Refer to findings in Tag A-2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, Policies and Procedures, emergency room logs, Facility time sheets, Patient Care Reports, Emergency Department Communication Report, Autopsy Report, Bureau Investigation Report, staff interviews and Paramedic interviews it was determined that the facility failed to provide an appropriate medical screening examination as evidenced by an inappropriately long delay based on the individual's clinical presentation between the individual's arrival and the provision of an appropriate medical screening examination for 1 (#4) of 20 sampled patients
Findings include:
FACILITY RECORDS & POLICIES AND PROCEDURES

The facility ' s policy and procedure titled " Examination, treatment and Transfers of Patients Presenting with Emergency Medical Conditions, Revised Date: 05/09/2013, was reviewed. The policy specified in part, " POLICY: Any individual l . . . who comes to SRMC (Southern Regional Medical Center) and a request is made by the individual or on the individual ' s behalf for an examination or treatment for a medical condition, SRMC will provide for an appropriate Medical Screening Examination within the capability of the hospital ' s emergency department as required by EMTALA. . .DEFINITIONS: Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity,(including severe pain, ... 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 an individual ...in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. . . Capacity: The physical ability of the hospital to accommodate the patient and includes bed availability, staff availability, staff ability and similar considerations that address the logistical ability of the hospital to meet the needs of the patient in a timely fashion ... PROCEDURES: A. Medical Screening Examination - All individuals who come to the emergency department pf SRMC ' s (Southern Regional Medical Center) main campus requesting examination or treatment of an Emergency Medical Condition must receive an appropriate Medical Screening Examination... 1. Scope of Examination: The scope of the examination must be tailored to the presenting complaint . . . This process may range from a simple examination that may include laboratory tests, MRI or diagnostic imaging, lumbar punctures, other diagnostic tests and procedures. .. 2. Personnel Qualified to Perform the Medial Screening Examination- A Medical Screening Examination may be performed by a physician or the following individuals under the supervision of a physician ... (1) a midlevel provider (i.e., Physician ' s Assistant, Certified Nurse Practitioner ...). "
The facility ' s policy titled, " Provision of Care Treatment and Services Emergency Services " effective 09/17/2009, version 18 specified in part, " Policy: . . . 7. Emergency Department: The purpose of the triage assessment is to prioritize patients into the system by setting level of care. The primary assessment can be completed in the triage area or at the bedside and consists of airway, breathing, circulation ...The secondary assessment is to discover all abnormalities . . .C. The triage assessment is used to set the priority of care ...2. ) Triage Level 2/Emergent is assigned for conditions that are a potential threat to life, limb or function, requiring rapid medical intervention. "

EMS REPORT, MEDICAL RECORDS REVIEWS, RADIO COMMUNICATIONS REPORT, ED LOGS AND TIME SHEETS

Patient #4 ' s " Patient Care Report " (Emergency Medical Service ambulance trip report) dates 01/11/2015 was reviewed. The report revealed the ambulance was dispatched to patient #4 ' s residence on 01/11/2015 at 7:33 p.m. The trip report revealed evidence the Emergency Medical Technicians/Paramedics arrived on the scene at 7:39 p.m. The section titled " History " documented that the patient ' s Chief Complaint was Poisoning/Overdose-Alcohol Poisoning. The section titled Medications was listed as " None. " The patients Past Medical History was listed as " Alcohol Abuse " and " Seizures. " The ambulance report in the " Assessments " section documented the patient ' s conditions as " airway was patent Breathing-Normal respirations; Circulation; pulses: radial 2+ and normal; Abdomen: soft non-tender and; Pelvis Stable. " All other body systems were documented as " Assessed with no abnormalities. " In addition, documentation revealed that the patient was alert and oriented to event, person and place. The " Impressions " section was listed as " Primary, Impression: Abdominal pain Secondary Impressions: Poison, ingested, injected, inhaled, absorbed. " The Vital Signs section revealed that the patient ' s heart rate ranged from 132-136 (normal heart rate 60-100),and the heart rate was strong and regular. The patients ' blood pressure ranged from (Systolic) 146-155 and Diastolic from 90-101 (normal 120/80). During this time the patient ' s respirations ranged from 18-20 and were normal and regular. The EMT documented that the patient ' s Lung Sounds were Normal and clear. Documentation revealed that the patient ' s oxygen saturation (measures the saturation of oxygen in the blood) was 92% (normal readings range from 95% to 100%). The oxygen saturation was reassessed at 99% and that a low concentration oxygen was administered at (1-5 liters per minute). A cardiac monitor was applied, a 20 gauge intravenous line (a flexible tube placed into a vein to administer medications and fluids) was started in the patient ' s right hand, 500 milliliters of 0.9% normal saline was hung and Zofran (medication used to treat nausea and vomiting) 4 mg (milligrams) was administered intravenously. Review of the " Narrative " section of the trip report revealed in part, " s (subjective) ...dispatched and responded emergency to a report of a 58 y/o (year/old) female experiencing a poss (possible) psychological breakdown. Once ...arrived on scene it was explained to RMA (rural metro ambulance) that the pt. (patient) was found in the back bed unresponsive and could not be awaken by her sister. The pt. admitted to drinking 3 40 oz. (total of 120 ounces) bottles of alcohol over 2 hour period. The pt. stated her abd (abdomen) was in pain and that it was distended. The pt. CC (chief complaint) was pos (positive) alcohol poisoning. When RMA assessed pt. ' s pain level the pt. assigned a numeric value of 4 out of 10. The pt. denied ...illegal drug use. ..O (objective) RMA made pt contact with one conscious alert but not aware female. The pt. was in a left lateral recumbent position and appeared to be in moderate distress. RMA noted three (3) 40 oz. beer cans near the pt. that were empty. The pt sister impede pt. care due to her being upset at the response time. RMA did explain to the pt. sister the reason for delay being pd (police department) had to clear the scene " The narrative report revealed the pt ' s Lungs remained clear, heart sounds remained normal, and that the patient ' s abdomen was soft and non-tender. Continued review of the narrative indicated in part, " ... A- Pt. transported for alcohol poisoning. P- The pt. was moved to the stretcher via walking. Once in the care of the RMA the pt. received the treatment assessment vitals. The pt condition improved post treatment. Once at the ER (emergency room ) the RMA explained the pt. hx (history) and care to the receiving nurse. Pt. care was relinquished without incident. Note: The pt. could not sign due to her being altered from poss. etoh (alcohol). "
The Emergency Department Radio Communication Report dated 01/11/2015 at 8:23 p.m. revealed that the Emergency Department Charge Nurse (#6) received the following radio report from the ambulance attendants: [AGE] year old female (Patient #4), report of alcohol, blood glucose 237 (normal 80-100), pulse 136, respirations 20, blood pressure 150/78.
Review of the " Daily Summary Emergency Department " (ED log) dated 01/11/2015 revealed that patient #4 arrived to the hospital ' s ED at 8:51 p.m. The Complaint was listed as " Dyspnea (difficult or labored breathing)/Resp. Distress, Priority ED.02. "
Patient #4 ' s Southern Regional Medical Center Patient ' s Legal Record dated 1/11/2015 indicated that at 8:51 p.m. the patient arrived in the Emergency Department triage area. Further review indicated that the patient ' s vital signs, started at 8:51 p.m. and entered at 9:14 p.m., were documented as Temperature 97 orally, (normal temperature hospital reference range was 97.6- 99.6), Pulse rate 141, (Hospital Reference Range normal Heart Rate 60-100) Blood Pressure 109/52, oxygen saturation by Pulse Oximetry was 98%, oxygen delivery method . . . room air, abdominal pain was listed as 10. Documentation by Triage Nurse( #5) at 9:14 p.m., revealed in part, " . . . Pain abdomen Pain Scale 10 pain description Aching Pain Alleviating Factors None pain Aggravating Factors None... Arrival Mode of Arrival Wheelchair, Source of Info (information) family, Limitations: Altered Mental Status (abnormal change in responsiveness and awareness, can affect thought, mobility, alertness, can range from slight confusion to complete unresponsiveness) ...Descriptions of symptoms PT HAS BEEN DRINKING-ABD SWOLLEN-SOB (SHORTNESS OF BREATH NOTED) VOMITED BLOOD HX DIFFICULT PT. WILL NOT ANSWER QUESTIONS PT INCONTINENT OF URINE TYPE OF EMERGENCY Medical Pt arrived by: EMS (Emergency medical services ) ... Acuity/Chief Complaint Acuity Level 2- Emergent Chief Complaint Dyspnea/Respiratory Distress Assign to area - ED ...Social History ...Substance Use Type Alcohol ... Mobility Level Requires assistance ... "
Nurse #5 noted that the secondary assessment, Electrocardiogram (test to determine heart rate and rhythm) /rhythm assessment, and a second Intravenous (IV) line a 20 gauge IV was placed in the patient ' s left forearm at 9:23 p.m. At 9:24 p.m. the nurse documented in the " Allergies " section " PT YELLING. " The Patient Order Summary indicated that the Abdominal Protocol was ordered and the triage nurse entered the following orders at 9:24 p.m.: the patient was made NPO (nothing by mouth); Stat Laboratory Orders completed were -Amylase, Comprehensive Metabolic Panel, lipase, Complete Blood Count Auto Differential. Further review of the orders indicated that a Complete Urinalysis was ordered, but canceled (Stop Reason: Order canceled -Patient discharged ). At 9:25 p.m., a Blood Alcohol level was ordered and completed. The results of the blood work at 11:32 p.m., was listed as follows: Amylase and Lipase were within normal limits; the Comprehensive Metabolic Panel in part, listed the patients Carbon Dioxide level as 18 (L- Low) (Hospital reference range 22-30); Creatinine 2.1 (H-high) (Hospital Reference range 0.7-1.3); Glucose- 387 (H); lactic Acid 13.1 (H); AST 168 (H) (Hospital reference range -5-40); ALT (110 H) (Hospital reference range- 7-56); Alkaline Phosphate 175 (H) (hospital reference range- 38-126); l Troponin Level 0.685 (Hospital reference range- 0.000-0.0045); Albumin 2.7 (L-low) (Hospital reference range-9-5). Review of the Summary Discharge Report dated Jan (January) 11 11:23 p.m. Blood Alcohol % indicated <0.01 (L) (hospital reference range 0-0.07). Patient #4 ' s vital signs were ordered every 1 hour per facility policy because the patient was a priority 2 Emergency level.
At 9:40 p.m., nurse #5 noted that patient #4 ' s heart rate remained 141 and respirations remained at 24 and the patient ' s oxygen saturation was 100% , oxygen delivery method " Non-Rebreather " mask (a device used in medicine and allows for the delivery of higher concentration of oxygen). There was no documentation as to when the non-rebreather mask was applied on Patient #4. There was also no documentation that an ED physician, or that a midlevel provider was notified in order to provide an appropriate and timely medical screening examination regarding the change in the patient ' s breathing status/pattern and a sustained heart rate of 141 beats per minutes for 49 to 50 minutes since presentation in the hospital ' s emergency department.
Review of the hospital ' s " ...Timesheet from 1/10/2015 to 1/13/2015 " revealed that on 1/11/2015 the hospital had ED physicians and midlevel providers were available in the ED to provide emergency interventions to treat patient #4 ' s significant and noted change in the patient ' s condition.
Further review of Patient #4 ' s medical record revealed at 10:20 p.m. (time entered into the computer), a nurse noted in part, Pt brought to rm (room) via stretcher actively coding, no pulse, no resp(respirations) Pt being bagged by rt (Respiratory Therapist)and cpr ((cardiopulmonary resuscitation-emergency procedure for reviving heart and lung function) was in progress. Dr. (name Physician #4) in to see. .. 22:30 (10:30 p.m.) Nurse Note by ...ATTEMPTED TO DRAW BLOOD PTS SKIN MOIST C/O (COMPLAIN/OF) DIB (difficulty breathing) CHARGE NURSE WAS NOTIFIED GOING TO ROOM-PT TRANSPORTED TO ROOM 23 WHEN SOB(shortness of breath)DIB GETTING WORSE DR (PHYSICIAN NAME) AT BEDSIDE. " Further review revealed that a urinary catheter was inserted and there was no urine output.
Physician #4 ' s documentation on the " Emergency Department Report " dictated on 1/12/2015 at 1:39 am indicated that Physician #4 saw patient #4 at 10:19 p.m. The " HPI (History of Present illness): CHIEF COMPLAINT: Patient Unresponsive ...[AGE] year old ...is being wheeled by me in the stretcher from the waiting room where she is unresponsive and does not appear to be breathing. (I had just arrived to work, and had just put down ...briefcase and noticed that patient ...appeared in extremis (at the point of death), so followed her into room 23. We immediately started bag valve mask with oxygen, and assessed for pulse which she had none. CPR was initiated. Monitor showed PEA (pulseless electrical Activity-defined as electrical activity with no palpable pulse) with a rate (heart rate) of about 40, Pt had IV access form EMS so, so IV 1 mg epinephrine (medication used to stimulate the heart) was given. Patient was orotracheally intubated (tube inserted into the lungs for ventilation) ... History obtained from sister report that she believes her sister (#4) had been taking excessive medications and drinking alcohol ...Review of the EMS report ... shows, the EMS crew found the patient to be complaining of abdominal pain and it was distended ...They describe the patient was awake and alert with them and appeared to be in moderate distress. They documented the patient could not sign her EMS sheet because she was altered from possible ETOH (Alcohol), also in the same noted with a document the patient was awake and alert. Their vital signs show blood pressure 155/100, pulse of 134, 02 saturation 92%, respiratory rate 18, and a blood pressure of 234. GCS was 14. She remained tachycardic (abnormal rapid heart rate) throughout the EMS documentation, but normal to high blood pressure. There is documentation of the patient getting supplemental oxygen, IV access, and IV Zofran 4 mg. They dropped the patient off in triage. Please see the triage notes of what happened with the patient between checking in at triage, and to when I saw her passing me by the stretcher unresponsive. ...Time seen: 2219 (10-19) ... SOURCE: Triage notes, EMS report, Nurse notes reviewed. Yes ...Timing: Unable to determine, cardiac arrest: unknown: onset ...ED Past Medical Hx (history) Additional medical history: Blood clot in the leg, per history form sister , obtained later when informing her of the patient ' s demise ....Physical Exam Vital Signs: 1/11/15 21:41 Temperature 97 F; Pulse rate: 141 H (high); Respiratory Rate :24 Blood Pressure: 109/52; 02 Sat by Pulse Oximetry: 98 ...01/11/2015 21:40 (9:40 p.m.); 02 Sat pulse oximetry 100; 01/11/2015 Temperature: (Blank); Pulse Rate: (Blank); Blood Pressure (Blank) )2 Sat by pulse Oximetry: 96.

Physical Exam (examination): General: The patient is ...unresponsive ...HENT (head eye nose throat): Normocephalic: Atraumatic. Patient has moist mucus membrane. EYES: pupils fixed and midrange ...CHEST/LUNGS: No respirations. HEART/CARDIOVASCULAR: Pulseless, no heart sounds. ABDOMEN: Abdomen is soft, obese, unsure if distended. SKIN: there is no diaphoresis. Neuro: The patient is unresponsive, GCS 3(a scoring system to determine level of consciousness- score of 3 deep coma or death) ... EKG Data ...EKG done at 2323 (11:23 p.m.) (done between code #3 and #4), shows a sinus tachycardia ( elevated heart rate greater than 100 beats per minute) at 150, with incomplete bundle branch block (heart block in the electrical conduction system), nonspecific ST wave changes-possible ischemic changes ...Radiology Results: Chest x-ray showed good placement of the ET (endotracheal Tube-flexible tube inserted through the mouth or nose in order to maintain an open airway passage or to deliver oxygen) ...Medical Decision Making: Code #1 Patient presents in PEA and was given IV epinephrine 1 mg x (times) 2, IV Narcan (medication used to reverse central nervous system depression because of suspected opioid overdose) 4 mg, and intubated. At 2330 (11:30 p.m.) she had a return of spontaneous circulation (ROSC). She was hypertensive and tachycardiac with bounding pulses. IV fluids were ordered. Laboratory was ordered. Patient was ordered to have IV antibiotics after blood cultures in case sepsis (sepsis is a potentially life-threatening complication of an infection) was involved. Procedure #1, Endotracheal INTUBATION Indication: Cardiac/ respiratory arrest (a sudden, sometimes temporary, cessation of function of the heart/ absence of breathing) ...Code #2: Approximately 28 minutes after the first ROSC, patient began to deteriorate with bradycardia (abnormally slow heart action) and hypotension (abnormally low blood pressure), and went into cardiac arrest again PES Pulseless Electrical Activity). Patient was given epinephrine (medication used to stimulate the heart) given x2, IV sodium bicarbonate (medication used to treat sudden cardiac arrest), atropine 1 amp (med used to treat bradycardia, and PEA) ...Patient has a ROSC at 2304 (11:04 pm). She was hypertensive and tachycardia. Patient had 6 more cardiac arrest that all had presentation. She would deteriorate from tachycardia and hypertension to bradycardia ... and PEA with no pulse. ACLS (advanced cardiac life support - a set of clinical interventions for urgent treatment of cardiac arrest) protocol was followed with epinephrine IV for each cardiac arrest, and patient would shortly later have an ROSC with the same tachycardia and hypertension. I decided vasopressors (medication causes a rise in blood pressure) might benefit this patient because of the intermittent ROSC, and quick demise to bradycardia hypotension and PEA Her laboratories did not return anything that need to be treated at this time. There was no alcohol in her system. She never made any urine output to assess a drug screen. I ordered Neo-Synephrine vasopressors if needed. Because of the patient getting vasopressor therapy, I set-up for central line placement during her episode of ROSC between code #7 and #8. Procedure #2: CENTRAL LINE (Catheter placed in Large vein used to administer medications and fluids, and to obtain blood for blood tests) PLACEMENT: Indication: Recurrent hypotension requiring vasopressor therapy. Chest x-ray was not done, because patient was pronounced prior to the x-ray being done.) Code #8: Patient again went into PEA ...patient was receiving IV norepinephrine full dose Drip through central line ...Patient did not respond to IV epinephrine during this code so the code was called. The patient was pronounced. Because of the patient ' s instability between cardiac arrest , and there was only brief episodes of ROSC, no further tests were able to be done on the patient except, EKG, chest x-ray and labs ...0039: Patient was pronounced (Patient #4 pronounced dead at 12:39 am, on 1/12/2015) ...ED Disposition: Cardiac arrest, Respiratory failure, lactic acidosis (elevated levels of lactic acid in the blood that can be caused by severe infections, heart disease, lung disease ...), Elevated troponin I, (indicates heart damage) Elevated LFT (liver function tests). "

Review of patient #4 ' s lab results revealed an elevated troponin 1 level was 0.685 and normal is 0.00 to 0.045, and elevated liver function tests (LFT), Aspartate transaminase (AST) was 168 and normal is 5-40, and her alanine transaminase (ALT) was 110 normal is 7-56.
AUTOPSY REPORT AND State BUREAU OF INVESTIGATION
The State Bureau of Investigation dated 2/9/2015 " Official Report " for patient #4 was reviewed. The report indicated in part, Results and conclusion: Ethyl Alcohol ...: negative ....Drug confirmation Results ...1) Negative for certain amphetamines, cocaine and cocaine metabolites. The Fulton Medical Examiner " Investigative Report " dated 1/12/2015 at 2:25 A.M. for patient #4 was reviewed. The investigative report specified in part, " Nurse called from Southern Regional Hospital ' s emergency room to report the death of a 58 y/o (year/old) ... Upon arrival into the emergency room the decedent was alert and responsive. When the decedent was brought back in the triage area (Approximately 1 hr (hour) after arrival). The decedent went unresponsive. Review of the _____County Medical Examiner ' s report dictated 01/12/2015 and finalized 01/22/2015 the cause of death was " Pulmonary thromboembolism (obstruction of an artery in the lung) due to deep venous thrombosis (blood clot) of the left lower extremity due to obesity. "
INTERVIEWS

During an interview on 06/24/2015 at 11:00 a.m., the Security Manager (#2) reviewed the Emergency Department videos and confirmed that there were no videos from 01/11/2015 thru 01/12/2015. The Manager stated the facility's videos are kept for 30 days unless requested by the Sheriff's Office or Risk Management.

During a telephone interview on 06/25/2015 at 9:40 a.m., the Paramedic (#3) who transported patient #4 on 01/11/2015) explained that he and his partner received a call and were dispatched to a patient who was down for unknown reasons. The Paramedic stated the police had gone in to clear the scene before they were allowed to go in to evaluate the patient. When questioned as to why the police had been on the scene, the Paramedic explained that when a patient is down the police go in to ensure that the scene is safe for the medical team. The Paramedic went on to explain that once on the scene the patient's sister impeded the patient's care because the sister kept asking why the medical team had not arrived sooner. The Paramedic stated that once they arrived at the hospital, the patient was placed in a wheelchair and brought into the Emergency Department through the ambulance bay. The Paramedic explained that Charge Nurse (#6) instructed the medical team to take the patient to the triage area. In addition, the Paramedic stated that once in the triage area the medical team had to wait a few minutes for the triage nurse who was in with another patient. The Paramedic explained that while he gave report to the triage nurse his partner was at the patient's side. The Paramedic confirmed that when he and his partner left the triage area the patient was still in the wheelchair and was responding appropriately.

During a telephone interview on 06/25/2015 at 10:15 a.m. with physician #4, the physician confirmed that on 01/11/2015 at 10:19 a.m. he observed the patient being taken by stretcher from the triage waiting area to an Emergency Department room. The physician said he did not recall whether the patient had been on oxygen at the time. The physician stated the patient was in cardiac arrest and was coded. The physician said that the patient's sister had reported that the patient had altered mental status possibly due to a drug overdose. In addition, the physician said that when he/she spoke with the patient's sister after the patient expired the sister had been inappropriate and that he/she thought the sister might be psychotic. The physician said that triage nurse #5 had started the abdominal protocol based on the reported information that had been obtained at the time of triage.

During an interview on 06/25/2015 at 10:25 a.m., nurse #5 (triage nurse on 01/11/2015) stated the ambulance attendants brought the patient in to the triage area by wheelchair from the ambulance bay. The nurse explained that the ambulance attendants would have gone by the nurses' station where the Emergency Department Charge Nurse #6 would have directed them to the triage area. The nurse confirmed that she received report while at the patient's side. The nurse stated the Paramedic reported that the patient was picked-up at the patient's residence, that the patient reportedly had been drinking, and that there were empty beer containers observed at the scene. The nurse explained the patient was fairly stable when she arrived, was very loud, acting out, and trying to get out of the wheelchair. The nurse went on to explain that the patient's sister was a problem because she had wanted to ride in the ambulance with the patient. The nurse stated the patient's sister was present during the triage assessment. The nurse explained that once the ambulance attendants left she started the patient's triage in triage room #1. The nurse stated she contributed the patient's elevated heart rate to the fact that the patient was yelling and anxious. The nurse said that she made the patient a level 2 priority because the facility's policy required any abnormal heart rate to be made a priority 2. The nurse stated she had been unable to get the patient's history. The nurse stated the patient was next in line for an Emergency Department room and that no beds were available at the time of the patient's arrival. The nurse said that after the patient was triaged the patient was placed in the assessment / reassessment so that the patient could be monitored. The nurse stated that she called Charge Nurse (#6) and asked for a bed and that she then moved the patient to a medical screening examination room, a room used to hold patients who need monitoring when there is no bed available. The nurse explained that the room was directly behind triage room #1. The nurse said that once in the medical examination room the patient was placed on a stretcher, a cardiac monitor was applied which included the pulse oximeter and blood pressure monitor. The nurse said she accompanied the patient and was 1:1 with the patient, busy ordering abdominal protocol labs, and that another nurse took over triage. The nurse confirmed that she got a rebreather on the patient and was taking the patient to room 23 when the patient coded. The nurse confirmed that [physician #4] responded immediately to room 23. The nurse explained that after the patient expired the patient's sister reported that the patient had a history of a blood clot in her leg. The nurse said that if she had known the patient's history she would have started the pulmonary embolus protocol.


During a telephone interview on 06/25/2015 at 12:30 p.m., nurse #6 (Emergency Department Charge Nurse on 01/11/2015), confirmed that on 01/11/2015 the Emergency Department had been at capacity when patient #4 was brought in by the ambulance attendants. The nurse said she tried to get a room as soon as possible and that the patient's care was started in triage. The nurse confirmed that the ambulance attendants had reported that the patient had possible alcohol overdose. The nurse said that the triage nurse assessed the patient and then put the patient in a medical screening room where nurse #5 monitored the patient until a room was available. The nurse said that during transport to room 23 the patient coded and that physician #4 arrived immediately.

During an interview on 06/25/2015 at 3:45 p.m., the Director of Risk Management explained that on 01/12/2015 she spoke with the patient's sister with the Director of Emergency Services and the Chief Operating Officer present. The Director said that they tried to watch the Emergency Department's video recordings but that there was no camera in the triage area and no evidence of the patient being in the waiting room on 01/11/2015. The Director confirmed that the recordings were only kept for 30 days.

During an interview on 06/25/2015 at 4:00 p.m., the Director of Emergency Services explained that the facility's Emergency Department had been built to handle about 45,000 patients a year and was currently handling 75,000 to 80,000 patients a year. The Director stated the increase was due to the increased number of patients who had no primary care physician. She stated the facility had or was implementing the following to aid with the increased number of patients:
--from 11:00 a.m. until 11:00 p.m. stations a Paramedic in the waiting room to perform hourly vital signs and reassessments, any changes are reported to staff;
--had piloted a short version triage that decreased the triage time from 8 minutes to 4 minutes and that the new triage system was to go live July 1, 2015;
--fast track area now utilized a system which moved patients who had been examined and were awaiting test results to a waiting area. The Director explained this system opened up fast track rooms quicker.


There was an inappropriate long delay based on Patient #4 ' s clinical presentation on 1/11/2015 (suspected altered mental status, sustained tachycardia and documented presentation listed on the ED Log at time of arrival to the ED at 8:51 p.m. as Dyspnea/Respiratory Distress), between the patient ' s arrival and the provision of an appropriate medical screening examination. There was a delay of Patients#4 ' s evaluation of 1 hour and 57 minutes before the ED physician saw patient #4 on 1/11/2015