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Based on interview, record review, policy review and video review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#20) out of 32 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 4,121.

Review of the hospital's policy, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 02/28/21, showed that a MSE is an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC and must include medically indicated screens, tests, history and physical examination, etc. In the presence of an EMC, the hospital must provide stabilizing treatment within the capability and capacity of the hospital. The stabilization of a patient means that no deterioration of the condition is likely. An EMTALA obligation ends when a physician or a qualified medical person has made a decision that no EMC exists (even though the underlying medical condition may persist) and the patient is discharged with follow-up instructions.

Review of the hospital's policy, "Required Elements of Daily Assessment/Reassessment (REDA)," dated 11/29/19, showed that in the ED a focused assessment would be completed upon arrival to the treatment area by the primary nurse and at the time of handoff by oncoming nurse. Vital signs would be assessed at the time of triage and then at a minimum of every two hours. If the patient's condition warranted more frequent vital signs or more frequent assessments that was also appropriate. Assessment frequency for the systems identified were based on the patient's diagnosis and chief complaint.

Review of Patient #20's ED record showed that she was a 100-year-old female that presented to the ED, via ambulance, on 02/08/23, at 1:13 PM, after a fall in her bathroom. She reported right shoulder blade pain and right arm pain. She denied hitting her head, losing consciousness (the state of being fully alert, aware, oriented, and responsive to the environment) or being on any blood thinners. She was transferred from the ambulance stretcher to a wheelchair and placed in the waiting room. Her vital signs at 1:16 PM were blood pressure (BP) 91/59 (normal was approximately 90/60 to 120/80), heart rate 66, respiratory rate 16, oxygen saturation 95% and a temperature of 97.9 degrees. She was assigned an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) acuity level of three. No re-assessment of vital signs occurred after triage. At 4:51 PM, Staff N, Advanced Practice Registered Nurse (APRN), documented that the patient reported severe pain in her right mid back, and right elbow, she was "lethargic (weak, sluggish) acting" and reported nausea. No pain level assessment was documented. She noted a review of all other systems were negative. An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), at 1:30 PM, showed a normal rhythm. Ordered lab work resulted at 7:33 PM and 8:07 PM. Lab work revealed abnormal values throughout her complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). At 7:20 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of thoracic (middle) spine showed a moderate sized left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart) and a dedicated chest x-ray was recommended. At 7:40 PM, a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the cervical (upper) spine showed a large left pleural effusion that extended to the lung apex (where the upper lobe beings) and a partially imaged aortic aneurysm (a bulge in the wall of the major blood vessel that carries blood from the heart to the body) "that was similar when compared to a prior chest CT that was performed on 03/07/22." After the patient's x-rays and CT scans were completed she returned to the waiting room. At 11:10 PM, an ED Provider note by Staff M, ED Physician, documented that he "was called to waiting room to evaluate patient for concerns that patient was no longer breathing. Resuscitation efforts continued through 11:49 PM, at which time the patient expired."

Based on interview, record review, policy review and video review, the hospital failed to provide an appropriate medical screening exam (MSE) within the hospital's capability and capacity for one patient (#20) of 32 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's ED average monthly census over the past six months was 4,121.

Findings included:

Review of the hospital's policy, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 02/28/21, showed that a MSE is an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC and must include medically indicated screens, tests, history and physical examination, etc. In the presence of an EMC, the hospital must provide stabilizing treatment within the capability and capacity of the hospital. The stabilization of a patient means that no deterioration of the condition is likely. An EMTALA obligation ends when a physician or a qualified medical person has made a decision that no EMC exists (even though the underlying medical condition may persist) and the patient is discharged with follow-up instructions.

Review of the hospital's policy, "Required Elements of Daily Assessment/Reassessment (REDA)," dated 11/29/19, showed that in the ED a focused assessment would be completed upon arrival to the treatment area by the primary nurse and at the time of handoff by oncoming nurse. Vital signs would be assessed at the time of triage and then at a minimum of every two hours. If the patient's condition warranted more frequent vital signs or more frequent assessments that was also appropriate. Assessment frequency for the systems identified were based on the patient's diagnosis and chief complaint.

Review of Patient #20's ED record showed that she was a 100-year-old female that presented to the ED, via ambulance, on 02/08/23, at 1:13 PM, after a fall in her bathroom. She reported right shoulder blade pain and right arm pain. She denied hitting her head, losing consciousness (the state of being fully alert, aware, oriented, and responsive to the environment) or being on any blood thinners. She was transferred from the ambulance stretcher to a wheelchair and placed in the waiting room. Her vital signs at 1:16 PM were blood pressure (BP) 91/59 (normal was approximately 90/60 to 120/80), heart rate 66, respiratory rate 16, oxygen saturation 95% and a temperature of 97.9 degrees. She was assigned an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) acuity level of three. No re-assessment of vital signs occurred at any time after triage. At 4:51 PM, Staff N, Advanced Practice Registered Nurse (APRN), documented that the patient reported severe pain in her right mid back, and right elbow, she was "lethargic (weak, sluggish) acting" and reported nausea. No pain level assessment was documented. She noted a review of all other systems were negative. An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), at 1:30 PM, showed a normal rhythm. Ordered lab work was drawn and resulted at 7:33 PM and 8:07 PM. Lab work revealed abnormal values throughout her complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). At 7:20 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of thoracic (middle) spine showed a moderate sized left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart) and a dedicated chest x-ray was recommended. At 7:40 PM, a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the cervical (upper) spine showed a large left pleural effusion that extended to the lung apex (where the upper lobe beings) and a partially imaged aortic aneurysm (a bulge in the wall of the major blood vessel that carries blood from the heart to the body) "that was similar when compared to a prior chest CT that was performed on 03/07/22." After the patient's x-rays and CT scans were completed she returned to the waiting room. At 11:10 PM, an ED Provider note by Staff M, ED Physician, documented that he "was called to waiting room to evaluate patient for concerns that patient was no longer breathing. Resuscitation efforts continued through 11:49 PM, at which time the patient expired."

Review of the hospital provided video footage titled, "ED Ambulance Entrance, Garage Entrance, Main Entrance, Receptionist Desk and Triage Hallway," dated 02/08/23, from 1:09 PM through 11:16 PM, showed the patient's movement throughout the ED and waiting room. It showed that at no time, with the exception of her initial triage, did the patient have a reassessment of her condition or vital signs. At 11:15 PM, the patient's family noticed that the patient had no pulse and notified ED Staff.

During an interview on 04/19/23 at 9:30 AM, Staff O, ED Registered Nurse (RN), stated that on 02/08/23, she was the only nurse in the triage area and the ED was "extremely full with very sick, high acuity patients." Patient #20 was brought in by ambulance, she received report from the paramedic, asked the patient some questions related to her fall, obtained a set of vitals and then placed the patient in the waiting room. The patient did not have any re-assessment of her vital signs while she waited in the waiting room. She stated that since the event with Patient #20 there had been education on patient re-assessment; however, unless there were additional staff that were assigned to complete those re-assessments, they were not always being completed. She stated when the ED waiting area was full it would be impossible for the triage nurse to complete all of the initial triages and all of the re-assessments.

During an interview on 04/18/23 at 11:30 AM, Staff N, ED APRN, stated that on 02/08/23 the ED was full and that "all patients needed a room but there weren't any available." She stated that Patient #20 looked "sick, pale and sort of slumped in her chair." She stated that "sometimes you don't know that an EMC exists until you get really wacky results. Many patients look sick, like she did, so there's no way of knowing until all the tests come back." She stated that she placed stat (immediately) orders for lab work, x-rays and CTs. When asked about how often patients should be re-assessed to identify a possible change in condition and the development of an EMC, she stated that she was "unsure what the re-assessment policy was" as it did not "fall under her duties."

During an interview on 04/19/23 at 7:15 AM, Staff M, ED Physician, stated that the severity of a patient's condition would determine the initial exam and orders. The MSE was completed when a patient first arrived, within the triage area, and that process was ongoing. The initial exam and MSE would be enough to tell us if a patient had an emergent condition that they needed to start treating urgently. However, if a patient was sent back to the waiting room because their condition was less urgent, their care was ongoing and they were always re-assessing for changes in condition because a patient's medical status could change and they could develop an EMC that they did not initially present with. Patient #20's imaging results of a pleural effusion would not be considered an emergent condition. The patient's aortic aneurysm would not be considered an emergent condition unless the aneurysm was leaking. He stated that his shift on 02/08/23 began at 11:00 PM and he was notified around 11:10 PM that Patient #20 was coding. He was not involved with the care of Patient #20 prior to her code.

During an interview on 04/19/23 at 12:35 PM, Staff Q, ED Medical Director, stated that patients who had long wait times should be re-assessed, by way of vitals, as often as possible. However, "at times there was one nurse up front and 40 patients in the waiting room." He stated that Patient #20's pleural effusion was not an emergent condition and that her aortic aneurysm "by itself, especially given that there were older imaging results that showed minor changes, it would not have been considered an emergent condition unless it was leaking or ruptured."

During an interview on 04/19/23 at 12:35 PM, Staff H, ED Nursing Director, stated that the REDA policy was in force prior to Patient #20's incident, and the expectation was that vitals were reassessed every two hours. He was aware that re-assessments were not being done. He stated that staffing was low and patient census and acuity were high. He stated that since the incident with Patient #20 an action plan was put into place. He stated that it was his responsibility for ensuring that vital signs were reassessed every two hours. He stated there was still opportunity for improvement on reassessing vital signs and that he "continued to look at the staffing plan to assign re-vitalizing duties." He stated that there was no dedicated staff member to reassess vital signs. It was the expectation that everyone took responsibility and updated their patient's vitals every two hours.