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Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to provide appropriate observation and medical screening screening examination. See A-2406.

The immediate jeopardy (IJ) began on 2/27/2025, due to the Hospital's failure to appropriately examine Pt. #1's medical condition while in the ED. Subsequently, Pt. #1 had a cardiac arrest and eventually died, and was identified on 3/19/2025. The IJ was announced on 3/19/2025 during a meeting with: President of the Hospital; Assistant Vice President of Accreditation; Chief Medical Officer; Chief Nursing Officer, Systems; Chief Nursing Officer, Evanston; Director of Emergency Services; Clinical Manager, ED, Evanston; Program Manager, Accreditation and Regulatory Compliance; and Program Manager, Accreditation and Regulatory Compliance, and was not removed by the survey exit date of 3/19/2025.

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department (ED), the hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA-Emergency Medical Treatment and Labor Act) that was visible to patients as they enter the hospital. This potentially affected all patients that enter the hospital through the ambulance bay.

Findings include:

1. On 3/18/2025, the hospital's policy titled, "EMTALA - Signage Policy" (dated 11/2021) was reviewed and required, "The Hospital will post appropriate signage notifying individuals of their right to a medical screening examination (MSE) and stabilization treatment as specified under EMTALA as well as information indicating whether or not the hospital participates in the Medicaid program. Signs will be posted in areas likely to be noticed by individuals entering the dedicated emergency department.

2. A tour of the ED was conducted on 3/18/2025 from 9:30 AM - 10:00 AM. There was EMTALA signage in both English and Spanish posted on the wall at the entrance door to the emergency department of the waiting room. The signs were not visible upon entrance to the ED. The ambulance bay lacked posting of the required EMTALA signage.

3. On 3/18/2025 at 9:45 AM, an interview was conducted with the Director of the ED (E #5). E #5 stated that EMTALA signage should be visible upon entering the ED and at the ambulance bay.

Based on document review, video surveillance review and interview, it was determined that for 1 of 10 patients' (Pt. #1) clinical records reviewed with an ESI (emergency severity index/triage acuity) of 2 (patients with threatened vital functions), the hospital failed to provide appropriate monitoring and medical screening examination. Subsequently, Pt. #1 had a cardiac arrest and died.

Findings include:

1. On 3/13/2025, the hospital's document titled, "Triage Nurse Job Description/Responsibilities" (4/2021), was reviewed and indicated, "The Triage Nurse maintains a systematic flow of patients to expedite immediate care of patients upon their arrival to the emergency department ... Assessment ... determine the acuity level ... Emergency Severity Index (ESI) ... Acuity Level Two: Threatened vital functions with likely but not always obvious life or organ threat ... Continuous monitoring ... Procedure ... 7. During times of high acuity and high census ... Re-assessment of waiting patients will be done by the triage nurse during frequent rounding and as necessary ..."

2. On 3/13/2025, the incident report for Pt. #1, dated 2/28/2025, was reviewed and indicated, " ... Summary of Findings: RCA (Root Cause Analysis) scheduled (on) 3/13/2025) (14 days after Pt. #1's incident). Immediate action implemented before RCA is complete. 1. ER (Emergency Room) CNM (Clinical Nurse Manager) has implemented (every 2) hour vitals on patient in the waiting room. 2. ED (Emergency Department) quality is implementing a pilot ... to add MD (physician) to triage ... to ensure patients get medical screening ASAP (as soon as possible) when ED has high volume/wait times ... Brief Factual Description: Cardiac arrest while in ED waiting room ..."

3. On 3/13/2025, the clinical record for Pt. #1 was reviewed. The clinical record included:

- On 2/27/2025, Pt. #1 had a physician's office visit. At 10:12 AM, MD #3's (Neurologist) note indicated, " ... Accompanied by mother and caregiver ... Had Shingles (viral infection causing painful blisters) 3 weeks ago ... Now very weak ... Severe leg pain ... Severe general weakness. Cachectic (physical state characterized by significant weight loss, muscle wasting and emaciation) ... Impression: Significant worsening of general condition including worsened lower extremities weakness and severe disability ... instructed to go to the Emergency Room for admission ..."

-At 10:48 AM, Pt. #1 arrived to the Hospital's ED.

- At 11:13 AM, E #6's (ED Triage RN/Registered Nurse) note indicated, "(Pt. #1) brought by mother and caregiver for bilateral leg pain 7/10 (moderate pain) ... recently diagnosed (with) Shingles ... complaints of nausea, no vomiting ... (History of Multiple Sclerosis/Neurologic Condition).. (At 11:15 AM), (Temperature) 97.4-degree Fahrenheit (Normal 97 to 99), Pulse: 126 (Normal 60-100), (Respiration) 17 (normal 12-20), (Blood Pressure): 104/66 (low blood pressure is below 90/60, high blood pressure 130/80 and above) ... (Oxygen Level): 100% (Normal 92% to 100%) ... Pain Location: Leg (left) ... aching. Clinical Progression: Not Changed ... Pain Score: 7 (moderate). Patient's Stated Pain Goal: 2 ... Patient Acuity: 2 ..."

- From 11:16 AM through 8:54 PM (9 hours and 38 minutes), there was no documentation of reassessment/monitoring, e.g., vital signs of Pt. #1.

- At 8:55 PM, E #8 (ED RN) documented Pt. #1's blood glucose level was 55 (Normal 70 to 99).

- At 9:28 PM, E #2's (ED Charge RN) note indicated, "(Pt. #1) brought back immediately from ER (Emergency Room) waiting room after staff noticed (Pt. #1 was not) responding. (Pt. #1) rushed into ER room 15 and CPR (cardiopulmonary resuscitation/life-saving measure) initiated ..."

- At 10:03 PM, MD #2's (ED Attending Physician) progress note indicated, " ...Physical Exam ... Upon arrival in ED room, (Pt. #1) in cardiac arrest ... Very thin cachectic ... pupils fixed and dilated (indicative of medical emergency) ... Impression/Plan: CPR started immediately in ER room ...prepping for intubation (artificial airway). Running code, ACLS (advanced cardiac life support/set of advanced medical procedure and protocol to treat life-threatening condition) ... Possible severe hypovolemia (low fluid volume) and hypoglycemia (low blood sugar) causing arrest ... Accepted to ICU (intensive care unit) ..."

- On 2/28/2025 at 1:34 AM, the ICU RN's progress note indicated, "(Pt. #1) received from Emergency Department ... Vital signs unstable on arrival ... Dependent lividity (bluish-purplish discoloration of the skin) noted ..."

- On 2/28/2025 at 4:07 AM, the ICU physician's note indicated, " ... On arrival ... Minimal gag reflex but no other significant signs of life ... (Pt. #1) passed away at (3:51 AM) ..."

4. On 3/17/2025 at 1:05 PM, a video surveillance review was conducted with E #4 (Program Manager for Accreditation), E #5 (ED Director), and E #11 (Manager, Public Safety):

- On 2/27/2025 at 10:49 AM, Pt. #1 was brought to the hospital's ED via wheelchair by an unidentified transporter. At 11:12 AM, Pt. #1 was taken to Triage Room 1 by (E #6). At 11:19 AM, Pt. #1 was brought back to the waiting room by (E #6). At 8:54 PM, a staff took and wheeled Pt. #1 into Triage Room 2.

- E #4 validated that there was no clinician observed taking/monitoring Pt. #1's vital signs while Pt. #1 continued in the waiting room waiting awaiting to be seen. Pt. #1 was brought back to the waiting room by an RN at 8:54 PM. E #4 stated that Pt. #1 was taken to the main ED through Triage Room 2.

5. On 3/17/2025 at approximately 9:45 AM and 10:45 AM, telephone interviews were conducted with E #2 (ED Charge RN) and E #6 (ED Triage RN) respectively. Before Pt. #1's incident, E #2 and E #6 stated that the usual practice of vital signs monitoring for patients waiting in the ED has been every two hours. After the incident, E #2 and E #6 stated that the ED has been enforcing that vital signs of patients are taken every two hours regardless of their ESI while waiting for a room. E #2 and E #6 also stated that either a PCT [Patient Care Technician] or nurse will be in the waiting room to monitor the patient at all times. E #6 stated E #6 did not know what happened with Pt. #1 after E #6's triage because there were so many patients in the ED, and E #6 only worked for 4 hours (11 AM through 3 PM).

6. On 3/17/2025 at approximately 11:30 AM, a telephone interview was conducted with MD #2 (ED Attending Physician). MD #2 stated that the triage assessment and monitoring are part of the medical screening examination to determine if an emergency medical condition exists. For patient with an ESI of 2, MD #2 stated that patients are typically roomed right away. If a patient has high heart rate, the staff should let the provider know. MD #2 stated, "If I was in the triage that day, I would have seen (Pt. #1) right away. (Pt. #1) would have been high on the list to be roomed. Regarding ESI 2 patients waiting in the ED, there should be a repeat of vital signs."

7. On 3/17/2025 at approximately 12:32 PM, a telephone interview was conducted with MD #3 (Neurologist). MD #3 stated that MD #3 contacted and talked to the ED charge nurse on 2/27/2025 after Pt. #1's mom said that Pt. #1 has been sitting in the ED waiting room for a long time. MD #3 stated, "I told the charge nurse that the patient is not doing well and needs to be seen (by a physician) as soon as possible."

8. On 3/18/2025 at approximately 10:20 AM and at 11:16 AM, interviews were conducted with E #5 (ED Director) and E #1 (ED Manager) respectively. Since Pt. #1's incident, E #1 clarified that what has been implemented every two hour vital signs monitoring of patients. E #1 stated that the process for having a clinician assigned in the waiting room to monitor patients has not been fully developed and implemented. E #5 stated that continuous monitoring means that the patient is attached to a monitor and in the presence of a clinician at all times. Regarding staff's compliance with vital signs monitoring every two hours, E #5 stated that there was about 30% (sample size of 10) non-compliance from March 10, 2025, and 20% (sample size of 10) non-compliance as of March 16, 2025. E #5 stated that the hospital is currently working on developing guidelines, policies, and procedures to facilitate consistent workflow in the ED so that processes can be replicated when educating staff.

Based on document review and interview, it was determined that for 3 of 3 emergency room clinical records (Pt #7, Pt. #8 and Pt. #13) reviewed for transfers, the hospital failed to ensure the transfer forms were completed, as required.

Findings include:

1. On 3/18/2025, the hospital's policy titled, "Transfer of Patients to Other Acute Care Facilities -COBRA/EMTALA" (dated 9/2024) was reviewed and required, "...If the patient is unstable the risks and benefits of the transfer will be explained and consent obtained. The completed form will be kept as part of the medical record, and a copy of the form will accompany the patient..."

2. On 3/18/2025, the Emergency Department (ED) clinical record for Pt #7 (dated 1/27/2025) was reviewed. Pt. #7 was seen in Hospital A's ED (transferring hospital) on 1/27/2025 with a diagnosis of RSV (respiratory syncytial virus). Pt. #7 was transferred to Hospital B (receiving hospital) for inpatient care. Pt.#7's ED clinical record from the Hospital A lacked the required physician certification that notes whether Pt. #7's emergency condition stabilized or unstable prior to transfer.

3. On 3/18, 2025, the ED clinical record for Pt. #8 (dated 1/28/2025) was reviewed. Pt. #8 was seen in Hospital A's ED on 1/28/2025 with a diagnosis of moderate persistent asthma, hypoxic respiratory failure, influenza A and pneumonia. Pt. #8 was transferred to Hospital B for inpatient care. Pt. #8's ED clinical record from Hospital A lacked a transfer form, as required.

4. On 3/18/2025, the ED clinical record for Pt.#13 (dated 2/26/2025) was reviewed. Pt.#13 was seen in Hospital A's emergency department on 2/26/2025 with a diagnosis of acute constipation and acute kidney injury. Pt.#13 was transferred to Hospital B for inpatient psychiatric treatment. Pt.#13's ED clinical record from Hospital A lacked the required physician certification that notes whether Pt. #13's emergency condition stabilized or unstable prior to transfer.

5. On 3/18/2025 at 12:15 PM, an interview was conducted with the ED Nurse Educator (E #10). E #10 stated that each ED clinical record should have a completed transfer form.