Based on a review of 25 emergency department medical records and review of the EMS reports for patient #1, it was determined that the hospital failed to assess and conduct a timely medical screening examination (MSE) for patient #1 commensurate to the patient's presenting condition as evidenced by: Patient #1 was an assisted living patient who became short of breath and was transported to the ED by EMS in January 2017. Patient #1 had a resuscitation order for DNR-B indicating the patient did not want resuscitation, but did want supportive/palliative care. Per the documentation provided by the Baltimore County Emergency Medical Services including the Paramedic (PM) who responded to the 911 call that resulted in the patient's presentation to Sinai Hospital, it was documented that patient #1 had a pulse of 120 (normal is 60-100) a respiratory rate of 32 (normal is 12-18) and an oxygen saturation (SpO2) of 83 (normal 94-100%). The PM documented the transport as "Priority One" which required lights and sirens due to patient #1's severe respiratory distress. The paramedic documented prior to transport that the hospital was contacted, and that the nurse advised him "We are on yellow, this pt needs immediate care." This indicated that the nurse was aware of the patient's condition. Per the Maryland Institute for Emergency Medical Services Systems MIEMSS, Yellow alert means that " ...The Emergency Department temporarily requests that absolutely no Priority II or Priority III patients be transported to their facility. Yellow alert is initiated because the Emergency Department is experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely." The Paramedic advised the nurse that Sinai Hospital was the closest hospital (approximately 5 minutes), and that another nearby hospital was on Red alert. The nurse responded "Sinai clear." Per the EMS documentation, Patient #1 was initially conscious and able to state his /her difficulty with breathing. Documentation revealed in part, " During transport pts hand, lips and nose became cyanotic (blue coloration resulting from lack of oxygen) and cold, breathing continued to be rapid and shallow, extremities including head became very flaccid (without muscle tone). " According to the EMS documentation reviewed by the surveyor, the Paramedic placed oxygen on the patient at 0504 at 15 liters per minute with slight improvement. The ambulance arrival at the ED was at 0508. Documentation in a report reviewed from the Paramedic stated in part, "After the Charge nurse spoke with EMS to obtain information ... she ...stated "You are going to have to wait a while until a room...Charge nurse never looked, talked or even walked over to the pt ...PT hands, lips and ears continued to get more cyanotic." The surveyor reviewed the Emergency Department policy " Assessment: Patient "(revised 9/16), which stated in part, "A. A Primary assessment will be performed by a Registered Nurse regardless of the method of entry into the department. The primary assessment will consist of an evaluation of airway patency, adequacy of breathing, and circulation. " Interviews with the Nursing Clinical Manager on 1/26/2017 at approximately 1030 revealed that when the hospital ED is busy, some patients may be kept on beds in the hallways while being treated. However, she stated that no level I or Level II patients are ever kept in the hallways. Review of the Hospital's medical records revealed entries un " Triage Assement :" The entries were entered at 1/10/2017 at 5:13 . The entries state : " ED Chief Complaint LBH: Shortness of breath Chief complaint description : pt from brookdale nursing home was sent here for sob, pt DNR Patient oprearrival treatment y/n: yes Suicide feeling or want to hurt self ?: No ESI: 2) Emergent/Echo Trauma Stroke Symptoms: No Pain scale : 0 Fever Screen: No Pre Arrival Treatments: Oxygen " There were no vital signs or documented evidence of any physical assessment of the patient by the nurse as part of this assessment as indicated in the statements from the paramedics. Documentation in a report reviewed from the Paramedic stated in part, "After the Charge nurse spoke with EMS to obtain information ... she ...stated "You are going to have to wait a while until a room...Charge nurse never looked, talked or even walked over to the pt ...PT hands, lips and ears continued to get more cyanotic." The patient was left on the EMS gurney in the hallway under the supervisor of the paramedics for the next hour. . The hospital's policy "Triage Five (5) Tier Emergency Severity Index system (ESI) Guidelines" (revised 8/13) states "ESI 1 includes patient who are "Critical-unstable with obvious life/organ/limb threatening. Requires immediate intervention by physician on arrival." An example of ESI 1 was listed in part as " ...Severe resp (respiratory) distress w/agonal/gasping respirations." ESI 2 includes "Unstable condition w/ responsibility of life/organ threatening illness/injury." Nursing staff interviewed by the surveyor on January 26, 2017 revealed that the hospital prioritizes placing ESI 1 and ESI 2 patients in rooms rather than the hallway during busy times. The patient remained under the direct care of the paramedic from arrival until 0614 as the hospital staff had not assumed the care of the patient. There was no hospital documentation in the medical records of vital signs, or any kind of intervention for patient #1 until 0614. The paramedic reported to his supervisor that the patient was deteriorating. Per the supervisor statement of 0600 at the time of her arrival at the hospital ED, she intervened and the hospital staff took over the patient's care. At 0614 the hospital staff obtained their first set of vital signs for patient #1 which were documented in the medical record by another nurse. Therefore, patient #1, who presented to the ED in severe respiratory distress at 0508 via EMS, was left under the care of the paramedics until 0614. The patient's vital signs at 0614 were pulse of 61, blood pressure of 91/55, respirations 26 with an oxygen saturation of 94% on a non-rebreather mask which were recorded by the nurse who took over the care of the patient. By 0648, the patient's vital signs were a peripheral pulse of 145 bpm, a respiratory rate of 34, and an O2 saturation of 74% on a non- rebreather. At 0719, a physician ordered oxygen, an IV, labs, vitals per acuity, a portable chest x-ray, an EKG, and an antibiotic. Patient #1 was seen by the physician for a medical screening exam when the results were obtained by 0803, nearly three hours after the patient's arrival in the ED. He documented in part, "The patient presents with difficulty breathing and respiratory problem. Degree at onset severe. Degree at present severe ..." Patient #1 remained unresponsive. The physician spoke with patient #1's son, and it was arranged that patient #1 be placed into hospice. Based on reports from the EMS and the lack of documentation on the medical record that the patient was assessed after arrival at the hospital, the hospital failed to assume care of a critically ill patient allowing the patient to remain under the care of the EMS who transported the patient to the hospital .