Based on medical record review, staff interviews and hospital document review, hospital staff failed to: 1- Properly triage and assign appropriate Emergency Severity Index score (ESI). 2- Perform a timely medical screening exam. 3- Provide urgent interventions timely for a patient with severe chest pain (notifying physician, obtaining orders for medications, applying oxygen, placing patient on a cardiac monitor) 4- Reassess the patient for changing/deteriorating medical condition. 5- Follow hospital care guidelines and protocols for a patient reporting chest pains. Patient #1 arrived to the Emergency Department (ED) during the evening of 3/17/15 reporting chest pain and nausea at registration. Patient #1 was promptly was triaged by the ED nurse. The triage nurse documented that the patient continued to report chest pain 10/10 with "chest uneasiness, nausea, and shortness of breath". Vital signs were obtained during triage and indicated an elevated blood pressure and low oxygen saturations of 92% on room air. A 12 lead EKG was obtained, which revealed abnormalities that indicated possible cardiac injury. About 45 minutes after arriving in the emergency department, blood was obtained from the patient and sent to the lab. Although initial assessment was done and diagnostic labs were drawn, the triage staff inaccurately assigned an Emergency Severity Index (ESI) level of 3 for patient #1's condition and he/she was placed in the ED waiting room to wait to be seen by a physician. The ESI is a tool used by emergency departments to triage the severity classification of a patient ranging from ESI-1 (most urgent) to ESI-5 (least urgent). An ESI of 3 would reflect a stable patient not in extreme pain who was safe to wait to be seen. Because the patient was triaged at ESI 3 he was not seen by the physician for 2.5 hours and patient #1 and was not provided oxygen until nearly four hours after his/her initial presentation to the ED. Interview with the clinical resource nurse on the morning of 09/08/15 revealed that a patient reporting severe pain should be scored as an ESI-2 requiring immediate medical attention and intervention, should be placed on a cardiac monitor with oxygen applied, and should be seated in the intake area of triage with constant monitoring of the patient. Medical record review with the clinical resource nurse confirmed that there was no documentation of cardiac monitoring, oxygen placement, or medication for chest pain for patient #1 initiated at the time of triage. About two and a half hours after arrival in the ED, patient #1 was taken from the waiting room to the intake triage area by the physician who then performed the first physician examination. The record revealed that a decision was then made to then admit the patient about three hours after the patient ' s initial presentation in the ED. The patient was then taken to a treatment room at where the second set of vital signs was obtained and the patient's chest pain was reassessed. Documentation by staff indicated that the patient was not placed on oxygen until approximately four hours after arriving in the ED. The nurse administered 0.4mg nitroglycerin (a medication used to treat chest pains) under the patient's tongue with no relief of chest pain and a second 12 lead EKG was obtained about the same time the patient received the oxygen. Shortly after the patient received the oxygen and nitroglycerin the nurse documented in a progress note that she left the treatment room with the patient sitting on the side of the stretcher to show the physician the new EKG; however, other documentation at this time stated that the patient was sitting on the stretcher with the side rails up. Medical record documentation indicated that patient #1 then collapsed, fell to the floor, was unresponsive, had no palpable pulse, and that CPR was initiated. The hospital's patient care guidelines and protocols for a patient reporting chest pains in the ED lists specific nursing interventions. These interventions include taking the patient directly to the treatment area and notifying the physician that the patient is having active chest pains, applying oxygen, attaching the patient to a cardiac monitor, establishing an IV, and administering medications. According to these guidelines the patient would have been placed on bedrest and had vital signs obtained at least every 15 minutes for 1 hour, then every hour, and frequent reassessment of the patient's degree of pain. A physician consultation report on 3/18 indicated that when the patient collapsed he/she apparently "had a ventricular fibrillation arrest. The subsequent EKG... showed acute inferior lateral wall <myocardial infarction>. " Patient #1 was rushed to the catheterization lab where an occluded artery was stented (a surgical intervention to open an occluded artery), and the patient went to the ICU but was " not doing too well... is intubated... blood pressure was also on the very low side, 60s over 30 at most.. " Patient #1 expired later the same day that he/she had been transferred into the ICU and the day after his/her initial presentation in the ED. Reference Federal Tags A 0142 and A0286