HospitalInspections.org

Based on document review and staff interview, the Hospital administrative staff failed to ensure Emergency Department (ED) staff followed the hospital's policies by providing an appropriate medical screening examination for 1 ED patient (Patient #11) who presented to the ED requesting care, out of 40 cases selected for review from August 2010 to January 2011. The hospital administrative staff identified an average of 3,751 emergency department visits per month.

Failure to provide an appropriate medical screening exam resulted in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed an elderly patient (# 11) presented to the ED by ambulance on 1/13/11 at 11:33 AM. The "Iowa EMS Report" revealed the ambulance crew arrived at patient # 11's home at 11:04 AM. The crew documented serial vital signs; that patient # 11 had a fast heart rate (120's - 130 beats per minute), a low blood pressure; that he required supplemental oxygen to maintain an oxygen saturation level of 90%; that he said he felt "dehydrated" ; and that he "described a thirty-six hour history of nausea, vomiting and not feeling well." Further documentation stated "The patient advised that he had nothing to eat or drink in approximately sixteen hours." "The patient described having flu-like symptoms with his last emesis at 4:00 AM prior to EMS arrival." "Physical exam revealed that the patient's abdomen was tender to palpation in the right upper quadrant." The ambulance crew administered 500 mL [approximately 2 cups] of normal saline intravenously to patient # 11 en route to the hospital.

Upon arrival to the ED at 11:33 AM, the nurse documented the elderly patient ( #11) complained of nausea, vomiting, and diarrhea yesterday, little vomiting today, no diarrhea, nothing to eat or drink today, that he had a temperature of 101.3 degrees Fahrenheit and his abdomen was soft and not tender. At 11:45 AM, the ED nurse documented the ED physician was at the patient's bedside. The ED physician examined the patient, documented he had a history of nausea and vomiting for 1 day; that he was weak and his abdominal exam was within normal limits. At 11:50 AM, the ED physician ordered basic lab work and a urine specimen for a urinalysis; medications to control nausea and reduce the fever; and intravenous fluids. The ED nurse scribbled through documentation in the medical record which would have specified the amount of intravenous fluids administered to patient # 11 and noted that the rate of infusion was "TKO" [to keep open, i.e., a rate of infusion such that the patient would receive negligible amounts of intravenous fluids]. At 12:10 PM the ED nurse documented patient #11 was taking sips of water without nausea or vomiting, and at 12:20 PM began taking sips of Sierra Mist. At 12:55 PM, 1 hour and 22 minutes after presenting to the ED, the physician determined Patient # 11 had gastroenteritis and discharged him home.

2. Review of the medical record revealed patient #11 returned to the ED by ambulance at 7:13 PM (approximately 7 hours after discharge) in full cardiac arrest with CPR in progress. Documentation in the medical record revealed the first attempt at intubation was "met with copious bloody fecal emesis." At 7:18 PM, the ED physician successfully intubated the patient and at 7:38 PM hospital staff ended resuscitation efforts and Patient # 11 died.

3. According to the statutorily mandated QIO physician peer review completed on 2/23/11, this elderly patient (# 11) did not receive an appropriate or sufficient examination to determine whether an emergency medical condition existed prior to discharge (at 12:55 PM).

4. During an interview on 1/31/11 at 4:40 PM, RN E reported that Patient #11 was in the ED earlier in the day on 1/13/11 and was discharged at 1:00 PM with a 101-degrees Fahrenheit temperature and that the patient's heart rate, during the first admission, was in the 120's (beats per minute). RN E stated those can be signs of sepsis in the elderly.

5. Review of the policy "Transfer and Emergency Examination - EMTALA", revised 11/09, revealed in part, "The medical screening examination provided shall be within the capacities of the ... hospital's Emergency Department... If the individual has an emergency medical condition, further medical examination ... within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition...". The hospital failed to follow this policy and did not provide an elderly patient (# 11), who was experiencing symptoms of gastrointestinal distress, a rapid heart rate and fever, with an appropriate examination sufficient to determine whether an emergency condition existed prior to discharge at 12:55 PM. Refer to tag A2406 for further details.

Based on document review and staff interviews, the hospital emergency department (ED) staff failed to provide an appropriate medical screening examination for 1 emergency department patient (patient #11), who presented to the emergency department requesting care, out of 40 cases selected for review from August 2010 to January 2011. The hospital administrative staff identified an average of 3,751 emergency department visits per month.

Failure to provide an appropriate medical screening exam resulted in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed an elderly patient (# 11) presented to the ED by ambulance on 1/13/11 at 11:33 AM. The "Iowa EMS Report" revealed the ambulance crew arrived at patient #11's home at 11:04 AM. The crew documented serial vital signs; that patient #11 had a fast heart rate (120's - 130 beats per minute), a low blood pressure; that he required supplemental oxygen to maintain an oxygen saturation level of 90%; that he said he felt "dehydrated" ; and that he "described a thirty-six hour history of nausea, vomiting and not feeling well." Further documentation stated "The patient advised that he had nothing to eat or drink in approximately sixteen hours." "The patient described having flu-like symptoms with his last emesis at 4:00 AM prior to EMS arrival." "Physical exam revealed that the patient's abdomen was tender to palpation in the right upper quadrant." The ambulance crew administered 500 mL [approximately 2 cups] of normal saline intravenously to patient #11 en route to the hospital.

Upon arrival to the ED at 11:33 AM, the nurse documented the elderly patient (#11) complained of nausea, vomiting, and diarrhea yesterday, little vomiting today, no diarrhea, nothing to eat or drink today, that he had a temperature of 101.3 degrees Fahrenheit and his abdomen was soft and not tender. At 11:45 AM, the ED nurse documented the ED physician was at the patient's bedside. The ED physician examined the patient, documented he had a history of nausea and vomiting for 1 day; that he was weak and his abdominal exam was within normal limits. At 11:50 AM, the ED physician ordered basic lab work and a urine specimen for a urinalysis; medications to control nausea and reduce the fever; and intravenous fluids. The ED nurse scribbled through documentation in the medical record which would have specified the amount of intravenous fluids administered to patient #11 and noted that the rate of infusion was "TKO" [to keep open, i.e., a rate of infusion such that the patient would receive negligible amounts of intravenous fluids]. At 12:10 PM the ED nurse documented patient #11 was taking sips of water without nausea or vomiting, and at 12:20 PM began taking sips of Sierra Mist. At 12:55 PM, 1 hour and 22 minutes after presenting to the ED, the physician determined Patient #11 had gastroenteritis and discharged him home.

2. According to the statutorily mandated QIO physician peer review completed on 2/23/11, this elderly patient (#11) did not receive an appropriate or sufficient examination to determine whether an emergency medical condition existed.

3. During an interview on 1/31/11 at 4:40 PM, RN E reported that Patient #11 was in the ED earlier in the day on 1/13/11 and was discharged at 1:00 PM with a 101-degrees Fahrenheit temperature and that the patient's heart rate, during the first admission, was in the 120's (beats per minute). RN E stated those can be signs of sepsis in the elderly. In elderly with an illness, you can see an increased heart rate and temperature. RN E added that Patient #11 returned to the hospital six hours later (7:17 PM) in full cardiac arrest.

4. During an interview on 1/31/11 at 3:00 PM, ED physician B stated when he examined patient # 11, ordered laboratory tests and medications, Patient # 11 told Physician B that he only needed some intravenous fluid. After receiving the laboratory test results, Physician B spoke with RN A who reported that Patient # 11 had started drinking clear soda and did not have any nausea. Physician B said he did not re-examine Patient # 11 but did talk with him. Physician B stated Patient # 11 said he did not have any complaints and was doing well. Physician B then wrote orders to discharge Patient # 11.

5. During an interview on 1/31/11 at 10:30 AM, ED nurse (RN A) stated "He [patient # 11] was tachy [cardiac], otherwise his vital signs were okay. He was on 2 liters of oxygen via nasal cannula. I know his oxygen saturation was down, but he didn't have any shortness of breath. I was shocked when he came back in."

6. During an interview on 1/31/11 at 12:35 PM, ED nurse (RN C) stated that "I discharged him [patient # 11]." "I got a wheelchair, wheeled him to the front, he got into a cab and left." "He [patient #11] seemed good for his age. He was in his pajamas and told me his plans to leave and have lunch with his son. It seemed strange, because he wasn't feeling good. I told him to eat foods like Jello and clear liquids."

7. Review of the medical record revealed patient #11 returned to the ED by ambulance at 7:13 PM (approximately 7 hours after discharge) in full cardiac arrest with CPR in progress. Documentation in the medical record revealed the first attempt at intubation was "met with copious bloody fecal emesis." At 7:18 PM, the ED physician successfully intubated the patient and at 7:38 PM hospital staff ended resuscitation efforts and Patient #11 died.