HospitalInspections.org

Based on policy review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination and stabilizing treatment was provided for a patient who presented to the hospital's DED for evaluation on 10/10/2019.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's DED for evaluation of a possible urinary tract infection on 10/10/2019.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

2. The hospital failed to ensure that stabilizing treatment was provided for a patient (Patient #2) who presented to the hospital's DED for evaluation of a possible urinary tract infection on 10/10/2019.

~cross refer to 489.24(d) (1-3), Stabilizing Treatment - Tag A2407.

Based on policy review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary routinely available to the emergency department to determine whether or not an emergency medical condition existed for a patient 1 (Patient #2) of 25 sampled patients who presented to the hospital's DED for evaluation of a possible urinary tract infection on 10/10/2019.

The findings included:

Review of a policy titled "Emergency Medical Screening" last reviewed 10/05/2016 revealed, "...The following policy is designed to ensure that (Hospital A Named) provides emergency medical screening examinations to any individual for whom an exam(examination) or treatment is requested in compliance with the Emergency Medical Treatment and Active Labor Act ... This federal law requires that any such individuals presenting to any (Hospital A Named) location receive a medical screening examination by personnel who are qualified to provide such screenings by virtue of their education, training, credentials, and experience ... All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary test, ancillary services, and/or on-call specialists when necessary..."

Review of a policy titled "Triage" last reviewed 07/26/2019 revealed, "...ED patients, excluding Fast Track, will have a reassessment of Vital Signs (VS) within one hour of discharge. These vital signs should include: blood pressure, heart rate and respiratory rate. Temperature, pulse oximetry and pain scale should be reassessed if clinically indicated ..."

The facility's policy titled, "Severe Sepsis and/or Septic Shock Patient Care" Policy number PC-171, origination 10/16/19, was reviewed. The policy revealed in part, "II. Process/Procedure for the ED A. Suspected sepsis is screening in the Emergency Department. 1.) Obtain a National Early Screening on all ED patients...2.) if score is 5 or greater...Implement the ED Suspected Sepsis Protocol...3. Notify the ED provider if the NEWS score is 5 or greater... 4. care of the sepsis patient will be determined and initiated by the ED for all patients who meet screening criteria for severe sepsis or septic shock. 5. Severe sepsis should be considered for any patient with a source of infection and a SBP (Systolic blood pressure) <90 and or MAP (Mean arterial Pressure) <65...Transition to inpatient care Sepsis Care- A. ED handoff of Sepsis - ED RN to include information regarding specific interventions that have been completed and interventions that are still pending in handoff to the inpatient RN."


Closed medical record review conducted on 12/03/2019 revealed Patient #2 was an 89-year-old male who presented to Hospital A's DED on 10/10/2019 at 0745, with a Chief complaint of Altered (confusion) , Stated complaint of UTI (Urinary Tract Infection-an infection in any part of a person's urinary system). Patient #2's vital signs at 0757 were: BP Blood Pressure) 123/65, P (Pulse) 81, R (Respirations) 22, Temp (temperature) 99.6 Pulse Ox (measures the blood oxygen levels in the body), 94%. Patient #2's past medical history included dementia, GERD, peptic ulcer disease, colon cancer with colon resection, prostate cancer, CKD (Chronic Kidney Disease) , and hyperthyroidism. Review of a Provider Note written by Doctor of Osteopathic Medicine (DO) #1 on 10/10/2019 at 1536 revealed, "...Patient is an 89-year-old male who presents to emergency room with wife. Family states patient has a known history of dementia and that today he has had some confusion. She states he gets this way when he gets urinary tract infections in the past. Patient denies any chest pain. He denies any cough. Family states patient complained of some painful urination yesterday. He currently denies any abdominal pain. There has been no vomiting or diarrhea. He denies any new onset one-sided numbness or weakness. There has been no slurred speech. Patient states he feels well and wishes to go home stating he has no complaints ... Review of Systems ... Genitourinary: painful urination ... Physical Exam ... Constitutional: alert Eyes: normal conjunctiva ENT: oropharynx appears normal, dry mucus membranes Respiratory: normal rate, lung sounds clear Cardiovascular: normal rate, regular rhythm Gastrointestinal: soft Musculoskeletal: head/face atraumatic, extremities atraumatic Integumentary: normal color, warm & dry Neurological: speech WNL (within normal limits), answering questions WNL, Other-Follows commands moves all extremities is alert to person and place. Is alert 2 year with some prompting. Psychiatric: calm demeanor. Documentation of the CODE SEPSIS Protocol (NEWS SCREENING PROTOCOL- helps hospital with early recognition of Sepsis) dated at 10:26 am revealed: in part, "Potential Infection- Yes...Respirations (20-22) - paient #2's resp was 22; Pulse oximetry 90 % - Patient #2's Pulse ox was 90% ON ROOM AIR. The patient's, NEWS SCREENING TOOL TOTAL was -5. Sepsis ( is a life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) Risk Implement Suspected Sepsis Protocol. ... Lab Results ... WBC (White Blood Count) ... 13.8 H (High) ... Neutrophils ... 10.3 H ... Lactic Acid ... 0.8 ... Urine Color ... Yellow ... Urine Color ... Cloudy ... Ur (Urine) Leukocyte Esterase ...Large A ... Urine WBC 328 ... Urine WBC Clumps ... Many ... Urine Bacteria ... Occ ... BUN (Blood Urea Nitrogen) 24 H ... Creatinine 1.4 H ... Chest X-Ray ... IMPRESSION: Possible new left lateral apical lung mass. Chest CT recommended ... Medical Decision Making: EKG (Electrocardiogram) obtained. October 10, 2019 826 as read by me sinus rhythm rate 79. no (sic) stmi (STEMI-ST elevation Myocardial infarction) Chest x-ray shows possible new left upper lung apical mass (sic) I discussed with patient's family there is a possible left upper lung mass for which he is to follow up with primary care physician for outpatient CT scan (sic) Patient is mildly dehydrated (A conditon that results when the body loses more water than it takes in) (sic) Will give patient a L (Liter) of IV (Intravenous) fluid Orthostatics negative patient is medically stable for discharge home (sic) Following IV fluid patient states he is feeling much improved is able to stand and ambulate with cane with no assistance (sic) Diagnosis & Disposition UTI, Possible left upper lung mass Stable - Prescriptions & Referrals Cephalexin (an oral antibiotic) ... 500 mg PO Q6HR ... Ondansetron (medication prevents nausea) ... 4mg PO Q6HR/PRN ... (Named primary care provider) 10/11/2019 ... Instructions An incidental finding of a possible left upper lung mass was found on chest x-ray for which he will need to follow up with primary care physician within 5 days time. Further outpatient workup by primary care physician may include CT scan to further characterize the mass. Return to ED for any worsening of symptoms could include worsening cough chest pain or shortness of breath or development of fever (sic) ..." Review of an ADDENDUM written by DO #1 on 10/10/2019 at 1556 revealed, "I discussed with patient's family present in room while patient was still in the emergency room, offering social worker to speak with patient and family regarding getting some help at home. Initially family was going to wait to speak with social order (sic) within decided to leave and not speak with social worker. Patient was able to stand and ambulate unassisted with a cane after some IV fluid. Patient was feeling much improved stating he wishes to go home." Total diagnostic studies ordered for Patient #2 were EKG, CXR, (Chest x-ray) CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panei), Lactic Acid, TSH (thyroid stimulating hormone), Troponin, Urinalysis, and Blood and Urine Cultures. Pertinent results were quoted in the above Provider Note. Patient #2 was also fed a regular diet during the DED visit. Patient #2 was administered 2 grams of Rocephin IV and 1 liter of normal saline IV during the DED visit. The last full set of vital signs was obtained at 1025 (4 hours and 28 minutes prior to discharge), and resulted as: BP (Blood Pressure) 123/65, P 81, R 22, Temp 98.8 Pulse Ox 90% Low (Normal Pulse Ox readings are between 95% to 100%). Orthostatic vital signs were as follows: lying BP 144/79, P 71, obtained at 1203; sitting BP 132/79, P 83, obtained at 1208; and standing BP 132/82, P 87, obtained at 1210. Patient #2 was discharged on 10/10/2019 at 1453, noting no evidence of a vital sign check within one hour of discharge. The facility failed to provide an appropriate medical screening as evidenced by failing to admit patient #2 to provide ongoing monitoring after it determined the patient met the criteria for sepsis, according to the facility's sepsis protocol.

Patient #2 returned to the Hospital A's DED on 10/10/2019 at 1545 (52 minutes after his discharge), with vital signs as follows: BP 113/65, P 117, R 18, T 102.8 (degrees), and Pulse Ox 92%; and he was ultimately admitted. Review of a Discharge Summary written by Nurse Practitioner (NP) #1 on 10/13/2019 at 1109 revealed, "...Admitting Diagnosis: Fevers Chills Sepsis UTI Acute kidney injury Discharge Diagnosis Sepsis, resolved Urinary tract infection Metabolic encephalopathy Acute kidney Injury Lactic acidosis, resolved Pulmonary nodules, patient and family opting not to pursue further ... Hospital Course: The patient is 89-year-old male who present (sic) to (Hospital A Named) Emergency Department on the morning of 10/10/2019 was diagnosed with UTI and given dose of Rocephin and discharged on Keflex. Patient got home and started having rigors and running high-grade fever and thus was brought back to the emergency department for further evaluation ... Initial urinalysis that was obtained earlier this morning revealed large urine leukocyte esterase, urine WBC 328 many WBC clumps occasional bacteria. When patient presented back to the emergency department patient temperature 102.8 (degrees), pulse 117, respirations 18, blood pressure 113/65. Lactic acid level was 2.3 and with concern of sepsis, hospitalist service was contacted for admission patient (sic) was admitted to the medical floor. On my exam, vital signs of (sic) improved to temperature 99.3 (degrees), pulse 97, respirations 16, blood pressure 99/68, pulse oximetry 90% on room air ... He was admitted to the medical floor and aggressively hydrated with IV fluid boluses. He received IV ceftriaxone for urinary tract infection. Fortunately, over the next 48 hours his symptoms rapidly resolved. His fever curve normalized. His renal function normalized. He was able to ambulate and to eat and drink well. He did undergo CT of the chest to evaluate chest x-ray abnormalities which did demonstrate some nodules. He and his wife are hesitant to pursue further diagnostic studies. He will be discharged home later on today with (Named Home Health Agency)..." Patient #2 was discharged from Hospital A on 10/13/2019.

Interview conducted with RN #1 on 12/03/2019 at 1628. revealed he vaguely recalled Patient #2. Interview revealed if the patient had been experiencing any distress "at all, he absolutely would not have discharged him." Interview revealed standard process was that if a patient did not appear safe to discharge when the nurse attempted to discharge them, a doctor would be notified.

Telephone physician interview conducted with DO #1 on 12/04/2019 at 0936 revealed he recalled Patient #2. Interview revealed Patient #2's lab work, including elevated white blood cell count and urinalysis results were consistent with a UTI, for which he was treated. Interview revealed his mildly elevated BUN and Creatinine were attributed to dehydration, for which he was also treated. Interview revealed DO #1 had discussed with the family about ordering a social worker to talk to them about getting "some help" caring for him at home, because it "was obvious family were having issues with care at home. But they didn't wait." Interview revealed the patient was in no acute distress prior to his departure, and he ambulated without difficulty. Interview revealed the facility normally did recheck vital signs prior to departure. Interview revealed before Patient #2 was discharged from the first visit, his overall clinical picture was well, but people can get worse and "that's why we give discharge instructions to return if necessary."

Based on policy review, medical record review and interviews the hospital failed to provide stabilizing treatment as required within the capabilities of the staff and facilities available at the hospital for 1 (Patient #2) of 25 sampled patients who presented to the hospital's DED for evaluation of a possible urinary tract infection on 10/10/2019. The facility also failed to have a policy that effectively addresses EMTALA stabilizing treatment.

The findings included:

Review of a policy titled "Emergency Medical Screening" last reviewed 10/05/2016 revealed, "...The following policy is designed to ensure that (Hospital A Named) provides emergency medical screening examinations to any individual for whom an exam or treatment is requested in compliance with the Emergency Medical Treatment and Active Labor Act ... This federal law requires that any such individuals presenting to any (Hospital A Named) location receive a medical screening examination by personnel who are qualified to provide such screenings by virtue of their education, training, credentials, and experience ... All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary test, ancillary services, and/or on-call specialists when necessary..." A review of the facilities revealed the policy lacked providing stabilizing treatment as required for emergency medical conditions within the hospital's capability and capacity.


The facility's policy titled, "Severe Sepsis and/or Septic Shock Patient Care" Policy number PC-171, origination 10/16/19, was reviewed. The policy revealed in part, "II. Process/Procedure for the ED A. Suspected sepsis is screening in the Emergency Department. 1.) Obtain a National Early Screening on all ED patients...2.) if score is 5 or greater...Implement the ED Suspected Sepsis Protocol...3. Notify the ED provider if the NEWS score is 5 or greater... 4. care of the sepsis patient will be determined and initiated by the ED for all patients who meet screening criteria for severe sepsis or septic shock. 5. Severe sepsis should be considered for any patient with a source of infection and a SBP (Systolic blood pressure) <90 and or MAP (Mean arterial Pressure) <65...Transition to inpatient care Sepsis Care- A. ED handoff of Sepsis - ED RN to include information regarding specific interventions that have been completed and interventions that are still pending in handoff to the inpatient RN."

Closed medical record review conducted on 12/03/2019 revealed Patient #2 was an 89-year-old male who presented to Hospital A's DED on 10/10/2019 at 0745, with a complaint of confusion. Patient #2's vital signs at 0757 were: BP 123/65, P 81, R 22, Temp 99.6 Pulse Ox 94%. Patient #2's past medical history included dementia, GERD (Gastroesophageal Reflux Disease), peptic ulcer disease, colon cancer with colon resection, prostate cancer, CKD, and hyperthyroidism. Review of a Provider Note written by Doctor of Osteopathic Medicine (DO) #1 on 10/10/2019 at 1536 revealed, "...Patient is an 89-year-old male who presents to emergency room with wife. Family states patient has a known history of dementia and that today he has had some confusion. She states he gets this way when he gets urinary tract infections in the past. Patient denies any chest pain. He denies any cough. Family states patient complained of some painful urination yesterday. He currently denies any abdominal pain. There has been no vomiting or diarrhea. He denies any new onset one-sided numbness or weakness. There has been no slurred speech. Patient states he feels well and wishes to go home stating he has no complaints ... Review of Systems ... Genitourinary: painful urination ... Physical Exam ... Constitutional: alert Eyes: normal conjunctiva ENT: oropharynx appears normal, dry mucus membranes Respiratory: normal rate, lung sounds clear Cardiovascular: normal rate, regular rhythm Gastrointestinal: soft Musculoskeletal: head/face atraumatic, extremities atraumatic Integumentary: normal color, warm & dry Neurological: speech WNL (Within Normal Limits), answering questions WNL, Other-Follows commands moves all extremities is alert to person and place. Is alert 2 year with some prompting. The patient's Psychiatric: calm demeanor. Documentation of the CODE SEPSIS Protocol (NEWS SCREENING PROTOCOL- helps hospital with early recognition of Sepsis) dated at 10:26 am revealed: in part, "Potential Infection- Yes...Respirations (20-22) - patient #2's resp was 22; Pulse oximetry 90 % - Patient #2 Pulse ox was 90% ON ROOM AIR. The patient's, NEWS SCREENING TOOL TOTAL was -5. Sepsis ( is a life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) Risk Implement Suspected Sepsis Protocol. ... Lab Results ... WBC ... 13.8 H (High) ... Neutrophils ... 10.3 H ... Lactic Acid ... 0.8 ... Urine Color ... Yellow ... Urine Color ... Cloudy ... Ur Leukocyte Esterase ...Large A ... Urine WBC 328 ... Urine WBC Clumps ... Many ... Urine Bacteria ... Occ ... BUN 24 H ... Creatinine 1.4 H ... Chest X-Ray ... IMPRESSION: Possible new left lateral apical lung mass. Chest CT recommended ... Medical Decision Making: EKG obtained. October 10, 2019 826 as read by me sinus rhythm rate 79. no (sic) stmi STEMI-(ST elevation Myocardial Infarction) Chest x-ray shows possible new left upper lung apical mass (sic) I discussed with patient's family there is a possible left upper lung mass for which he is to follow up with primary care physician for outpatient CT scan (sic) Patient is mildly dehydrated (sic) Will give patient a L of IV fluid Orthostatics negative patient is medically stable for discharge home (sic) Following IV fluid patient states he is feeling much improved is able to stand and ambulate with cane with no assistance (sic) Diagnosis & Disposition UTI, Possible left upper lung mass Stable - Prescriptions & Referrals Cephalexin (oral antibiotic) ... 500 mg PO Q6HR ... Ondansetron (medication that prevents nausea) ... 4mg PO Q6HR/PRN ... (Named primary care provider) 10/11/2019 ... Instructions An incidental finding of a possible left upper lung mass was found on chest x-ray for which he will need to follow up with primary care physician within 5 days time. Further outpatient workup by primary care physician may include CT scan to further characterize the mass. Return to ED for any worsening of symptoms could include worsening cough chest pain or shortness of breath or development of fever (sic) ..." Review of an ADDENDUM written by DO #1 on 10/10/2019 at 1556 revealed, "I discussed with patient's family present in room while patient was still in the emergency room, offering social worker to speak with patient and family regarding getting some help at home. Initially family was going to wait to speak with social order (sic) within decided to leave and not speak with social worker. Patient was able to stand and ambulate unassisted with a cane after some IV fluid. Patient was feeling much improved stating he wishes to go home." Total diagnostic studies ordered for Patient #2 were EKG (electrocardiogram), CXR (Chest x-ray), CBC (complete Blood Count), CMP (Comprehensive Metabolic Panel), Lactic Acid, TSH (Thyroid Stimulating Hormone), Troponin, Urinalysis, and Blood and Urine Cultures. Pertinent results were quoted in the above Provider Note. Patient #2 was also fed a regular diet during the DED visit. Patient #2 was administered 2 grams of Rocephin (antibiotic) IV and 1 liter of normal saline IV during the DED visit. The last full set of vital signs was obtained at 1025 (4 hours and 28 minutes prior to discharge), and resulted as: BP 123/65, P 81, R 22, Temp 98.8 Pulse Ox 90%. Orthostatic vital signs were as follows: lying BP 144/79, P 71, obtained at 1203; sitting BP 132/79, P 83, obtained at 1208; and standing BP 132/82, P 87, obtained at 1210. Patient #2 was not stabilized prior to discharge, as the patient required admission for the monitoring of the infection. Patient #2 returned to the hospital's ED within 52 minutes with a worsening clinical picture.


Interview conducted with RN #1 on 12/03/2019 at 1628. revealed he vaguely recalled Patient #2. Interview revealed if the patient had been experiencing any distress "at all, he absolutely would not have discharged him." Interview revealed standard process was that if a patient did not appear safe to discharge when the nurse attempted to discharge them, a doctor would be notified.

Telephone physician interview conducted with DO #1 on 12/04/2019 at 0936 revealed he recalled Patient #2. Interview revealed Patient #2's lab work, including elevated white blood cell count and urinalysis results were consistent with a UTI, for which he was treated. Interview revealed his mildly elevated BUN and Creatinine were attributed to dehydration, for which he was also treated. Interview revealed DO #1 had discussed with the family about ordering a social worker to talk to them about getting "some help" caring for him at home, because it "was obvious family were having issues with care at home. But they didn't wait." Interview revealed the patient was in no acute distress prior to his departure, and he ambulated without difficulty. Interview revealed the facility normally did recheck vital signs prior to departure. Interview revealed before Patient #2 was discharged from the first visit, his overall clinical picture was well, but people can get worse and "that's why we give discharge instructions to return if necessary."