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Based on medical record review, document review, and staff interview, the hospital failed to comply with their provider agreement to provide an appropriate medical screening exam (MSE) to determine if a patient had an emergency medical condition (EMC) for one patient that presented to the hospital Emergency Department (ED) of 20 sampled records reviewed (patient #1).


Failure of the hospital to comply with their agreement to provide an appropriate MSE to determine if the patient had an EMC led to the patient's condition worsening and requiring additional medical treatment and hospitalization at another hospital.


Findings include:


- The hospital's policy titled "EMTALA" reviewed on 11/09/2015 at 12:50pm directed "... It is the policy of Hospital AA to provide a medical screening examination and stabilizing treatment to those persons presenting with an emergency medical condition, and to execute appropriate transfers when services are not available to treat those presenting with emergency conditions ..."

- Policy titled "Emergency Department" reviewed on 11/10/2015 reviewed on 10:45am directed" ... Patients are discharged from the Emergency Department once they have been examined and treated by the Physician and/or Mid-level and appropriate discharge instructions have been provided. Discharge vital signs will be taken within 30 minutes for ESI (triage level) level 1, 2, and 3 patients ..."

- Refer to Findings for tag A 2406- Medical Screening Examination
The hospital failed to ensure that no material deterioration of a patient's medical condition was likely to occur after discharge by sending a patient (patient #1) home on room air when she had required supplemental oxygen to maintain adequate oxygen levels during her entire ED visit. The hospital's failure to provide stabilizing treatment potentially led to deterioration in her condition causing her to need further medical treatment and hospitalization.

Based on medical record review, document review, and staff interview the hospital failed to provide an appropriate medical screening exam (MSE) to determine if a patient had an emergency medical condition (EMC) for one of 20 sampled patients (patient #1).

The hospital's failure to provide an appropriate MSE to determine if the patient had an EMC led to the patient's condition worsening and requiring additional medical treatment and hospitalization at another hospital.

Findings include:

- Patient #1 presented to the ED on 10/2/2015 at 8:17am via ambulance with a complaint of weakness. Patient #1's vital signs showed patient had a low grade fever with a temperature of 100.1 (normal 98.6), and low oxygen saturation of 86% on room air (97-99% normal). Physician Staff A assessed the patient in the ED at 8:43am and ordered an electrocardiogram (test to identify heart rhythms), laboratory tests that included a cardiac panel, chest x-ray, urine testing, blood chemistry, and medications including 1,000ml (milliliter) of Sodium Chloride (medication used to increase fluid in the body) and Norco (pain medication) and continuous pulse oximetry (a device used to measure oxygen in the body).

- Certified Nursing Assistant (CNA) B documented at 08:36 under NURSING PROCEDURE: OXYGEN THERAPY..."Oxygen saturation 86%, ...2 L Oxygen (O2) given, via nasal cannula (NC - a device used to deliver oxygen into each nostril)...

- Physician Staff A documented O2Sat Interpretation at 09:04 O2SAT: "...Oxygen Saturation 86%, on room air, ...interpretation: Hypoxic (a condition in which the body or a region of the body is deprived of adequate oxygen supply)

- Physician Staff A documented at 10:34 under DOCTOR NOTES RE-EVALUATION: The patient's condition has worsened, temperature going up with increased myalgias (muscle pains that are often a symptom of other diseases or disorders).

- Physician Staff A's next entry under DOCTOR NOTES RE-EVALUATION documented with a time of 10:34 also read: "Marked improvement appears to be viral syndrome (a general term used for a viral infection that has no clear cause; symptoms depend on the part of the body the virus affects) to see Physician Staff F tomorrow. Able to stand."

- Physician Staff A's next entry at 12:02pm under DOCTOR NOTES PATIENT PLAN: The patient will be discharged, The patient will follow up with their primary care physician, (Physician Staff F) tomorrow (Saturday) if needed.

- Vital Signs documentation at 09:00, 10:00, 11:00, and 12:03 show patient #1 on 2L O2 via NC with O2 sats between 90 and 94.

- Patient #1 was discharged to home on room air at 12:34pm with instructions to follow up with primary care physician the following day or return if their condition worsened. The last set of vital signs recorded at 12:03pm revealed an oxygen saturation of 91% on 2L of oxygen via nasal cannula. The medical record lacked evidence that a patient with suspected pneumonia and who remained hypoxic (low oxygen level in the blood) despite supplemental oxygen, received a medical screening examination sufficient to determine whether an emergency medical condition existed prior to discharge.

- Patient #1 was admitted through the ED to Hospital AA on 10/2/15 at 9:13pm with acute hypoxic respiratory failure (disorder that interferes with the lung's ability to oxygenate blood as it flows through the pulmonary arteries and veins), sepsis (whole body inflammatory response to infection), and atypical pneumonia (infection caused by different bacteria than usual) approximately 9 hours after being discharged from this hospital.

- During an interview with Paramedic H (from ambulance service Y) on 1/5/16 at 1:30pm, she indicated that she went to patient #1's house twice on 10/2/15. Once in the morning around 7:00am and once in the evening around 7:00pm. Paramedic H indicated that patient #1 was transferred from local ambulance service Y to regional ambulance service X to the hospital in the morning. Several hours later, ambulance service Y received another phone call for assistance at patient #1's address. She indicated that patient # 1 was completely "out of it" on arrival, she did not respond appropriately to verbal questions, but would respond appropriately to painful stimulus. Paramedic H indicated that the patient had oxygen saturations in the 70's on room air and that when they hooked the patient up to the heart monitor, the patient's heart rhythm would change from atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) to a junctional rhythm (describes an abnormal heart rhythm resulting from impulses coming from an area of tissue in the "junction" between atria and ventricles--It is not necessarily dangerous, but can be a sign of underlying pathology in need of treatment). Paramedic H indicated that they felt like the patient might be having some sort of stroke and that the best option for the patient was to transfer her to a stroke center. So, we took her to the helicopter landing pad and Helicopter Service Z picked her up and took her to hospital AA (75 miles away).

- Registered Nurse Staff D interviewed on 11/10/2015 at 7:55am indicated they did not remember this patient, but revealed any patient that required oxygen during their stay in the ED should be on room air for about 15-20 minutes before they are discharged to ensure they can go home safely. Registered Nurse Staff D acknowledged it is "common knowledge to check a patient's oxygen saturation before they go home if they were hypoxic when they arrived in the ED ".

- CNA (Certified Nurse Aid) Staff B interviewed on 11/10/2015 at 8:17am revealed they do not remove oxygen from patients at discharge because that is something the nurses do. CNA Staff B indicated they chart in the flow sheet and acknowledged their final vital sign check was at 12:03pm while the patient was still on 2 liters of oxygen with an oxygen saturation of 91%.

- Registered Nurse Staff C interviewed on 11/10/2015 at 8:40am acknowledged they charted discharging the patient, but did not remember the patient's ED visit. Registered Nurse Staff C indicated they were not sure if there is a policy directing staff to wait a specific amount of time after removing oxygen and rechecking oxygen saturation before discharge. Registered Nurse Staff C acknowledged they failed to document the patient's oxygen saturation on room air prior to discharge.

- Physician Staff A interviewed on 11/10/2015 at 9:05am when asked about the two entries timed at 10:34 indicated that the electronic medical record system (EMR) has a glitch that causes any notes to document the time as the same time as the original note; making it appear like all documentation occurred at the same time. Physician Staff A revealed that their expectation is the nurse discharging any patient would do a final set of vital signs and alert the physician if there are any abnormal values such as low oxygen saturation. Physician Staff A indicated they had been in the Patient #1's room multiple times to reevaluate, speak with family, and had directed nursing staff to ensure the patient could stand without assistance. Physician Staff A reported they contacted the patient's attending physician and discussed the case with them and a decision was made to discharge the patient to their home with instructions to return if their condition worsened otherwise to see their doctor the next day. Physician Staff A reported that at the time of discharge the patient was in improved condition with their temperature decreasing from 100.5 to 100.1; the patient reported decreased pain level as well; the patient was very alert and cooperative prior to discharge. Physician Staff A indicated Patient #1 was not in any cardio/pulmonary (heart or lung) distress while in the ED. Physician Staff A acknowledged if they had been made aware of a low oxygen level on room air and the patient did not have oxygen at home they may have admitted the patient for that reason.

- Registered Nurse Staff E interviewed on 11/10/2015 at 9:52am indicated the discharge process includes providing the patient with discharge instructions, information indicating when a patient should return to the ED, education on any prescribed medications, and a final set of vital signs to include oxygen saturation and if not on oxygen at home, the nurse should take an oxygen reading while the patient is on room air. Registered Nurse Staff E acknowledged they would expect the nurse discharging the patient to alert the physician of any abnormal vital signs prior to discharging the patient. Registered Nurse Staff E indicated they have a social worker in the ED that is available and has the ability to ensure a patient requiring home oxygen is set up with it prior to discharge.

Based on medical record review, document review, and staff interview the hospital failed to provide an appropriate medical screening exam (MSE) to determine if a patient had an emergency medical condition (EMC) for one of 20 sampled patients (patient #1).

The hospital's failure to provide an appropriate MSE to determine if the patient had an EMC led to the patient's condition worsening and requiring additional medical treatment and hospitalization at another hospital.

Findings include:

- Patient #1 presented to the ED on 10/2/2015 at 8:17am via ambulance with a complaint of weakness. Patient #1's vital signs showed patient had a low grade fever with a temperature of 100.1 (normal 98.6), and low oxygen saturation of 86% on room air (97-99% normal). Physician Staff A assessed the patient in the ED at 8:43am and ordered an electrocardiogram (test to identify heart rhythms), laboratory tests that included a cardiac panel, chest x-ray, urine testing, blood chemistry, and medications including 1,000ml (milliliter) of Sodium Chloride (medication used to increase fluid in the body) and Norco (pain medication) and continuous pulse oximetry (a device used to measure oxygen in the body).

- Certified Nursing Assistant (CNA) B documented at 08:36 under NURSING PROCEDURE: OXYGEN THERAPY..."Oxygen saturation 86%, ...2 L Oxygen (O2) given, via nasal cannula (NC - a device used to deliver oxygen into each nostril)...

- Physician Staff A documented O2Sat Interpretation at 09:04 O2SAT: "...Oxygen Saturation 86%, on room air, ...interpretation: Hypoxic (a condition in which the body or a region of the body is deprived of adequate oxygen supply)

- Physician Staff A documented at 10:34 under DOCTOR NOTES RE-EVALUATION: The patient's condition has worsened, temperature going up with increased myalgias (muscle pains that are often a symptom of other diseases or disorders).

- Physician Staff A's next entry under DOCTOR NOTES RE-EVALUATION documented with a time of 10:34 also read: "Marked improvement appears to be viral syndrome (a general term used for a viral infection that has no clear cause; symptoms depend on the part of the body the virus affects) to see Physician Staff F tomorrow. Able to stand."

- Physician Staff A's next entry at 12:02pm under DOCTOR NOTES PATIENT PLAN: The patient will be discharged, The patient will follow up with their primary care physician, (Physician Staff F) tomorrow (Saturday) if needed.

- Vital Signs documentation at 09:00, 10:00, 11:00, and 12:03 show patient #1 on 2L O2 via NC with O2 sats between 90 and 94.

- Patient #1 was discharged to home on room air at 12:34pm with instructions to follow up with primary care physician the following day or return if their condition worsened. The last set of vital signs recorded at 12:03pm revealed an oxygen saturation of 91% on 2L of oxygen via nasal cannula. The medical record lacked evidence that a patient with suspected pneumonia and who remained hypoxic (low oxygen level in the blood) despite supplemental oxygen, received a medical screening examination sufficient to determine whether an emergency medical condition existed prior to discharge.

- Patient #1 was admitted through the ED to Hospital AA on 10/2/15 at 9:13pm with acute hypoxic respiratory failure (disorder that interferes with the lung's ability to oxygenate blood as it flows through the pulmonary arteries and veins), sepsis (whole body inflammatory response to infection), and atypical pneumonia (infection caused by different bacteria than usual) approximately 9 hours after being discharged from this hospital.

- During an interview with Paramedic H (from ambulance service Y) on 1/5/16 at 1:30pm, she indicated that she went to patient #1's house twice on 10/2/15. Once in the morning around 7:00am and once in the evening around 7:00pm. Paramedic H indicated that patient #1 was transferred from local ambulance service Y to regional ambulance service X to the hospital in the morning. Several hours later, ambulance service Y received another phone call for assistance at patient #1's address. She indicated that patient # 1 was completely "out of it" on arrival, she did not respond appropriately to verbal questions, but would respond appropriately to painful stimulus. Paramedic H indicated that the patient had oxygen saturations in the 70's on room air and that when they hooked the patient up to the heart monitor, the patient's heart rhythm would change from atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) to a junctional rhythm (describes an abnormal heart rhythm resulting from impulses coming from an area of tissue in the "junction" between atria and ventricles--It is not necessarily dangerous, but can be a sign of underlying pathology in need of treatment). Paramedic H indicated that they felt like the patient might be having some sort of stroke and that the best option for the patient was to transfer her to a stroke center. So, we took her to the helicopter landing pad and Helicopter Service Z picked her up and took her to hospital AA (75 miles away).

- Registered Nurse Staff D interviewed on 11/10/2015 at 7:55am indicated they did not remember this patient, but revealed any patient that required oxygen during their stay in the ED should be on room air for about 15-20 minutes before they are discharged to ensure they can go home safely. Registered Nurse Staff D acknowledged it is "common knowledge to check a patient's oxygen saturation before they go home if they were hypoxic when they arrived in the ED ".

- CNA (Certified Nurse Aid) Staff B interviewed on 11/10/2015 at 8:17am revealed they do not remove oxygen from patients at discharge because that is something the nurses do. CNA Staff B indicated they chart in the flow sheet and acknowledged their final vital sign check was at 12:03pm while the patient was still on 2 liters of oxygen with an oxygen saturation of 91%.

- Registered Nurse Staff C interviewed on 11/10/2015 at 8:40am acknowledged they charted discharging the patient, but did not remember the patient's ED visit. Registered Nurse Staff C indicated they were not sure if there is a policy directing staff to wait a specific amount of time after removing oxygen and rechecking oxygen saturation before discharge. Registered Nurse Staff C acknowledged they failed to document the patient's oxygen saturation on room air prior to discharge.

- Physician Staff A interviewed on 11/10/2015 at 9:05am when asked about the two entries timed at 10:34 indicated that the electronic medical record system (EMR) has a glitch that causes any notes to document the time as the same time as the original note; making it appear like all documentation occurred at the same time. Physician Staff A revealed that their expectation is the nurse discharging any patient would do a final set of vital signs and alert the physician if there are any abnormal values such as low oxygen saturation. Physician Staff A indicated they had been in the Patient #1's room multiple times to reevaluate, speak with family, and had directed nursing staff to ensure the patient could stand without assistance. Physician Staff A reported they contacted the patient's attending physician and discussed the case with them and a decision was made to discharge the patient to their home with instructions to return if their condition worsened otherwise to see their doctor the next day. Physician Staff A reported that at the time of discharge the patient was in improved condition with their temperature decreasing from 100.5 to 100.1; the patient reported decreased pain level as well; the patient was very alert and cooperative prior to discharge. Physician Staff A indicated Patient #1 was not in any cardio/pulmonary (heart or lung) distress while in the ED. Physician Staff A acknowledged if they had been made aware of a low oxygen level on room air and the patient did not have oxygen at home they may have admitted the patient for that reason.

- Registered Nurse Staff E interviewed on 11/10/2015 at 9:52am indicated the discharge process includes providing the patient with discharge instructions, i