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Based on review of facility policy, review of Emergency Medical Service (EMS) report, medical record review, security staff documentation, and interviews the facility failed to provide an appropriate comprehensive medical screen exam (MSE) and stabilizing treatment for 1 patient (Patient #26) who presented to the Emergency Department (ED) of 30 ED patients reviewed.

The findings include:

Patient #26, a 60-year-old female, arrived at Facility A's ED after flying to Knoxville from a nursing home in Rhode Island, where she had lived for 6 years, on 2/4/2023. The patient developed abdominal pain during the flight and was taken to Facility A upon landing. When EMS arrived, the patient was sitting upright in a wheelchair and was alert and oriented to person, place, and time. The patient admitted to having 3 alcoholic drinks on the plane. She reported abdominal pain at level of 8/10 with 10 being the worst possible pain, but could not describe the pain. The patient was assisted in standing and pivoting from the wheelchair to the stretcher. The patient's blood pressure for EMS was 97/59, pulse 120, respirations were 16. The patient was confused and agitated with a Glasgow Coma Scale of 14 (level of consciousness with 15 being the best possible score). The patient was oriented to person, place, time, and event. Patient #26 arrived in the ED on 2/4/2023 at 7:45 PM. She was triaged with an Emergency Severity Index (5 level system to determine urgency of patient symptoms) score of 2, indicating emergent needs. Upon arrival to the ED, her blood pressure was 85/53, pulse was 64, and respirations were 20. Her pain level was documented at 5/10 and described as aching. The patient had a history of stroke. A complete blood count (CBC-blood test) and Comprehensive Metabolic Panel were performed. No other blood tests were performed for Patient #26. A Computed Tomography (CT scan) of the abdomen was performed which showed a large amount of stool in the patient's colon for Patient #26. Further testing was not performed to rule out other possible causes for the patient's abdominal pain. Patient #26 was agitated, combative, and argumentative while in the ED. Diagnostic testing was not performed to determine possible causes for the patient's agitation and behavior. She was instructed to take Colace (stool softener) for constipation and was instructed to follow-up with her primary care provider, even though she was from out of state. Patient #26 was discharged from the facility with a diagnosis of constipation. The patient left Facility A's ED in a taxi and went to Facility B on her own. Patient #26 presented to Facility B's ED on 2/4/2023 at 11:57 PM (36 minutes after leaving Facility A's ED) with complaint of abdominal pain and reported constipation for 2 weeks. The patient was discharged from Facility B's ED on 2/5/2023 at 6:55 AM with diagnoses including Agitation and Constipation. Patient #26 presented to Facility B's ED status post cardiac arrest on 2/5/2023 at 10:00 AM. The patient was admitted to Facility B's Intensive Care Unit on 2/5/2023 with diagnoses including but not limited to Cardiac Arrest, Acute and Chronic Respiratory Failure, Shock, Altered Mental Status, Metabolic Acidosis, Advanced COPD, and Peripheral Vascular Disease. Patient #26 expired on 2/6/2023 at 9:57 PM. The documented cause of death was Out-of-hospital-cardiac arrest and cerebral herniation.

Please refer to A-2406 and A-2407.

Based on review of facility policy, Emergency Medical Services (EMS) report review, medical record review, security staff documentation, and interviews the facility failed to provide a comprehensive medical screening exam (MSE) for 1 patient (Patient #26) who presented to the Emergency Department (ED) of 30 patients reviewed.

The findings include:

Review of Facility A's policy "Transfer Policy-Emergency medical Treatment and Active Labor Act (EMTALA)" last revised 7/21/2021 showed "...Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions...Serious dysfunction of any bodily organ or part...The Medical Screening Examination shall include both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an emergency medical condition...The hospital must provide the Medical Screening Examination and treatment to stabilize within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the ED for examination and treatment...A Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist...Depending on the patient's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as, but not limited to, lumbar punctures, clinical laboratory tests, CT [computed tomography-detailed x-rays] scans and other diagnostic tests and procedures...A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer..."

Review of an EMS Patient Care Report showed EMS was dispatched to the airport for a female patient (Patient #26) with complaint of abdominal pain on 2/4/2023 at 7:05 PM. Upon arrival, the patient was sitting upright in a wheelchair and was alert and oriented to person, place, and time. The patient admitted to having 3 alcoholic drinks on the plane. She reported abdominal pain of 8/10 (10 being the worst possible pain), but could not describe the pain. The patient was assisted in standing and pivoting from the wheelchair to the stretcher. The patient's blood pressure was 97/59, pulse 120, and respirations were 16. Her Glasgow Coma Scale was 14 (level of consciousness with 15 being the best possible score). The patient was oriented to person, place, time, and event, but was confused and agitated.

Medical record review of a Nurse Triage Note showed Patient #26 presented to Facility A's ED by EMS on 2/4/2023 at 7:45 PM with complaint of lower abdominal pain. The patient had flown from a nursing home in Rhode Island where she had lived for 6 years. The patient reported a history of stroke with left sided weakness. Patient #26 was triaged with an Emergency Severity Index (5 level system to determine urgency of patient symptoms) score of 2 indicating emergent needs. The patient's blood pressure was 85/53, pulse 64, respirations 20, and oxygen saturation was 90% in room air. The patient's Glasgow Coma Scale was 15. The patient's pain level was documented as 5/10 and described as aching.

Medical record review of Facility A's ED Physician Documentation dated 2/4/2023 at 7:54 PM showed Patient #26 had a history of a stroke and presented to the ED for abdominal pain. The patient had flown to Tennessee from her nursing home in Rhode Island. During the flight, the patient experienced abdominal pain and urinated and had a bowel movement on herself. The patient also complained of left sided weakness and constipation. She was alert and oriented to time, place, and person. The plan of care progress showed Patient #26 improved. "...Patient refused to give urinalysis. She threw her feces [stool] loaded diaper at the nurse..." Patient #26 was dispositioned to discharge from Facility A on 2/4/2023 at 9:31 PM with diagnosis of Constipation.

Medical record review of a nursing note dated 2/4/2023 at 9:00 PM showed the patient reported she had not had a bowel movement for 1 week. She denied vomiting, nausea, or having any other symptoms such as shortness of breath, chest pain, or dizziness. "...Pt is verbally abusive and does not follow instructions..." The patient's gastrointestinal assessment showed she was incontinent (no control for bowel movements). Her abdomen was firm/round with hypoactive (decreased) bowel sounds throughout. Patient #26 was assessed as alert, combative, and irritable. A second nursing note dated 2/4/2023 at 9:00 PM showed "...Patient is combative and screams at stuff [staff]. She tells me that she wants me to call Ambulance to take her to her boyfriend's home. Patient argues with staff and does not understand that she was discharged and is free to go home. Her boyfriend is not able to pick her up tonight and she has nobody else to come and get her. Patient refuses to be helped to the wheelchair..."

Medical record review showed a Complete Blood Count and Comprehensive Metabolic Panel for Patient #26 on 2/4/2023 at 8:03 PM and showed:
*White Blood Count (test to indicate infection): 14.1 (reference range 4.5-11.0)
*Glucose (test for blood sugar): 119 (reference range 65-105)
* Lipase (breaks down fat): 10 (reference range 11-82)
*Ethanol (alcohol level): <10 (reference range <10)

Medical record review showed additional blood tests were not performed to rule out other causes for Patient #26's confusion, agitation, and behaviors.

Medical record review showed a CT (computed tomography-detailed x-ray) scan of the abdomen/pelvis without contrast was performed for Patient #26 on 2/4/2023 showed "...Left colonic [large intestine] diverticulosis [small bulging pouches]. Large volume colonic stool...IMPRESSION...Large volume colonic stool could be compatible with constipation; no evidence of obstruction...Coronary artery [supplies blood to the heart muscle] calcification [calcium build up in plaque found in the walls of the coronary arteries] is seen which is indicative of coronary artery disease..."

Medical record review showed further diagnostic studies were not performed to rule out other causes for Patient #26's abdominal pain, confusion, agitation, and behaviors.

Medical record review of an ED Discharge/Left Without Being Seen/Against Medical Advice notes dated 2/4/2023 at 10:12 PM showed Patient #26 was without a ride to Mohawk, TN. "...Patient refuses offer of cab to KARM [Knoxville Area Rescue Mission]. Pt [patient] unwilling to call friends or family. Pt argumentative cursing staff. Patient unwilling to go to local hotel. Pt informed of no reason for admission to hospital..." A note timed 10:15 PM, showed Patient #26 refused to leave when she was notified the ED physician had discharged her. "...pt was refusing to get up out of bed and was yelling at staff. Pt yelled 'i'm going to sue you. I want to go to [Facility B]. I told them to take me there in the first place and they wouldn't listen. This is ridiculous. I'm going to call 911 from that lobby and have them take me to [Facility B]. I hate this place. [Facility B] is better than this [s...hole]. you're all [bi.....]..." Patient #26 was made aware that an ambulance would not pick her up from the facility and transport her to another hospital. Patient #26 continued to refuse to get out of bed. At 10:30 PM, Patient #26 was cleaned, and a new brief was applied. Patient #26 refused to sign the discharge papers. The patient was assisted to a standing position by an ED Tech and RN and was assisted to a seated position in a wheelchair. The patient was then wheeled to the lobby with her belongings. A note timed 10:34 PM, showed Patient #26 transferred to a wheelchair with assistance and had transferred without difficulty. "...patient again argumentative with staff. Pt again offered cab to mission. Patient stated 'I can't go to the mission' pt encouraged to call friend for ride to Mohawk, TN..." The telephone number for a taxi was given to the patient.

Review of Facility A's Security Documentation dated 2/4/2023, showed at approximately 10:30 PM a security officer observed Patient #26 being argumentative with staff. The patient was being discharged and was angry. Patient #26 was telling nursing staff they had to take care of her and demanded that Facility A pay for a cab to take the patient to Facility B. A Registered Nurse told the patient she was being discharged and the facility would not pay for a cab to take her to another hospital. Patient #26 then demanded they call an ambulance to take her to Facility B. The RN told the patient an ambulance would not take her from Facility A to Facility B, especially since she was discharged. The security officer entered the patient's room to try to talk to the patient who stated "...'oh, here is the a...hole again'..." The security officer told her he had just arrived, and she had not met him. The security officer "...gave her some options as she was being discharged and she refused them saying 'I am not going to a shelter and I don't want to go back to the airport'...[Patient #26] had been complaining that AMR [EMS] left her wheelchair at the airport, but refused to go back for it via cab..." The patient was discharged and taken to the ED lobby. Patient #26 agreed to pay for a cab ride to leave the facility. The security officer called a local taxi for the patient. "...A short time later they arrived and took [Patient #26] to [Facility B], which is where she demanded to go..." The patient threatened to sue and press charges about her care while at Facility A. The patient's property was placed in the taxi and Patient #26 was assisted into the taxi (van) by ED staff.

Medical record review showed Patient #26 was discharged from Facility A's ED on 2/4/2023 at 10:34 PM. The patient was instructed to take Colace (stool softener) 100 mg (1 capsule) by mouth 2 times per day as needed and to follow-up with her primary care physician within 2-3 days.

Medical record review showed no documentation to indicate Patient #26 was re-evaluated by the physician before being discharged.

During an interview on 3/2/2023 at 11:10 AM, in the ED, RN #1 stated Patient #26 didn't want to be discharged and began yelling/cussing when she was told she was being discharged from Facility A's ED. Patient #26 said the ED had not helped her and she was upset that EMS had brought her to Facility A. RN #1 stated the patient was going to call 911 and have them take her to Facility B. RN #1 explained EMS wouldn't pick her up to take her to another hospital unless there was a need for a higher level of care.

During a telephone interview on 3/2/2023 at 1:23 PM, ED Tech #1 stated he assisted with getting Patient #26 in the front seat of the taxi after she was discharged from the ED. ED Tech #1 stated the patient was able to "...stand a little bit..." but required assistance.

During a telephone interview on 3/2/2023 at 2:12 PM, Physician #1 stated he explained the patient's diagnosis to her. He stated the patient never asked to delay or cancel her discharge from the ED. Physician #1 stated the patient didn't offer any other complaints of distress.

During an interview on 3/2/2023 at 2:55 PM, in the ED, RN #2 stated Patient #26 couldn't do much for herself due to a previous stroke and left sided weakness. She stated the patient was cleared for discharge. RN #2 stated Patient #26 wanted to be transferred to Facility B. RN #2 explained to the patient, there wasn't a medical reason to transfer her to another facility. RN #2 stated the patient became upset and very loud. RN #2 was concerned because the patient had no family to pick her up and she had no money.

Medical record review showed Patient #26 presented to Facility B's ED on 2/4/2023 at 11:57 PM with complaint of abdominal pain and reported constipation for 2 weeks. The patient was discharged from Facility B's ED on 2/5/2023 at 6:55 AM with diagnoses including Agitation and Constipation. Patient #26 presented to Facility B's ED status post cardiac arrest on 2/5/2023 at 10:00 AM. The patient was admitted to Facility B's Intensive Care Unit on 2/5/2023 with diagnoses including but not limited to Cardiac Arrest, Acute and Chronic Respiratory Failure, Shock, Altered Mental Status, Metabolic Acidosis, Advanced Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Patient #26 expired on 2/6/2023 at 9:57 PM. The documented cause of death was out-of-hospital-cardiac arrest and cerebral herniation.

Based on review of facility policy, Emergency Medical Services (EMS) report review, medical record review, and interviews the facility failed to provide stabilizing treatment for 1 patient (Patient #26) who presented to the Emergency Department (ED) of 30 patients reviewed.

The findings include:

Review of Facility A's policy "Transfer Policy-Emergency medical Treatment and Active Labor Act (EMTALA)" last revised 7/21/2021 showed "...Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions...Serious dysfunction of any bodily organ or part...Stable for Discharge: A patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions...The hospital must provide the Medical Screening Examination and treatment to stabilize within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the ED for examination and treatment..."

Review of an EMS Patient Care Report showed EMS was dispatched to the airport for a female patient (Patient #26) with complaint of abdominal pain on 2/4/2023 at 7:05 PM. Upon arrival, the patient was sitting upright in a wheelchair and was alert and oriented to person, place, and time. The patient admitted to having 3 alcoholic drinks on the plane. She reported abdominal pain of 8/10 (10 being the worst possible pain), but could not describe the pain. The patient was assisted in standing and pivoting from the wheelchair to the stretcher. The patient's blood pressure was 97/59, pulse 120, and respirations were 16. Her Glasgow Coma Scale was 14 (level of consciousness with 15 being the best possible score). The patient was oriented to person, place, time, and event, but was confused and agitated.

Medical record review of a Nurse Triage Note showed Patient #26 presented to Facility A's ED by EMS on 2/4/2023 at 7:45 PM with complaint of lower abdominal pain. The patient had flown from a nursing home in Rhode Island where she had lived for 6 years. The patient reported a history of stroke with left sided weakness. Patient #26 was triaged with an Emergency Severity Index (5 level system to determine urgency of patient symptoms) score of 2 indicating emergent needs. The patient's blood pressure was 85/53, pulse 64, respirations 20, and oxygen saturation was 90% in room air. The patient's Glasgow Coma Scale was 15. The patient's pain level was documented as 5/10 and described as aching.

Medical record review of Facility A's ED Physician Documentation dated 2/4/2023 at 7:54 PM showed Patient #26 had a history of a stroke and presented to the ED for abdominal pain. The patient had flown to Tennessee from her nursing home in Rhode Island. During the flight, the patient experienced abdominal pain and urinated and had a bowel movement on herself. The patient also complained of left sided weakness and constipation. She was alert and oriented to time, place, and person. "...Patient refused to give urinalysis. She threw her feces [stool] loaded diaper at the nurse..." Patient #26 was dispositioned to discharge from Facility A on 2/4/2023 at 9:31 PM with diagnosis of Constipation.

Medical record review showed a Complete Blood Count and Comprehensive Metabolic Panel for Patient #26 on 2/4/2023 at 8:03 PM and showed:
*White Blood Count (test to indicate infection): 14.1 (reference range 4.5-11.0)
*Glucose (test for blood sugar): 119 (reference range 65-105)
* Lipase (breaks down fat): 10 (reference range 11-82)
*Ethanol (alcohol level): <10 (reference range <10)

There was no documentation the abnormal blood test results were addressed prior to discharge.

Medical record review showed additional blood tests were not performed to rule out other causes for Patient #26's confusion, agitation, and behaviors and to determine if further treatment was required.

Medical record review showed a CT (computed tomography-detailed x-ray) scan of the abdomen/pelvis without contrast was performed for Patient #26 on 2/4/2023 showed "...Left colonic [large intestine] diverticulosis [small bulging pouches]. Large volume colonic stool...IMPRESSION...Large volume colonic stool could be compatible with constipation; no evidence of obstruction...Coronary artery [supplies blood to the heart muscle] calcification [calcium build up in plaque found in the walls of the coronary arteries] is seen which is indicative of coronary artery disease..."

Medical record review showed further diagnostic studies were not performed to rule out other causes for Patient #26's abdominal pain, confusion, agitation, and behaviors and to determine if further treatment or consultations were required.

Medical record review showed Patient #26 was discharged from the facility on 2/4/2023 at 10:34 PM. The patient was instructed to take Colace (stool softener) 100 mg (1 capsule) by mouth 2 times per day as needed and to follow-up with her primary care physician within 2-3 days.

Medical record review showed no documentation to indicate Patient #26 received pain medication or intravenous (IV) fluids while in the ED.

Medical record review showed no documentation to indicate Patient #26 was re-evaluated by the physician before being discharged.

During an interview on 3/2/2023 at 11:10 AM, in the ED, RN #1 stated Patient #26 didn't want to be discharged and began yelling/cussing when she was told she was being discharged from Facility A's ED. Patient #26 said the ED had not helped her and she was upset that EMS had brought her to Facility A. RN #1 stated the patient was going to call 911 and have them take her to Facility B. RN #1 explained EMS wouldn't pick her up to take her to another hospital unless there was a need for a higher level of care.

During a telephone interview on 3/2/2023 at 1:23 PM, ED Tech #1 stated he assisted with getting Patient #26 in the front seat of the taxi after she was discharged from the ED. ED Tech #1 stated the patient was able to "...stand a little bit..." but required assistance.

During a telephone interview on 3/2/2023 at 2:12 PM, Physician #1 stated he explained the patient's diagnosis to her. He stated the patient never asked to delay or cancel her discharge from the ED. Physician #1 stated the patient didn't offer any other complaints of distress.

During an interview on 3/2/2023 at 2:55 PM, in the ED, RN #2 stated Patient #26 couldn't do much for herself due to a previous stroke and left sided weakness. She stated the patient was cleared for discharge. RN #2 stated Patient #26 wanted to be transferred to Facility B. RN #2 explained to the patient, there wasn't a medical reason to transfer her to another facility. RN #2 stated the patient became upset and very loud. RN #2 was concerned because the patient had no family to pick her up and she had no money.

Medical record review showed Patient #26 presented to Facility B's ED on 2/4/2023 at 11:57 PM with complaint of abdominal pain and reported constipation for 2 weeks. The patient was discharged from Facility B's ED on 2/5/2023 at 6:55 AM with diagnoses including Agitation and Constipation. Patient #26 presented to Facility B's ED status post cardiac arrest on 2/5/2023 at 10:00 AM. The patient was admitted to Facility B's Intensive Care Unit on 2/5/2023 with diagnoses including but not limited to Cardiac Arrest, Acute and Chronic Respiratory Failure, Shock, Altered Mental Status, Metabolic Acidosis, Advanced Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Patient #26 expired on 2/6/2023 at 9:57 PM. The documented cause of death was out-of-hospital-cardiac arrest and cerebral herniation.