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Based on Emergency Department (ED) medical record review, staff interviews, and policy review, the facility failed to ensure that an appropriate medical screening examination was performed which included laboratory services routinely available in the Emergency Department (ED) to include an evaluation of the patient's blood glucose level on a patient that presented to the ED with a known history of insulin dependent diabetes for one (1) of 22 patients reviewed (Patients #1). Refer to findings in Tag A2406.

Based on Emergency Department (ED) medical record review, staff interviews, and policy review, the facility failed to ensure that an appropriate medical screening examination was performed which included laboratory services routinely available in the Emergency Department (ED) to include an evaluation of the patient's blood glucose level on a patient that presented to the ED with a known history of insulin dependent diabetes for one (1) of 22 patients reviewed (Patients #1).

Findings include:

1. Patient #1's ED record review revealed the following information:
Patient #1 arrived at the ED on 6/01/2010 at 10:52 p.m. complaining of a sudden, dull, persistent, acute, frontal headache, with nausea and vomiting. "Worst headache of life" was checked on the form. On a scale of one (1) to 10 the patient's pain was assessed to be "5". His/her blood pressure was 158/87 millimeters/mercury (mm/Hg), pulse was 99 beats/minute, and respirations were 20 per minute. The patient's past medical history included diabetes. A list of home medications included Novolog Insulin 50 units subcutaneous daily. A CT (X-ray computed tomography) of the patient's head was ordered. The report revealed "No acute intracranial hemorrhage, mass, mass effect, or acute major vascular territory infarct is identified. The patient was given Demerol 75 milligrams (mg) and Phenergan 25 mg intramuscular (IM) at 12:10 a.m. The clinical impression was "Headache, acute... Diabetes." There was no documented evidence that the triage nurse or the physician obtained a history of the patient's compliance with taking prescribed diabetic medication, and/or the frequency of checking his/her blood glucose (A blood glucose test measures the amount of a type of sugar, called glucose in your blood) levels. No laboratory blood work was ordered to evaluate patient #1's blood glucose levels. There was no documented evidence in the medical record to indicate that blood work was refused by Patient #1 .The patient was discharged home with discharge instructions for headache on 6/02/2010 at 12:50 a.m.

Patient #1 returned to the ED within 19 ? hours on 6/3/2010 at 7:38 p.m. The patient's complaint was abdominal pain, nausea, and vomiting for 3-4 days. The patient's blood pressure was 65/36 mm/Hg (normal B/P 120/80-110/70), pulse was 115 beats/minute(60-100), and respiratory rate was 48/minute (16-20). The patient was disoriented to person, place, and time. He/she was lethargic, unable to stand without assistance, and speech was slurred. An Accu-check (fingerstick blood glucose) of the patient's blood glucose revealed that it was 2009 milligrams/deciliter (mg/dL) (critically high). Intravenous (IV) fluids were started. Phenergan 12.5 mg IV was administered at 8:34 p.m. Humulin Regular 10 units was administered IV at 8:38 p.m. The clinical impression was: Diabetes; Dehydration. The patient was transferred to the Critical Care Unit for inpatient admission.

Admission history and physical review revealed:
"The patient is a 39-year-old (------ ------) with a history of insulin requiring diabetes, who presented to the emergency department complaining of a 3-4 day history of abdominal pain, nausea and vomiting. He was seen in the emergency department on June 1 for the same, but no lab was obtained at that time. He presented to the ED earlier this evening and was noted to be hypotensive (low blood pressure) and tachycardic (rapid heart beat). Dr. ------ evaluated the patient in the ER (emergency room) and found the patient to have severe diabetic ketoacidosis. I was contacted on behalf of the hospitalist service to admit the patient for further evaluation and treatment. I have seen and evaluated the patient upon his arrival to the critical care unit. The patient is somewhat confused, although he does answer simple questions. He is oriented to person and place. He reports to me that he has been out of his insulin for approximately two (2) weeks but cannot tell me the exact reason for this. The remainder of the history is difficult to obtain due to the patient's current mental status. The remainder of his history is obtained from records and from the ER physician." "The patient does complain of significant diffuse abdominal pain. He complains of excessive thirst." The admission diagnoses were: 1) Diabetic Ketoacidosis.(Diabetic ketoacidosis, also known as DKA, is a serious complication of diabetes, which occurs when a very high blood sugar level (above 300 mg/dL) is coupled with a severe shortage of insulin in the body.); 2) Acute Kidney injury; 3) Hyponatremia (Level of Sodium in your body abnormally low; 4) Hyperkalemia (level of Potassium in your body abnormally low); 5) Abdominal Pain.

Review of the patient #1's laboratory reports revealed the following information. On 6/3/10 at 10:32 p.m. the glucose was 2270 mg/dL; at 11:47 p.m., the glucose was 1630 mg/dL. On 6/4/10 at 4:46 a.m. the glucose was 884 mg/dL; at 6:58 a.m. the glucose was 638 mg/dL; at 9:48 a.m. it was 326 mg/dL; at 11:52 a.m. the glucose was 260 mg/dL, at 3:35 p.m. it was 161 mg/dL. The patient's consultation report on 6/05/2010 revealed the following information. "Reason for consultation: Acute renal failure, hyperkalemia, and metabolic acidosis (occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body) in a setting of multi-organ failure (is altered organ function in an acutely ill patient requiring medical intervention to achieve homeostasis (balance)." He presented to the emergency department with a 3-4 day history of abdominal pain, nausea, and vomiting. He was noted to have severe diabetic ketoacidosis on his initial evaluation. This included having a blood sugar of 2,270." "Aggressive volume resuscitation and control of his blood sugars was begun." He also was noted on admission to a lipase of 20,769 consistent with severe pancreatitis. Soon after volume resuscitation was begun, he had clonic seizures and then developed a full cardiopulmonary arrest. ACLS (advanced cardiac life support) protocol was initiated. He was intubated. After a prolonged code of approximately 30 minutes, he had a pulse and a blood pressure. At that point, his sodium had corrected. His potassium had corrected. His blood glucose had responded appropriately to his IV fluids and insulin. A CT (X-ray computed tomography) of the head at that point was basically unremarkable. He was given some Decadron for the potential of having some cerebral swelling correction of his marked hyperosmolar state. Through the next day, which was 06/04/10, he continued to have a very rocky course with blood pressures often in the 50's and 60's systolic. He was on maximum dose Levophed and Vasopressin (medications used to treat critically low blood pressures), ventilatory support. He started running temperatures in the 105 and 106 degree (normal temperature 97.5-98.6) Fahrenheit range. Through all of this, he is completely unresponsive. He has received no sedation." "Consult was asked for consideration of renal replacement therapy in this gravely ill with what appears to be a severe neurological injury as well as other multi-organ failure patient. Again, he is currently unresponsive. His pupils are fixed and dilated. There is no gag reflex. He is breathing with the ventilator."

Patient #1's The certificate of death contained the following information: The patient was pronounced dead on June 5, 2010 at 1:42 p.m. The immediate cause of death was Multi-organ Failure. Sequentially listed conditions leading to the cause of death were: Diabetes Ketoacidosis; and Pancreatitis.

Physician #1 provided the following signed statement on 12/11/2010. " ----------- (patient), 39 y/o (year old) male seen in ED 6/1/10 c (with) HA (headache) & N/V (nausea/vomiting). I interviewed pt (patient) and ------- (spouse), who indicated that he was a diabetic, but did not feel his diabetes was causing any difficulties at this time. Pt was asked & declined any lab, but his --- (spouse) & myself felt that CT of the brain was warranted for severe HA c(with) associated N/V."

An interview conducted with Registered Nurse (RN) #1 on 12/11/2010 from 12:55 p.m. to 1:03 p.m. revealed the following information. She was asked if she remembered the patient. She stated, "To be honest with you I can't." She reviewed the patient's medical record. She again reported that she could not remember the patient.

The facility's Triage policy and procedure reference #147, with last review/revision date 08/09, page one (1) contained the following requirements. "Patients presenting to the Emergency Department are triaged as soon as possible after arrival. The goal of triage is the identification of patients needing immediate care."

The facility's Admission, Emergency Services Department policy and procedure reference #122, last review date of 08/09, pages one (1) and two (2) contained the following requirements. "Appropriate medical treatment as determined by the physician shall be rendered to all persons requesting care in the Emergency Services Unit without discrimination." "A nursing assessment shall be performed within 30 minutes of bed placement on each patient presenting for evaluation/treatment in the Emergency Service Unit prior to or in conjunction with examination. Assessment shall include: vital signs, physical assessment, and review of system, brief history, and evaluation of chief complaint."