HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview the hospital failed to provide stabilizing treatment for a sampled 48-hour return Dedicated Emergency Department (DED) patient (Patient #5).

The findings include:

The hospital failed to provide stabilizing treatment for a sampled 48-hour return DED patient (Patient #5).

~cross refer to Stabilizing Treatment, Tag A2407.

Based on policy and procedure review, closed medical record review, and provider interview the hospital's dedicated emergency department (DED) failed to provide stabilizing treatment for one of two, 48-hour return DED patients (Patient #5).

The findings included:

Review of the policy and procedure titled "EMTALA" Effective 11/10/2021 revealed "Policy Statement: ...A Medical Screening Examination ('MSE'), within the Capabilities of the hospital; If the patient determined to have an Emergency Medical Condition ('EMC'), Stabilizing treatment within the Capabilities and Capacity of the hospital ....b. Stabilize: If an Emergency Medical Condition is identified: i. Provide treatment necessary to Stabilize the individual's EMC or admit the individual as an inpatient for further care ..."

Review of the medical record revealed Patient #5 was a 28-year-old female who presented to the emergency department (ED) on 07/07/2022 at 1846 due to low back pain. Review revealed Patient #5's triage started at 1855 and MSE by PA (physician assistant) #4 at 1859. Review of the ED triage note on 07/07/2022 at 1855 revealed "Multiple Medical complaints (Pt c/o L. Sided low back pain, L. Flank pain that radiates to her abd (abdomen) X (times) 1 month that is progressively getting worse. Pt states she feels very weak, fatigued, nauseous, and has shortness of breath on exertion since having covid 2 weeks ago.)" Patient #5's vital signs at 1856 were as follows: BP (blood pressure)-197/93, HR (heart rate)-87, Resp (respirations)-18, Sp02 (oxygen saturation)- 100% room air, and T (temperature)-98.1. Review revealed orders for a Pregnancy test, Urinalysis, CBC (complete blood count), CMP (comprehensive metabolic panel), Lipase, Chest x-ray, and Zofran 4mg (milligrams) were placed at 1856 and Magnesium and 12-lead ECG (electrocardiogram) at 1858 by the PIT (provider in triage) provider. Review revealed Patient #5's urinalysis resulted at 2018 and the following abnormal results were noted: Urine Clarity: HAZY [Ref Range: Clear], Urine Albumin: 3+ [Ref Range: Negative], Urine Hemoglobin: SMALL [Ref Range: Negative], Urine Bacteria: 1+ /HPF [Ref Range: Trace] Urine RBC: 3-20 /HPF [Ref Range: <3] Urine WBC: 5-10 /HPF [Ref Range: <5]. Patient #5 received intravenous Zofran 4mg at 2028. Review revealed Patient #5's CMP resulted at 2053 and the following abnormal results were noted: Chloride: 114 mmol/L [Ref Range: 99 -108], CO2: 20 mmol/L [Ref Range: 21 - 31], BUN: 29 mg/dL [Ref Range:7 - 25], and Creatinine: 2.48 mg/dL [Ref Range: 0.51 - 1.00]. Patient #5's vital signs at 2109 were as follows: BP-217/114, HR-83, Resp-16, Sp02-99%, pain 7/10. At 2131 a CT abdomen pelvis colic without IV contrast was ordered. Patient #5 was administered Toradol 15mg at 2133, Morphine 4mg and Magnesium 2g (gram) at 2235. At 2236 a normal saline 1000ml (milliliter) bolus was administered. Review of PA #4's provider note dated 07/07/2022 at 1846 revealed "Medical Decision Making (Patient #5) is a 28 y.o. female complaining of back pain. States is sharp in nature. She states has been going on for about a month. She feels generally weak and tired and nauseous she has shortness of breath at times. She had COVID 2 weeks ago. However, her vital signs appear normal outside of mild blood pressure elevation. I do not suspect PE (pulmonary embolism). She is not tachycardic she is nontoxic. Will check labs. Her pain is all in the lower back and wraps around to her abdomen so could be kidney stone. So we will get a CT scan to evaluate for kidney stone. Do not suspect abdominal aneurysm or aortic dissection Patient has no saddle anesthesia, bowel or bladder dysfunction, IV drug use. No reason to suspect cauda equina or cord compression. Her kidney function is at baseline. She has a history of lupus. I did replace the magnesium ..." Review failed to reveal a blood pressure upon discharge. Patient #5 was discharged on 07/08/2022 at 0101.

Review of care everywhere note between Patient #5 and her primary rheumatologist revealed Patient #5 sent her rheumatologist a message on 07/08/2022 at 0952 reporting complaints of "face swelling, difficulty breathing, chills, cold sweating, extreme fatigue, high blood pressure which she has gone to the ER (emergency room) for it ..." Review of Patient #5's Rheumatologist response at 1021 revealed "Talked with the patient over the phone, reviewed her recent ER visit labs ...She is noted to have worsening kidney function, and worsening albumin. Recommend her to go back to the ER to further investigate the case of her worsening kidney function."

Review revealed Patient #5 returned to the DED on 07/08/2022 at 1055. Review revealed Patient #5's chief complaint at 1103 was "Patient comes in from home. Was seen yesterday in ER for back pain and sent home. Reports called rheumatologist and states he seen her labs and were abnormal to come back to ER for eval." Patient #5's vitals at 1103 were BP-208/117, Resp-18, Sp02-100%, HR-114, and T-97.9. Review of the DED provider note dated 07/08/2022 at 1055 revealed "Medical Decision Making & ED course Patient presents back to the emergency department with concerns of worsening generalized fatigue nausea with the development of shortness of breath and peripheral edema. Due to symptoms will obtain chest x-ray to evaluate for focal infiltrate or possible pulmonary congestion. Will obtain baseline blood work to evaluate for electrolyte metabolic abnormalities requiring emergent inventions chest x-ray EKG cardiac markers. Symptoms not consistent with PE requiring CT of the chest at this time and is anticoagulated. Patient is tachycardic and hypertensive at this time. Denies headache or focal neurologic symptoms 12:54 PM PROGRESS NOTE: Patient's hemoglobin of 7.8 is stable from most recent comparisons. Patient with AKI of 2.63. BNP of 582. Uncertain how much of this is from her AKI versus fluid overload. Chest x-ray reveals questionable infiltrate versus vascular congestion. No overt evidence of heart failure. Urinalysis reveals questionable UTI. Noncon (non-contrast) CT renal protocol yesterday reveals perinephric stranding. Will empirically be placed on course of antibiotics. No leukocytosis. Patient is tachycardic however afebrile. She is hypertensive not hypotensive. I do not suspect sepsis. Worsening albumin of 1.7. Suspect that her chronic kidney disease and her hypoalbuminemia is driving her peripheral edema. Due to patient's symptoms we will discuss the case with hospitalist for recommendations. 1:01 PM PROGRESS NOTE: I discussed the case with the hospitalist. Agreeable to seeing (sic) evaluate patient for current medical condition ... History of Present Illness (Patient #5) is a 28 y.o. female with a past medical history of chronic kidney disease, recent COVID-19 infection, fibroids, lupus, renal vein thrombosis, anemia presents emergency department with multiple concerns. Seen yesterday due to flank pain. States overall she has had fatigue for the past month with some nausea over the past few days. Yesterday she started to notice some swelling to her face arms and legs with the development of some shortness of breath. She also appreciates some chest tightness with physical activity but not at rest. It is not pleuritic in nature. Her abdomen feels bloated but has no pain. Due to symptoms discussed the case with her rheumatologist and was advised to come back to the emergency department for symptoms ..." Patient #5 was admitted on 07/08/2022 at 1943.

Review of Patient #5's H&P (history and physical) dated 07/08/2022 at 1337 revealed "Assessment/Plan: 28 y.o. female with a history of lupus, chronic kidney disease, renal vein thrombosis, anemia, PE (6/24/2020) COVID (03//21, 06/8/22), anxiety, depression, HTN (hypertension), presents with 3 weeks of intermittent back and abdominal pain, edema, fatigue, and SOB, concerning for a lupus flare. Abdominal Pain, Fatigue, SOB, Edema Presented with one month of intermittent L flank pain radiating to LLQ of abdomen. UA with 3+ albumin, mod Hb, elevated RBCs and WBCs, and 1+ bacteria. Differential at this time also includes Lupus nephritis and pyelonephritis. Worsening edema, frothy urine, fatigue, and elevated blood pressure raises concern for worsening lupus nephritis. Will consult Nephrology given high suspicion for lupus flare as cause of presentation ..." Review revealed Patient #5 was discharged from the hospital on 07/14/2022.

Review of Patient #5's baseline Creatinine dated 04/13/2022 at 0817 was 1.09 and on 05/15/2022 at 1347 was 1.12.

Interview on 07/28/2022 at 1435 with PA #4 revealed he was Patient #5's primary provider during her first DED visit on 07/07/2022. PA #4 stated he vaguely recalled Patient #5. Interview revealed he learned the next day Patient #5 had returned to the DED the following morning and was admitted. PA #4 stated he realized he made a "human error" and discharged her when he should have "admitted her since her creatinine was elevated over 1 point" from a few weeks ago. PA #4 stated he was not exactly sure what happened, but he believes he must have looked at another patient's chart which had an elevated creatinine because he recalled having seen a patient with a creatinine above 2. He stated he recalled thinking if Patient #5's was above 2, then it was near her baseline, and she could be discharged. Interview revealed, Patient #5 was not stable for discharge and should have been admitted.