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Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Medical record review revealed Patient #1, a 36 year old female, presented to the ED per private vehicle on 9/14/2024 at 5:38 AM with complaints of lower abdominal pain and flank (area in the side of the body below the rib and above the waist) pain. The Patient was on day 10 post tubal reversal surgery (a surgical procedure to reconnect fallopian tubes to allow a woman to become pregnant after having her tubes tied). The Patient was initially evaluated and examined by ED Provider #1 at 5:50 AM who documented Patient #1 presented with complaints of moderate pain in the right abdomen and flank areas with associated symptoms of "fever." The Provider ordered diagnostic studies which included a complete blood count (CBC; a group of blood test that measure the number and size of the different cells in the blood), comprehensive metabolic panel (CMP; a blood test that measures 14 substances in the blood to provide an overall picture of your body's chemical balance and metabolism), urine pregnancy test, urinalysis (UA), and computerized tomography (CT; a medical imaging procedure that uses x-rays to create detailed, cross-sectional pictures of the inside of the body) scan of the abdomen and pelvis with contrast medium (a substance used in medical imaging to enhance the visibility of organs, blood vessels and tissues in the body).

A nursing triage assessment was completed at 5:54 AM which revealed Patient #1 was "crying" and grimacing" and was complaining of pain and pressure in her lower abdomen and right flank. Patient #1 informed the triage nurse she thought she might have a urinary tract infection (UTI). Patient #1 was assigned an acuity of 3.

At 6:42 AM, ED Provider #1 documented, "...Patient care transitioned to [ED Provider #2]...Toradol [a non-narcotic, non-opioid medication used to treat moderate to severe pain] order 30 mg [milligrams] IV [intravenous] Push..."

A CT of the abdomen and pelvis was obtained at 6:43 AM with results posted at 7:00 AM revealing, "There is a low transverse [horizontal] incision at the anterior pelvic wall [the part of the pelvis that's next to the bladder] There is a small amount of gas and fluid present within the incision along the subcutaneous fat [fat that is stored just beneath the skin]. This could represent sequalae [a pathological condition resulting from a disease, injury, therapy, or other trauma] of recent drain removal. Correlation with history required. Infection cannot be excluded. There is a large underlying inferior rectus sheath hematoma [The rectus sheath is a fibrous compartment that surrounds the rectus abdominis and pyramidalis muscles in the abdomen. A rectus sheath hematoma is an accumulation of blood in the sheath of the rectus abdominis muscle. It causes abdominal pain with or without a mass] measuring up to 12.9 cm [centimeters] transverse by 3.9 cm AP [anterioposterior meaning front-to-back] dimension, extending 9.8 cm craniocaudal [length]. There is a small amount of sympathetic stranding [an indicator of inflammation] within the extraperitoneal [outside the peritoneal cavity] space of Retzius [The term Retzius describes the space in the peritoneal cavity in which the bladder can move by changes in volume] deep to this process and anterior to the bladder..."

Registered Nurse (RN) #2 administered 30 mg of Toradol IV at 7:30 AM. Patient #1 was still "Crying" and "Grimacing."

At 8:17 AM, RN #2 documented, "Patient states that there is no change in pain since Toradol was received."

At 8:52 AM, RN #2 documented Patient #1 was still "Crying" and "Grimacing" and reported her pain as "severe."

At 8:59 AM, ED Provider #2 documented, "...Patient's laboratory was remarkable for a white count of 12.4 [the acceptable range for white blood cells is a range of 4.8 - 11.0] with 74 segs [neutrophils, which are the most common type of white blood cells; high levels of segmented neutrophils indicate infection; neutrophil segs has a normal range of 50-70]. Patient has no signs of fever. Patient's CT scan showed a inferior rectus she has [sheath] hematoma. I called and discussed case with [Surgeon #1] who did her surgery. [Surgeon #1] felt that patient could be discharged. She plans on calling inpatient [in the patient] some antibiotics because there was a small amount of stranding seen on CT scan which could indicate beginnings of an infection. However, there was no signs of severe infection at this time. [Surgeon #1] plans on following up with the patient at convenient care tomorrow afternoon for re-examination and repeat of her CBC. Patient currently has Percocets [medication to treat moderately severe pain] at home for pain and did not request any further pain medication. Patient was given IV Toradol here and was offered Tylenol and even IV Morphine but refused...Impression and Plan...AP (abdominal pain)...Pelvic hematoma, female..."

There was no documentation ED Provider #2 informed Surgeon #1 there was a small amount of gas and fluid present in the incision along the subcutaneous fat visible on the CT scan.

At 9:13 AM, RN #2 documented Patient #1 reported moderate pain and was still "Crying" and "Grimacing."

Patient #1 was discharged from the ED at 9:32 AM with instructions to pick up and start her antibiotics that were called in (to the pharmacy) and to follow up with Surgeon #1 the following day (9/15/2024). RN #1 documented Patient #1 reported "Moderate pain" and was "Crying."

Interviews conducted with ED Provider #2 and Surgeon #1 revealed ED Provider #2 failed to inform Surgeon #1 the full CT scan results which included the presence of gas near the incision site in the subcutaneous tissue. This finding was discovered by Surgeon #1, after the Patient had been discharged home. Surgeon #1 contacted Patient #1 and instructed her to go to Hospital #2's ED where she would be seen by Surgeon #2 for further evaluation and treatment.

Patient #1 was hospitalized, had serial CMPs completed, treated with IV fluids, IV antibiotics, and pain medications. The Patient's admitting and discharge diagnoses included Rectus Sheath Hematoma and Abdominal Pain in female.

Although ED Provider #2 consulted Surgeon #1 prior to discharging the Patient, he failed to recognize and relay all clinically significant CT scan findings to the Surgeon and failed to conduct an appropriate and ongoing MSE. Therefore, Patient #1 had to be notified and sent to [Hospital #2] for further evaluation and treatment after she left Hospital #1's ED.

Cross Refer to A2406.

Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy titled, "EMTALA [Emergency Medical Treatment and Labor Act], Definitions and Terminology, 7265" approved 4/2024 revealed, "...EMTALA Definitions...Emergency Medical Condition...A medical condition manifesting itself by acute signs and symptoms of sufficient severity (including severe pain...) such that the absence of immediate medical attention could reasonably be expected to result in either: 1. placing the health of the individual...in serious jeopardy; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part..."EMTALA" means the Emergency Medical Treatment Labor Act...which requires hospitals to provide medical screening, treatment and transfer of individuals with Emergency Medical Conditions..."Medical Screening Examination" means an examination conducted by a QMP [Qualified Medical Person] of a sufficient nature to determine whether or not an Emergency Medical Condition exists...A Medical Screening Examination includes ancillary services routinely available to the ED, including tests, procedures, and the services of on-call physicians..."Stabilized" or "to stabilize" means resolution of the Emergency Medical condition such that the patient's condition is one where no material deterioration is likely, within reasonable medical probability, to occur during or result from the transfer/discharge of the patient... Stable for Discharge" means that after providing a Medical Screening Examination and stabilizing treatment, the Hospital may discharge a patient if the treating physician has determined, within reasonable clinical confidence, that the patient has reached the point where his her continued care (including diagnostic work up and treatment) could be reasonably performed as an outpatient or at a later time as an inpatient, provided that the patient is provided with an appropriate plan for follow-up care and discharge instructions..."

Review of the hospital policy titled, "EMTALA - Medical Screening Examinations, 7269" approved 6/2022 revealed, "...Any individual presenting to the ED or other Hospital property and requesting emergency care will receive a MSE within the capabilities of the Hospital's ED to determine whether or not an Emergency Medical Condition exists. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and the ED...For individuals who are determined to have an Emergency Medical Condition, the Hospital will provide, within its capabilities, the individual with such further medical examination and treatment as required to stabilize his/her Emergency Medical Condition unless the individual is transferred..."

2. Medical record review revealed Patient #1, a 36 year old female, presented to the ED per private vehicle on 9/14/2024 at 5:38 AM. The Patient was initially evaluated and examined by ED Provider #1 at 5:50 AM who documented Patient #1 presented with complaints of moderate pain in the right abdomen and flank (area in the side of the body below the rib and above the waist) areas with associated symptoms of "fever." The Provider further documented, "Patient had a tubal reversal surgery [a surgical procedure to reconnect fallopian tubes to allow a woman to become pregnant after having her tubes tied] less than 2 weeks ago [Patient #1 had the surgery on 9/4/2024], had some difficulty with and here recently she has right flank pain...Physical Examination...Gastrointestinal: Tenderness: Suprapubic [the area of the abdomen below the belly button and above the pubic bone], right flank, Rebound: Surgical Incision is Clean and Healed..."

A nursing triage assessment was completed at 5:54 AM which revealed Patient #1's chief complaint was "moderate... abdominal pain." The "Pain Assessment" revealed the Patient had cramping, pressure and sharp pain in her abdomen, lower back and right flank region with associated symptoms of "Crying, Grimacing..." At 5:59 AM, the nurse documented, "...Patient come to the ED via POV [private owned vehicle] with c/o [complaints of] abdominal pressure and back pain after she had surgery on Sept [September] the 4th to reanastimos [reanastomosis (reverse)] her tubes and she has been feeling lots of pressure and she thinks she may have a UTI [urinary tract infection]...Urinary Symptoms: Difficulty starting stream..."

The Patient's blood work was collected at 5:57 AM, and the urine specimen was collected at 6:08 AM. Patient #1's white blood cell (WBC) count was 12.4 with an acceptable range of 4.8 - 11.0, and neutrophilic segmented cells (segs) was 74 % with normal range of 50-70. (Neutrophils are a type of white blood cell that fights against infection.) The UA (urinalysis) showed moderate bilirubin with a normal range of negative, urine WBC was rare with a normal range of 0, and trace bacteria with a normal range of negative.

The Patient was reassessed for pain by Registered Nurse (RN) #2 at 6:42 AM who documented Patient #1 was having "severe" abdominal pain.

At 6:42 AM, ED Provider #1 documented, "...Condition: Stable...Disposition: Medically cleared, Patient care transitioned to [ED Provider #2]...Toradol [toradol is a non-narcotic, non-opioid medication used to treat acute, moderately severe pain that occurs after surgery] 30 mg [milligrams] IV [intravenous] Push..."

The CT of the abdomen and pelvis was obtained at 6:43 AM with results posted at 7:00 AM revealing "There is a low transverse [horizontal] incision at the anterior pelvic wall [the part of the pelvis that's next to the bladder] There is a small amount of gas and fluid present within the incision along the subcutaneous fat [fat that is stored just beneath the skin]. This could represent sequalae [a pathological condition resulting from a disease, injury, therapy, or other trauma] of recent drain removal. Correlation with history required. Infection cannot be excluded. There is a large underlying inferior rectus sheath hematoma [The rectus sheath is a fibrous compartment that surrounds the rectus abdominis and pyramidalis muscles in the abdomen. A rectus sheath hematoma is an accumulation of blood in the sheath of the rectus abdominis muscle. It causes abdominal pain with or without a mass] measuring up to 12.9 cm [centimeters] transverse by 3.9 cm AP [anterioposterior meaning front-to-back] dimension, extending 9.8 cm craniocaudal [length]. There is a small amount of sympathetic stranding [an indicator of inflammation] within the extraperitoneal [outside the peritoneal cavity] space of Retzius [The term Retzius describes the space in the peritoneal cavity in which the bladder can move by changes in volume] deep to this process and anterior to the bladder..."

Patient #1 was given 30 mg of Toradol IV push at 7:30 AM by RN #2 who documented the Patient was "Crying" and "Grimacing" with abdominal pain and pressure.

At 8:17 AM, RN #2 documented, "Patient states that there is no change in pain since Toradol was received."

At 8:52 AM, RN #2 documented Patient #1 had abdominal pain present and the Patient was "Crying" and "Grimacing". The Patient's pain intensity was documented as "severe pain."

At 8:59 AM, ED Provider #2 documented, "Patient evaluated for right flank and right abdomen pain...Patient's laboratory was remarkable for a white count of 12.4 with 74 segs. Patient has no signs of fever. Patient's CT scan showed a inferior rectus she has [sheath] hematoma. I called and discussed case with [Surgeon #1] who did her surgery. [Surgeon #1] felt that patient could be discharged. She plans on calling inpatient [in the patient] some antibiotics because there was a small amount of stranding seen on CT scan which could indicate beginnings of an infection...Impression and Plan...AP (abdominal pain)...Pelvic hematoma, female..."

There was no documentation to indicate ED Provider #2 informed Surgeon #1 there was a small amount of gas and fluid present in the incision along the subcutaneous fat visible on the CT scan.

At 9:13 AM, RN #2 documented Patient #1 was in "Moderate pain" and was still "Crying" and "Grimacing."

Patient #1 was discharged from the ED at Hospital #1 at 9:32 AM with instructions to pick up antibiotics at the pharmacy and start the antibiotics that were called in to the pharmacy and to follow up with Surgeon #1 the following day (9/15/2024). RN #1 documented Patient #1 reported "Moderate pain" and was "Crying."

After Patient #1 left Hospital #1's ED, the patient received a call from Surgeon #1 who instructed the patient to go to Hospital #2 to be evaluated and treated by Surgeon #2

3. Patient #1 presented to Hospital #2's ED via private vehicle on 9/14/2024 at 12:32 PM, just 3 hours after she was discharged from Hospital #1.

Review of the Pre-Arrival Summary called in by Surgeon #1 at 12:34 PM revealed Patient #1 would be arriving with a chief complaint of "abdominal wall hematoma" and should be evaluated and treated by the ED Provider. The Summary further revealed Surgeon #1 "anticipates admission - please call [Surgeon #2]..."

Patient #1 was admitted to an inpatient bed where she was treated with IV antibiotics including Ampicillin, Clindamycin, and Gentamycin as well pain medication of Toradol. The Patient's repeat White Blood Counts were 14. 6 at 12:46 PM, 9.1 at 8:43 PM, and 8.7 at 5:57 AM on 9/15/24.

4. During a telephone interview on 10/22/2024 at 8:20 AM, ED Provider #1 verified he initiated the MSE for Patient #1 and initially thought she had a "possible abscess," but the workup wasn't completed when he left and transferred her care to ED Provider #2. The Provider continued and stated what he would normally do is to "work her up [labs, diagnostics] and present the information to her OB [obstetrician (Surgeon)] and let them decide what to do." ED Provider #1 was asked if he felt Patient #1 should have been admitted to the hospital. The Provider stated, "I was in the middle of the workup. I guess I told her [Patient #1] there may have been an abscess there. I ordered labs and CT scans to look for infectious process...I wouldn't have told her she would be admitted because I didn't know what the surgeon or OB would say about the need for admission. This case was a surgical case. No one wants to go behind another surgeon..."

During an interview on 10/22/2024 at 8:40 PM, ED Provider #2 verified he received report from ED Provider #1 and assumed care of Patient #1. The Provider stated Patient #1 was very upset because he thought ED Provider #1 told Patient #1 she might have "some sort of infection and might need to be transferred." The Provider continued and stated, he reviewed everything, and the Patient's white blood cell count was "okay" and there were no signs of infection. ED Provider #2 stated, "I went in to talk to her [Patient #1] and she was crying. I offered to give her Morphine and Tylenol, but she refused. I did give her Toradol. I told her I didn't believe she had a major infection or needed to be transferred." ED Provider #2 continued and stated he spoke with Surgeon #2 and told her about the Patient, but she didn't know the Patient, so she was going to reach out to Surgeon #1 and get back with him. The ED Provider stated Patient #1 called Surgeon #1 herself, and he spoke to the Surgeon and told her his findings and that he didn't think she needed to be admitted. ED Provider #2 continued and stated, "She [Surgeon #1] agreed with my findings. She agreed to call in antibiotics and see the Patient the next day...We discharged the Patient." ED Provider #2 stated Surgeon #1 called him back after the patient had been discharged, and she had reviewed the CT results that showed a small amount of gas at the incision site, "I didn't tell her about the gas initially." The Provider continued and stated Surgeon #1 called Patient #1 herself and told her to see Surgeon #2 at [Hospital #2].

During a telephone interview on 10/22/2024 at 9:20 AM, RN #2 verified she was Patient #1's primary nurse on 9/14/2024. The RN stated Patient #1 was upset with ED Provider #2 because ED Provider #1 had told her something different. She was upset with the "decision made to discharge her." RN #2 verified Patient #1 had been offered pain medications, but she told ED Provider#2 she already had prescriptions at home.

During a telephone interview on 10/22/2024 at 1:03 PM, Surgeon #1 stated Patient #1 called her cell phone after she was unable to reach the on-call Surgeon. The Patient was very upset and confused. One doctor (ED Provider #1) "said 1 thing and the other doctor [ED Provider #2] said something else...I talked with [ED Provider #2] and the initial plan was for lab rechecks and to discharge her home on antibiotics." Surgeon #1 continued and stated ED Provider #2 "had CT results available and he described hematoma and early stranding." Surgeon #1 then stated after she reviewed the CT scan results, she discovered the CT scan showed "gas in the sub-q [subcutaneous] tissue which raised a red flag for possible necrotizing fasciitis, so we [Surgeon #1 and Surgeon #2] got her up here to [Hospital #2] to see [Surgeon #2]..." Surgeon #1 continued and stated, "I called and talked to [ED Provider #2] about what he didn't relay to me was gas in the sub-q. I told him it needs to be investigated." Surgeon #1 continued and stated, "I do know the night ED physician [ED Provider #1] told her she had a significant infection. There was a major communication gap between the 2 physicians, and not seeing the gas on the CT report. When [Surgeon #2] tried to view the CT scan and wasn't able to, she had the Radiologist at [Hospital #2] review it and didn't see anything alarming." Surgeon #1 was asked if Patient #1 should have transferred to Hospital #2 before being discharged. Surgeon #1 stated, "Based on the information I was given, I didn't think she should have been admitted. When I got the actual CT results, I felt she needed to be more thoroughly assessed. Gas visible in a post-operative patient needs to be transferred and evaluated. The hematoma was a distracting issue. "Surgeon #1 continued and stated, "some clinical failure in not recognizing the issue. [ED Provider #2] relayed some information to me and at the time, I didn't think she should be transferred at that time. Once I got the Radiologist's report, I realized she needed to be evaluated so I called [ED Provider #2] and the Patient."

Although ED Provider #2 consulted Surgeon #1 prior to discharging the Patient, he failed to recognize and relay all clinically significant CT scan findings to the Surgeon and failed to conduct an appropriate and ongoing MSE. Therefore, Patient #1 had to be notified and sent to [Hospital #2] for further evaluation and treatment after she left Hospital #1's ED.

During a telephone interview on 10/23/2024 at 12:06 PM, Patient #1 verified she was offered pain medications during her time at Hospital #1, but she wasn't there for pain medications; she was there to find out was causing her pain and difficulty urinating and get it treated.