HospitalInspections.org

Based on interview, record review and policy review the hospital failed to follow its policies and procedures when they did not provide stabilizing treatment within its capabilities and capacity for one patient (#17) out of 31 sampled cases from June 8, 2021 through December 8, 2021 that presented to the Emergency Department (ED) seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 1,179.

Review of the hospital's policy titled, "EMTALA Guidelines or Emergency Department Services," revised 07/2018 showed the hospital would not transfer or discharge a patient at risk to deteriorate from, during or after the transfer or discharge. A patient at reasonable risk to deteriorate due to the natural process of their medical condition was considered unstable.

Review of hospital document titled, "Daily Census," dated 10/05/21 showed the census for the Intensive Care Unit (ICU) was four (capacity of seven) and a census for the medical surgical unit of 15 (capacity of 27).

Review of Patient #17's ED medical record showed that he was a 75 year old male who presented to the ED, by ambulance, on 10/05/21 at 9:58 AM with symptoms of dehydration and incoherent speech. The family reported that the patient had had symptoms of COVID-19 (highly contagious, and sometimes fatal, virus) for a few days prior to the ED visit and had not drank for approximately four days. Staff H, ED Physician documented the family reported the patient had some slurring of his speech over the past two days and that the patient had weakness, fatigue and the new onset of speech difficulties. Staff H documented the patient and family confirmed he did not desire any resuscitative measures (a do not resuscitate order was not found within the medical record). The patient's initial vital signs at 10:00 AM showed an elevated blood pressure of 179/109 and heart rate of 112 beats per minute. A computed tomography scan (CT scan, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) showed a subacute infarction (stage of stroke onset of 24 hours to 5 days prior) with other chronic infarctions (stage of stroke onset of at least a week prior). Blood tests were completed with elevated cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) with elevated creatinine kinase (CK, enzyme that leaks out of damaged muscle), an elevated BUN and Creatinine level and urine test results indicative of dehydration. Staff H's physical exam showed the patient was oriented to person and place and that his speech was incoherent, not slurred. The NIH (National Institutes of Health) Stroke Scale score was eight which was categorized as a moderate stroke level. An Electrocardiogram (ECG or EKG, test that checks for problems with the electrical activity within the heart) showed possible atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected) and abnormal heart rhythm with an elevated heart rate of 117. The patient received 1,000 milliliters (ml, a measurement of liquid) of fluids intravenously (IV, in the vein).

Review of Patient #17's re-evaluation note by Staff H, ED Physician, dated 10/05/21 at 11:43 AM showed that the patient had received IV fluids and that all test results had been discussed with the patient and family member present. The family and the patient reported that they did not wish to pursue any further evaluation or treatment and wished to go home. The patient was discharged to home at 11:55 AM with a diagnosis of hypertension, COVID-19 and a subacute stroke. The patient's blood pressure on discharge was 155/108 with a heart rate of 105 at 11:55 AM.

Review of a second medical record dated 10/06/21 showed that patient # 17 returned to Hospital A at 11:45 AM (approximately 24 hours after the initial ED visit) as a direct admit, after his family called Staff K's, Internal Medicine Physician (patient's primary care physician) clinic and informed them that they were no longer able to care for the patient at home since his ED visit the previous day. The family reported that the patient was unable to talk or make sentences and was unable to take his oral medications. Physical examination on admission noted that the patient was unable to converse, had expressive aphasia (an impairment in the understanding or verbalizing idea by language, such as reading, writing, or speaking; due to injury or disorders of the brain) and seemed confused but if allowed repeated attempts, responded appropriately. At 6:15 PM, the hospital transferred the patient by ambulance to a hospital with neurological and neurosurgical capabilities (Hospital B).

Review of Patient #17's inpatient medical record from Hospital B dated 10/06/21 showed that he was a direct admit from Hospital A with a subacute stroke. The patient had been seen in the ED at Hospital A the previous day with worsening aphasia. He had also been diagnosed with COVID and was discharged home on hospice (no documentation was found in the medical record from Hospital A that showed the patient was on hospice). He was then transferred to Hospital B for further stroke evaluation and workup. Patient #17's vital signs on admission to Hospital B were blood pressure of 164/104 and pulse of 77. The patient was awake and alert but unable to answer questions due to aphasia and unable follow commands. Admitting diagnoses were acute stroke and acute aphasia.

Please refer to tag A-2407 for further details.

Based on interview and record review, the hospital failed to ensure an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) was stabilized when one patient (#17), out of 31 sampled cases from June 2021 through December 2021 was discharged with an unstable emergency medical condition. The hospital's average monthly Emergency Department (ED) census over the past six months was 1,179.

Findings Included:

Review of the hospital's undated document titled "Hospital A Administrative Structure Standards; Ethical/Legal Issues, Element XV, 4. Informed Consent," showed that the physician's duty included providing the patient with a full explanation of diagnostic and therapeutic interventions. Competence and voluntary decisions were required for valid patient consent or refusal. The document directed that when capacity to make decisions were considered, the patient's ability to communicate and demonstrate understanding of information presented and decisions made were accounted for. The physician documents all information made available to the patient, including risks, benefits, availability, and alternate methods of treatment and the patient's understanding in the medical record; and that the patient is participating in their decisions. The hospital's document directed that when patient's refused treatment; the physician should document the content of the discussion with the patient, that the patient was competent and that the patient refused. The hospital's document showed that when a patient cannot legally consent to treatment, the substitution of authority in order of preference was: legal guardian; spouse; a child (over 18 years old); and then next of kin by blood or marriage.

Review of hospital document titled, "Daily Census," dated 10/05/21 showed the census for the Intensive Care Unit (ICU) was four (capacity of seven) and a census for the medical surgical unit was 15 (capacity of 27).

Review of the hospital document titled "On Call Schedule" dated 10/05/21 showed that the hospital did not have neurology (neuro, relating to or affecting the nervous system) specialty on call for 10/05/21.

Review of ambulance report dated 10/05/21 at 9:18 AM showed that the patient was found in his home, sitting on the floor at the foot of his bed. The Emergency Medical Service (EMS) provider documented that the patient had episodes of incoherent, garbled speech and the patient was frustrated that he was unable to communicate his thoughts. The wife told EMS that the change in the patient's speech began approximately two days prior and he had not had anything to eat or drink for four days. The patient received 250 ml (ml, a measurement of liquid) of intravenous (IV, in the vein) fluids and was transported to Hospital A's ED.

Review of Patient #17's ED medical record for 10/05/21 showed that he was a 75-year-old man who presented to the ED at 9:58 AM by ambulance with dehydration and incoherent speech. The patient was accompanied by patient's daughter (later identified as the patient's daughter-in-law). Staff H, ED physician, Chief Medical Officer (CMO), documented that family reported the patient had symptoms of COVID-19 (highly contagious, and sometimes fatal, virus) over the past few days and had not eaten or drank for approximately four days. He also had some slurring with his speech over the same timeframe. The patient had a prior history of brain aneurysm (an excessive localized enlargement of an artery caused by a weakening of the artery wall), hypertension, hyperlipidemia, seizures and cardiac surgeries. The ED physician's physical examination documented the speech was incoherent but not slurred, tacky (dry texture) mucosal membranes, and tachycardia (increased heart rate, greater than 100 beats per minute). Staff I, Registered Nurse (RN) documented that the patient didn't follow commands, would not smile or frown, was confused, disorientated, speech was unintelligible, had severe aphasia, severe dysarthria, and patient had "word salad" and she was unable to understand what the patient was saying. The patient had a capillary refill (time taken for color to return to the skin or nail after pressure is applied) of greater than two seconds, thready pulses (a scarcely perceptible and commonly rapid pulse that feels like a fine thread) pulse and the mucous membranes were dry. Staff J, RN documented the respiratory rate as 20 breaths per minute and the oxygen saturation (oxygen saturation in the blood) on room air as 93%. The patient's vital signs (body temperature, blood pressure, heart rate, and breathing rate) at 10:00 AM showed an elevated blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) of 179/109 and an elevated pulse rate (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) of 112 bpm. The patient's COVID-19 test result was positive, without documentation of vaccine status. Laboratory blood tests included abnormal results of cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle). Other blood tests and urinalysis had abnormal results indicative of dehydration (elevated blood urea nitrogen, creatinine level, and concentrated urine with presence of ketones). The 10:38 AM computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues) results indicated a subacute infarction (stage of stroke onset of 24 hours to 5 days prior) involving the left posterior parietal temporal regions (prominent anatomical structures of the brain that are involved in language cognition, processing, and comprehension of both written and spoken language of the brain). The 10:29 AM electrocardiogram (EKG, test that checks for problems with the electrical activity within the heart) showed abnormal with possible atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected) and rhythm abnormalities, in addition to an elevated heart rate of 117 bpm. The patient received 1,000 ml of IV fluids.

A re-examination/re-evaluation note documented by Staff H, ED Physician, CMO, on 10/05/21 at 11:43 AM indicated that in discussion with the patient and his daughter (later determined to be daughter in-law) after the results of the CT, EKG, and labs were provided, the family did not want any hospital treatment at that point. Staff H documented the patient was DNR/DNI (do not resuscitate and do not intubate) and that the daughter stated there are several family members who will assist in his care. The documented impression/diagnosis showed COVID-19, subacute stroke, and dehydration. Documentation showed the patient and daughter in-law were provided with patient education materials regarding COVID-19, dehydration, and stroke. The patient's vital signs recorded at the time of discharge were elevated BP of 155/108, elevated pulse of 105, and respiratory rate of 16 and oxygen saturation of 93% on room air. Patient #17 was discharged to home at 11:55 AM.

The evidence in the medical record showed the 75 year old patient with multiple medical co-morbidities was discharged with an un-stabilized emergency medical condition and at significant risk for deterioration. The medical record did not include evidence of any changes made to the patient's medication regime, or any recommendations for future follow up appointments prior to discharge. There was no swallow evaluation done to ensure the patient had the ability to swallow without choking, there was no testing to evaluate for any reversible or treatable causes for the patient's stroke, no management of the patient's elevated blood pressure, no chest x-ray was performed or a trial of ambulation to ensure he could walk without his oxygen saturation levels dropping. There was no evidence in the medical record the patient and his family understood the severity of his emergency medical condition. There was no evidence in the medical record about the patient's capacity for decision making or whether he or his family had appropriate insight into what the decision for discharge would mean. There was no documentation of the medical risks of discharge prior to treatment to stabilize the emergency medical condition and no evidence the patient signed an informed refusal (refusal to consent to treatment to stabilize his emergency medical condition).

The demographic information included with Patient #17's ED medical record on 10/05/21 showed the patient's wife was his Emergency Contact and the Next of Kin was the patient's daughter. The consent for treatment dated 10/5/21 at 10:00 AM was signed by the patient's daughter-in-law with relationship to patient identified as "Patient". A statement in the medical record dated 10/5/21 at 11:41 AM that the patient received and understood his diagnosis, instructions, medication and what to do regarding follow-up was marked as "verbal consent" in place of the patient's signature and a nurse signature below.

During an interview on 12/09/21 at 9:15 AM, Staff H, ED Physician, CMO, stated that he recalled Patient #17 and events from his visit in the ED on 10/05/21. He stated he remembered the hand-off report from the paramedic who indicated that it appeared that the family at the home was reluctant to have the patient brought to the hospital. Staff H stated that another reason he recalled Patient #17 was because discussion of discharge to home in a patient with a stroke was an unusual situation. Staff H stated that this discussion occurred with the patient and the patient's daughter. Staff H stated that the hospital did not have a neurologist on staff. He stated that there was nothing more in the way of emergent treatment to be offered to the patient and that he discussed with the daughter and Patient #17 options of arranging for the patient to be admitted to the hospital, evaluated at a stroke center or transferred to a hospital with a neurologist on staff. The daughter and the patient wished to go home. Staff H stated that the patient presented on 10/05/21 with weakness and garbled speech. He stated that the patient was able to speak and did not feel that the patient had aphasia (an impairment in the understanding or verbalizing ideas by language, such as reading, writing, or speaking; due to injury or disorders of the brain). Staff H stated that the patient's speech was not always understood or the response did not make "sense" with the context of the question. Staff H stated that he believed that the patient understood the discussions presented to him and that the patient was competent and able to make his own decisions. He stated the patient was able to respond to questions with gestures and nods. He stated that he did not recall Patient #17's hospice or home health status. Staff H stated that he does not rely solely on a previously documented entries in the medical record when DNR decisions were discussed. He stated that he attempted to confirm that a patient's and family choices were clarified before DNR orders were placed.

During an interview on 12/09/21 at 12:45 PM, Staff K, Internal Medicine Physician, stated that he recalled the events of Patient #17's admission to the hospital on 10/06/21. He stated that the patient's daughter-in-law called his clinic office and reported that after the patient's discharge from the ED the previous day, the family discovered that they were not able to provide the level of care he needed. He stated that the family wished to have him admitted and re-evaluated. Staff K stated that the patient and his wife had been longstanding patients in his practice, although he had not seen Patient #17 in his clinic for more than a year. He stated that he had no knowledge of Patient #17 being placed on hospice at any time and knew of no medical condition prior to this event which necessitated hospice. Staff K stated that he admitted the patient to the hospital as a direct admit. He stated that he understood that during the ED visit the patient and his family had expressed DNR/DNI decisions and wanted to go home. After the patient's admission on 10/06/21, Staff K discussed the options of further treatment with the family and the family decided they wished to pursue more aggressive care. He stated that Patient #17 was then transferred to Hospital B for further neurologic work-up and evaluation.

During an interview on 1/10/22 at 11:35 AM Patient #17's daughter-in-law stated that she was present with the patient during his ED visit on 10/05/21. She stated that the patient was experiencing some difficulty with his speech but that he was competent and articulated his wishes effectively. The patient was upset that the family had him transported to the ED and insisted on "going home". The patient's wife was also ill with COVID-19 and was unable to assist with plans or decisions for the patient. The daughter-in-law stated that the ED physician did discuss options of admission to the hospital for further hydration with IV fluids and discharge home if the family could insure that the patient received adequate oral hydration. She reported that transfer to another facility was not offered as another option, but she thought that the patient would not have agreed to transfer. The daughter-in-law stated that she believed the patient was stable when discharged from the ED on 10/05/21 and that he deteriorated again during the night after discharge and they pursued further treatment the next morning.

During an interview on 1/10/22 at 2:08 PM the patient's wife stated that she asked the daughter-in-law to assist Patient #17 with decisions during his ED visit on 10/05/21 and all subsequent hospital visits. She stated that the patient was "good" when he came home from the ED on 10/05/21. Patient #17's wife stated that she believed that his kidneys were not functioning well after his stroke, he worsened overnight and had to return to the hospital the next day.

Review of a second medical record dated 10/06/21 showed that the patient was directly admitted to the ICU at 11:45 AM, approximately 24 hours after discharge from Hospital A's ED, and then transferred to Hospital B at the request of the family on the same day at 6:15 PM. Staff K, Internal Medicine Physician (admitting physician and the patient's primary medicine provider) documented in the history and physical that the patient had been evaluated in the ED on 10/05/21; diagnosed with hypertension, COVID-19 and a subacute stroke; and discharged home. Staff K documented that the patient's family notified his office on the morning of 10/06/21 and stated that they were not able to care for the patient and needed help. The family reported that the patient was unable to talk or make sentences and could not take his oral medications. Staff K documented that Patient #17 would be a direct admit and that he was a DNR/DNI. Staff K documented that he planned to discuss with the family how aggressive they wished to treat the patient and options regarding transfer to a facility with neurology specialty capabilities. Physical examination noted that the patient was unable to converse; had expressive aphasia and seemed confused. Nursing assessment indicated a need for feeding precautions as the patient had swallowing difficulties and neurologic concerns which included cognitive deficit, memory problems and a language barrier due to his inability to verbalize. The family reported that the patient was unable to talk or make sentences and could not take his oral medications.

Review of Patient #17's inpatient medical record from Hospital B dated 10/06/21 showed that he was a direct admit with a subacute stroke. The patient had been seen in the ED at Hospital A the previous day with worsening aphasia. He had also been diagnosed with COVID-19 and was discharged home on hospice (no documentation was found in the medical record from Hospital A that showed the patient was on hospice), and today he returned to Hospital A where he was then transferred to Hospital B (capabilities included neurology and neurosurgery) for further stroke evaluation and workup.