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Based on review of medical records, ambulance report, hospital policy and procedure and interview the hospital failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department for an individual related to presenting signs and symptoms for 1 (#12) of 30 sampled patients with complaint of abdominal pain, patient complaint of blood in stools, and low oxygen saturation rates prior to arrival to the emergency department.

~ Cross refer to §489.24(a) Medical Screening Examination - Tag A2406.

Based on review of medical records, ambulance report, hospital policy and procedure and interview the hospital failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department for an individual related to presenting signs and symptoms for 1 (#12) of 30 sampled patients with complaint of abdominal pain, patient complaint of blood in stools, and low oxygen saturation rates prior to arrival to the emergency department.



Findings:



The Ambulance Service report for Patient #12 dated 4/1/2016 was reviewed. Review of this report revealed in the section of the report titled, "Clinical Information "revealed in part, "Primary Impression: Abdominal Pain; ...duration 2..days ...Secondary complaint : Blood in stools duration 2 ...Days." The patient's Vital signs were listed as follows: At 10:32 PM: Heart rate 123 (normal heart rare 60-100); SP02 85; (SP02 refers to oxygen saturation- normal ranges healthy individual is 95% to 100%): Blood glucose level 177 (hospital reference range 70-110 mg/dl); Temp (temperature) 98.9 RR (Respiratory rate)-20; At 10:42 PM: Heart Rate : 117; SP02: 83%; B/P (blood Pressure) 152/87; At 10:58 PM: B/P (blood Pressure): 148/96; RR: 20; SP02: 100%. Further review revealed the following treatments were provided for patient #12 in the ambulance, "3 lead EKG (electrocardiogram) Comments: 4 LEAD; Patient Response. Unchanged ... Oxygen; NC (Nasal Cannula): Flow rate: 4 lpm (liters per minute); Pt response: Improved. Continued review in the "Narrative" section specified in part, " ...EMS DISPATCHED TO ...UNIVERSITY ...IN REF (reference) TO PT (patient) FEELING SICK AND DIZZY ...EMS (emergency medical services) WAS ESCORTED UP THE ELEVATOR ...Where PT WAS LOCATED. PT SITTING IN HIS ROOM IN A CHAIR.C/O (COMPLAIN/OF) LOWER ABD (ABDOMINAL) PAIN, NAUSEA, BODY ACHES, AND BLOOD IN HIS STOOL. PT. ADVISED HE VOMITED YESTERDAY AND WENT TO THE ER (emergency room) WHERE HE WAS TESTED FOR FLU. PT ADVISED FLU TEST WAS NEGATIVE. HE ALSO ADVISED THAT HE HAD AN ABD SCAN DONE BUT HE DIDN'T GET THE RESULTS. VITALS ASSSESSED.PT ADVISED HE COULD WALK AND WAS ESCORTED TO UNIT ...PT SAT ON ...CHAIR .BP OBTAINED. PT THEN ASKED TO SIT ON STRETCHER .PT PLACED ON 4 L OF O2 NC. PT'S O2'S (oxygen) READING LOW,BUT PATIENT DENIES SOB (shortness of breath) AND IN NO RESP (respiratory) DISTRESS. PT PLACED ON 4 LEAD. EN ROUTE TO VRCH (Vidant Roanoke Chowan Hospital). ED LOOKED FOR IV (INTRAVENOUS) SITE. NONE FOUND. VITALS REASSESSED ...AT VRCH-EDPT TAKEN TO TREATMENT ROOM ...SIGNATURES OBTAINED AND PT LEFT IN THE CARE OF NURSE."




Closed medical record review for Patient #12 revealed a 18 year old male that presented by ambulance to Hospital A's DED on 04/01/2016 at 2322, with a complaint of Abdominal Pain, Diarrhea, Nausea, and Dizziness. Review revealed the ED nurse documented at 2324, "Pre-Hospital Rpt (report), "Pre-Hospital transports-Pre-Hospital interventions: 02 Vital Signs and pain prior to arrival-BP 152/88mm/Hg; pulse: 123 ...Prehospital FBBS (fingerstick blood sugar): (177). Vital signs on 04/01/2016 at 2327 were as follows: Blood Pressure (BP) 128/75 mmHg (millimeters of Mercury) (normal); Pulse (P) 111 BPM (Beats per Minute) (elevated); Respirations (R) 20 RPM (Respirations per Minute) (normal); Temperature (T) 97.4° (degrees) F (Fahrenheit) (normal); and Pulse Oximetry (SpO2) 98 % (percent) the section for the oxygen mode was left blank. There was no documentation if the patient was on oxygen per nasal cannula or room air. At 1:45 AM the patient's vital signs were documented as Blood Pressure: 145/84; Temperature: 98.2; Heart rate: 101; Respirations: 20 and SP02 was 100% on Room Air. The patient's pain scale (Zero (0) indicating no pain- 10 worst pain imaginable) was 5. The pain was located in the mid abdominal pains which were characterized as intermittent and sharp pains. The patient's triage by the ED nurse at 11:28 PM was listed at an "acuity 3." Morphine (pain medication) 4 mg/ml was administered at 11:45. Patient #12's pain was reassessed at 0031 and the pain level was documented as 3.
Review revealed Medical Doctor (MD) #1 initiated a MSE on 04/01/2016 at 2332. Review of an ED Physician Note, written by MD #1 on 04/01/2016 at 2343, revealed, "... HPI (History of Present Illness): 18-year-old African-American male presents by EMS (Emergency Medical Services) to the emergency department complaining of abdominal pain with vomiting and diarrhea. The patient states that he's had diarrhea for the last 2 weeks. He'll have severe episodes per day. The last 2 days he's been having generalized abdominal pain with nausea. He had 3 episodes of emesis yesterday but none today. He also feels very weak and dizzy. He admits he has been having some chills but has not checked his temperature to see if he had a fever. He denies any urinary symptoms such as dysuria or frequency. He was seen at a clinic in Murfreesboro (a local town) yesterday with a check and for the flu and that was negative. They sent him to the hospital today to have an abdominal x-ray series which was negative for any acute process. REVIEW OF SYSTEMS: Constitutional: no fever. Respiratory: no cough, no shortness of breath. Cardiovascular: no chest pain. GI (Gastrointestinal): no nausea, no vomiting, no diarrhea. Extremities: no myalgias (muscle pain). Neurologic: no weakness, no numbness. PAST MEDICAL HISTORY: No past medical history on file. FAMILY HISTORY: No family history on file. SOCIAL HISTORY: ... Smoking status: Never Smoker. Smokeless tobacco: Not on file. Alcohol Use: No. SURGICAL HISTORY: No past surgical history on file ... Current Outpatient Prescriptions ... Zofran (a medication used to treat nausea) ... MOTRIN (a medication used to treat pain and/or fever) ... Allergies: Review of patient's allergies indicates no known allergies ... CONSTITUTIONAL: Awake and alert. No obvious distress and non-toxic appearing. Patient is obese. HEENT (Head Eyes Ears Nose Throat): Atraumatic and Normocephalic. TM (Tympanic Membranes)'s clear. Nares clear. Oropharynx appears to have dry mucosa but no exudates or lesions. Airway patent. Neck: No lymphadenopathy. No meningismus. CARDIOVASCULAR: Tachycardic rate, regular rhythm, without murmur, rub or gallop. PULMONARY/CHEST: Symmetrical and non-tender. Clear to auscultation bilaterally. No wheezes, rales or rhonchi. ABDOMEN: Soft, non-distended, generalized tenderness throughout, no rebound, no guarding, no peritoneal signs, no masses or organomegaly. No CVAT (Costovertebral Angle Tenderness). EXTREMITIES: 2 + pulses (normal), no deformities, no clubbing, no cyanosis or edema ... MEDICAL DECISION MAKING: I reviewed the past medical, family and social history sections; including the medications, nurses notes, VS (Vital Signs), and allergies listed in the above record. ED COURSE/PLAN: We'll do standard abdominal pain workup on the patient including labs with urinalysis and a CT (Computerized Tomography) scan of the abdomen pelvis (sic). He clinically looks somewhat dehydrated with an elevated heart rates (sic) we'll give him a liter of fluids. Treat his nausea with some Zofran and his pain with some morphine (a pain medication). 0220-patient feels better after his fluids and medicines. Discussed that he probably has a viral gastroenteritis but the scan did show slight diaphragmatic hernia with some involvement of the liver and he has slight elevation in his liver tests. I want him to follow up with his primary care doctor to have his LFT's (Liver Function Tests) rechecked and to see if anything needs to be done about the diaphragmatic hernia..." Review revealed the following diagnostic studies were ordered by MD #1 on 04/01/2016 at 2343: CT Abdomen and Pelvis w/ (with) Contrast, Complete Blood Count with Differential, Lipase, Comprehensive Metabolic Panel, and Urinalysis. Review of a CT Abdomen and Pelvis w/ Contrast result, written on 04/02/2016 at 0115 by Radiologist #1, revealed, "... EXAMINATION: CT of the abdomen and pelvis with contrast ... FINDINGS: Large Morgagni hernia (rare form of congenital diaphragmatic hernia) containing fat and part of the liver. Visualized lungs are clear. Visualized heart is normal in size. Scoliotic curvature of the spine with thoracic spinal hardware in place. Hepatic steatosis (fatty liver disease). The gallbladder, kidneys, adrenals, pancreases, spleen, lower esophagus, stomach, duodenum, small bowel, appendix, large bowel, bladder, prostate and seminal vesicles are unremarkable. Small bilateral fat filled inguinal hernias. No bulky adenopathy in the abdomen or pelvis. The aorta is normal in caliber. IMPRESSION: No acute intra-abdominal pathology. Large Morgagni hernia containing fat and part of the liver. Scoliotic curvature of the spine with thoracic spinal hardware in place. Hepatic steatosis." Review of relevant laboratory findings revealed, "...Hemoglobin (red blood cells that carries oxygen throughout the body) 10.6 L g/dL (grams per deciliter) (hospital reference range 12.0-16.0: hematocrit (percentage of red blood cells in the blood): 35.3 % L; (Hospital reference range 37-47%) ... AST (aspartate aminotransferase- part of the liver functions tests -hospital reference range 15-37): 51 H (high) U/L (Units per Liter-); and ALT (alanine aminotransferase- Hospital reference range - 12-78): 149 H (U/L)... "Review revealed all other results were either Negative or normal, as appropriate. Review revealed Patient #12 received the following medication during this DED admission: Normal Saline 1 Liter fluid bolus IV (Intravenous), Zofran 4mg IV, and Morphine 4 mg IV. Review revealed Patient #12 ' s vital signs on 04/02/2016 at 0145 as follows: BP 145/84 mmHg; P 101 BPM; R 20 RPM; T 98.2° F; and SpO2 100% RA. Review revealed Patient #12 was discharged from Hospital A's DED on 04/02/2016 at 0233, via wheelchair, accompanied by a friend. Review of discharge instructions written by MD #1, revealed, "... Diagnoses this visit: VIRAL GASTROENTERITIS ... Use the Zofran if needed for nausea and vomiting. You can use over-the-counter Imodium if needed for diarrhea. Make sure you drink plenty of fluids to prevent dehydration. Your vomiting and diarrhea symptoms should resolve over the next 2-3 days. Return to emergency department if worse or if not improved after 3 days. Follow-up with your primary care doctor to have your liver blood tests rechecked and to see if anything needs to be done about the hernia." Review revealed Patient #12 was prescribed Motrin 800 mg (milligrams) Oral Tablet, 1 tablet by mouth every 8 hours as needed for pain; and Zofran 4 mg Oral Tablet, 4 mg by mouth every 8 hours as needed for Nausea.

Physician interview conducted on 07/20/2016 at 1348 with MD #1, revealed Patient #12's MSE revealed no acute processes. Interview revealed hernias often do not need immediate surgical intervention. Interview revealed, "Lots of people walking around have hernias." Interview revealed a hernia that presents with strangulation (constricted so that the blood supply to the area is cut off) or incarceration (a type of strangulated hernia) require immediate surgical intervention. Interview revealed Patient #12's hernia presented as neither, and did not require immediate surgical intervention. Interview revealed Patient #12's laboratory studies did not reveal any acute processes. Interview revealed the elevated liver enzymes could have resulted from irritation from the hernia, but "they were not that high." Interview revealed patient #12 displayed mild anemia, but no acute process. Interview revealed Patient #12 was discharged with instructions to follow up with a primary care physician for recheck of blood work, and to determine further course of action in regards to his hernia. Interview revealed Patient #12 was medically stable at the time of discharge, as he was afebrile, his heart rate was down, he denied emesis, and reported feeling better.


The hospital's policy and procedure titled "EMTALA Policy" Policy #: VH-RM37, reviewed 2/16 was reviewed. The policy revealed in part, "7. All Nursing staff shall record the details and times of relevant medical information, history, observations, patient complaints, vital signs ... care and treatment rendered on the triage form or emergency department record for each individual."

The hospital failed to ensure that an appropriate medical screening examination was provided on 4/1/2016 for patient #12 related relevant to all medical information was not effectively communicated regarding the patient's low oxygen saturation levels and the patient's complaint of blood in stools times 2 days duration to EMS prior to arrival to the hospital's emergency department.