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Based on medical record review, document review and interview, it was determined the facility failed to ensure that a patient who presented to the Emergency Department (ED) received appropriate screening evaluation and treatment of the patient's medical condition before discharge.

The failure to assure appropriate medical evaluation and treatment before discharge of the patient resulted in a readmission of the patient at another facility for emergency surgery.

Findings include:

See Tag A-1104

Based on medical record review, document review and interview, it was determined that in 1 of 16 medical records reviewed, the facility failed to ensure (1) that a patient who presented to the Emergency Department (ED) received appropriate screening evaluation and treatment of the patient's medical condition before discharge; (2) the implementation of ED policies and procedures for specimen collection.

Findings include:

1- Patient #1 is a 58-year-old female who presented to the ED at Facility A via ambulance on 11/1/15 at 8:30 AM with a chief complaint of abdominal pain and drowsiness. The patient's medical history included hypertension and substance abuse. Triage vital signs at 9:14 AM were Temperature 98o Fahrenheit, Pulse 71, and Respirations 17, Blood Pressure 150/80, and Spo2 97percentage.

At 9:22AM, the physician documented that the patient was grossly intoxicated, moaning and staring off in the distance and does not respond to command well. The physician noted on the assessment form that he could not review the systems because it was difficult to assess due to patient's mental status. He further noted that there was mild guarding of the abdominal wall with no locality or quality. The working diagnoses were opioid abuse with intoxication, unspecified.

There was no further definitive testing regarding the patient's complaint of abdominal pain and no documentation of a reassessment before she was discharged on 11/1/15 at 1:40 PM.

The vital signs for Patient #1 were not reassessed by staff prior to her discharge from the facility. The documentation for vital signs simply notes, "Unable to assess". There was no reason stated for the lack of assessment of vital signs.

Facility policy titled "Assessment and Reassessment of Patients in the Emergency Department" last revised November 2015 states, "If patient has been in ED for greater than 4 hours, a complete set of vital signs, including Temperature, when clinically indicated should be obtained prior to patient discharge."

Patient #1 had been in the facility for more than 4 hours (9:14AM to 1:40PM) without reassessment of her vital signs.


Interview with Staff D, ED Attending Physician on 11/20/15 at 2:00 PM, she stated that she recalled the patient being intoxicated and that the patient failed to exhibit any rebound tenderness upon examination of her abdomen. Staff D said that the plan was to give the patient time to metabolize the opioid in her system before re-examining her for discharge. When her sobriety increased, the patient complained of burning on urination and since the patient failed to exhibit any costovertebral angle tenderness, her diagnosis became urinary tract infection and the decision was made to treat empirically with Macrobid (an antibiotic used to treat urinary tract infections).

During interview with Staff E, Resident Physician on 11/23/15 between 10:00AM and 11:15AM, the physician stated the patient did not have an acute abdomen at discharge; however, he confirmed that patient pushed his hand away and he could not complete the re-evaluation of the abdomen. Staff E stated that he did not document the re-assessment in the patient's medical record.

Patient #1 was discharged from the facility and there was no further definitive testing regarding the patient's complaint of abdominal pain and no documentation of a reassessment before she was discharged on 11/1/15 at 1:40 PM.


The review of medical record from another facility, Facility B revealed that the patient was brought to the Emergency Department on 11/1/15 at 3:48PM, approximately two hours after discharge from the initial facility. The ambulance Call Report noted the patient was on the street mumbling and in pain. At the facility, the patient was noted to be febrile at 99.5 Fahrenheit, tachycardic at 120, and BP was 189/89. A computed tomography (CT) scan of the abdomen and pelvis revealed the presence of pneumoperitoneum and likely perforated gastric antrum. The patient underwent an emergency surgery on 11/1/15 at 11:56 PM with findings consistent with 0.5 millimeter gastric perforation with leakage of 300 centiliters (cc) to 500 cc gastric contents throughout the abdomen and extensive peritonitis.

2- Urine sample requested for testing for Patient #1 during ED visit at Facility A was not done. The urine collected by the patient was not immediately labelled and therefore was discarded after a mix up with another patient's urine specimen.

Facility policy titled, "Clean Catch Midstream Urine" last revised December 2012 requires that staff label specimen in front of the patient after collection.