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Based on policy review, patient and staff interviews, the hospital inappropriately discharged 1 (Patient 14) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether Patient 14 had an infection and if the presence of an Emergency Medical Condition (EMC) existed, in accordance with the facility Emergency Medical Treatment and Transfer Policy (EMTALA). Patient 14 presented to the Emergency Department seeking medical care for nausea, vomiting, fever at home of 103° and sickle cell crisis and the staff failed to provide an adequate MSE to assess the patient for sepsis due to nausea/vomiting/fever and pain due to sickle cell crisis. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment.

Findings are:

See also A 2406.

A. Review of facility policy titled "Emergency Medical Treatment and Active Labor Act" last revised 2/21 states, "an examination within the capability of the Hospital's DED (Dedicated Emergency Department), including ancillary services routinely available to the ED, to determine with reasonable clinical confidence whether an EMC exists. The MSC must be provided by Qualified Medical Personnel (QMP)." Any individual, who is not otherwise a Patient of the Hospital, shall be provided an appropriate MSE within the capabilities of the ED as follows: Upon presentation at a DED of Hospital, and upon a request for examination or treatment for a medical condition. Such a request will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition." "The MSE is an ongoing process in many cases and may require documentation of continued monitoring and evaluation."

B. The hospital failed to follow the policy titled "Emergency Medical Treatment and Active Labor Act" and did not provide a medical screening exam sufficient for Patient 14 when the patient presented to the dedicated emergency department with complaint of vomiting, fever, possible infection/sepsis and sickle cell crisis on 4/4/2022 at 2:24 PM and dismissed on 4/5/22 at 12:05 AM. Patient 14 was not evaluated for 5 hours after presenting to the ED. Upon leaving the ED at 12:05 AM with his mother, Patient 14 went to (Hospital B's) ED 2.5 miles away, arriving at 12:50 AM and was admitted to the hospital for sepsis possibly due to pneumonia; sickle cell pain crisis and sickle cell anemia. Patient 14 was transferred back to (Hospital A) for heart surgery not available at (Hospital B), and remained hospitalized at time of exit on 4/21/22.

C. An interview with Patient 14 on 4/20/22 at 11:45 AM revealed, "My girlfriend brought me here (Hospital A) (on 4/4/33) at about 2:30 PM because I had a temperature of 103 and had taken Tylenol and had been throwing up for a day or so. I had been in the hospital about 2 weeks ago with MRSA in my chemo port and they had to take it out, I just finished antibiotics about 1 week ago. I felt like my infection was coming back, worse then before. My Sickle Cell was causing me a lot of pain because I couldn't keep my medications down at home. I got in a room about 7-7:30 PM, the Doctor saw me and ordered labs and gave me IV's and med's. He came in back in a little before 10:00 PM and said he would give me another dose of pain med's and if I felt better I could go home. The next thing I know the nurse came in and said I was dismissed. I told her No, I don't want to go home, I am too sick yet, I want to talk to the doctor. She told me he went home, and he discharged me. I said no, I am too sick, I wouldn't let her take out my IV and wouldn't do my discharge instructions. She left the room and I called my Mom. She called the ED and talked to the head nurse and was on her way. The head nurse came in when Mom was here and said there was no doctor for me to talk to about staying and I had to go. They brought 3 security guys into my room. We finally left about 12:-12:15 Midnight. We got out in the garage and we called the infection doctor and asked is she could admit me directly, she said couldn't, and told us if we could return to the ED again. My Mom said no, they got Security to escort us out. The infection doctor told us we could go to another ED if we thought we needed more care. So Mom took me to (Hospital B). I got there and they took me straight back to a room in the ED and I had a fever over 103 again, I had been there until 4/17/22 when they had to transfer me back here to get some special heart surgery." "I just knew if I went home that night I would die and no one would listen to me."

Based on policy review, review of facility property video, patient and staff interviews, the hospital inappropriately discharged 1 (Patient 14) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether Patient 14 had an infection and if the presence of an Emergency Medical Condition (EMC) existed, in accordance with the facility Emergency Medical Treatment and Transfer Policy (EMTALA). Patient 14 presented to the Emergency Department seeking medical care for nausea, vomiting, fever at home of 103° and sickle cell crisis and the staff failed to provide an adequate MSE to assess the patient for sepsis due to nausea/vomiting/fever and pain due to sickle cell crisis. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment. According to the facility provided information this ED sees an average of 2282 patients per month.

Findings are:

A. An interview with Patient 14 on 4/20/22 at 11:45 AM revealed, Patient 14's girlfriend brought him to this hospital (Hospital A) at about 2:30 PM on 4/4/22 because he had a temperature of 103 and had taken Tylenol and had been throwing up for a day or so at home. He had been in the hospital about 2 weeks ago with MRSA (Methicillin Resistant Staph Aureus) in his venous access port and they had to take it out, he just finished antibiotics about 1 week ago. He said he felt like my infection was coming back, worse then before. His Sickle Cell Crisis was causing him a lot of pain because he couldn't keep his medications down at home. He said he was initially sitting in a wheel chair in the lobby wrapped up in a blanket I brought from home because he was cold. "But I couldn't sit any longer in the wheel chair due to pain and I just had to lay on the floor in the lobby because I felt so terrible. I had thrown up 3-4 times while I was waiting and I could feel my fever coming back up, so I went to the bathroom and got cool wet paper towels and used them. I finally asked the nurse at the entrance desk for a ice pack [at 18:49 (6:48 PM)], and she got me one which I put on the back of my neck." He said he was taken back to an ED room about 7-7:30 PM, the Doctor examined him and ordered labs, IV's and med's. He came in back in a little before 10:00 PM and said he would give (Patient 14) another dose of pain med's and if he felt better he could go home. "The next thing I know the nurse came in and said I was dismissed. I told her No, I don't want to go home, I am too sick yet, I want to talk to the doctor. She told me he went home, and he discharged me. I said no, I am too sick, I wouldn't let her take out my IV, do my discharge vital signs and wouldn't do my discharge instructions. She left the room and I called my Mom. She called the ED and talked to the head nurse and was on her way. The head nurse came in when Mom was here and said there was no doctor for me to talk to about staying and I had to go. The head nurse went and got me one more dose of pain medication and another prescription for nausea, a pill and I was still nauseated and felt like I could throw up. They brought 3 security guards in to escort us out because I was discharged. We got walked out about 12:-12:15 Midnight. We called the infection doctor (Dr J) from the garage at the hospital and she said she couldn't admit me so Mom took me directly to (Hospital B). I got there and they took me straight back to a room in the ED and I had a fever of over 103 again, I had been there until 4/17/22 when they had to transfer me back here (Hospital A) to get some special heart surgery. "I just knew if I went home that night I would die, but no one would listen to me."

B. Review of Patient 14's 4/4/22-4/5/22 ED medical record showed that he arrived at 14:24 (2:24 PM) the patients vital signs (VS) were temperature 98°, pulse 112, respirations 18, blood pressure 105/58 and 97% oximetry (measurement of oxygen) and pain level of 8. The ED Doctor (Dr H) examined Patient 14 on 4/4/22 at 19:21 (7:21 PM). This was an inappropriately long delay to initiate the medical screening examination and placed the patient at risk for deterioration in his health.

The ED medical record identified that the patient's chief complaint was "admitted for sickle cell crisis and MRSA infections 2 weeks ago, states "ALL THE SYMPTOMS ARE BACK.", he states he has been feeling like this for 4 days and its just getting worse." It was noted that the pain in his extremities, back and chest are similar symptoms with the MRSA infection hospitalization. It was noted that he had presented to the ED on 3/25/22 with similar symptoms and leukocytosis (WBC 29.6) at that time. He is no longer on antibiotics at this point, has started having diarrhea a couple of days ago. He also has had fevers at home up to 103° and has been taking Tylenol. Diagnosis management comments: "Patient is uncomfortable on my exam. Vital signs show tachycardia, otherwise normal. Likely somewhat dehydrated with nausea and vomiting. Reviewed documentation from previous emergency department visit. He had a fairly significant leukocytosis at that time as well. Pt has a normal lactate at 1.1, no bandemia, lower suspicion for sepsis. Procalcitonin is elevated at 0.94. He was given pain medication, nausea medicine and Benadryl. Today given his recent antibiotic use and his diarrhea as well as worsening leukocytosis I discussed the case again with (Dr J -Infectious disease). Recommends obtaining C Difficile. Difficile screen and repeat cultures."
Review of 4/4/22 lab revealed WBC (white blood count) 38.3 [normal 4-11; indicates infection]; HGB (hemoglobin) 7.9 [normal 12-17; indicates anemia]; Preliminary ANC 32.3 [normal 1.5-8.8; this test is to check for the number of neutrophils a type of WBC's in the blood to fight infection]; Procalitonin 0.94 [normal <=0.08; a test that checks for bacterial infection, the higher the number the possibility of serious bacterial infection or sepsis] and Sodium of 129 [normal 136-145; a test that can indicate dehydration]. Blood Cultures were drawn prior to discharge. The patient was discharged and walked out on 4/5/22 at 12:05 AM. Discharge instructions included information about Sickle Cell Anemia; the patient was directed to keep on medications as before and a prescription for Phenergan 25 mg 1 tablet every 6 hours for nausea for 5 days; call infectious doctor for an appointment in 2-4 days; continue to push fluids and use zofran for nausea and home pain medications.

The Nurses Notes for the 4/4/22-4/5/22 ED visit for Patient 14 indicated:
-14:20 (2:20 PM) the "quick assessment" completed
-18:48 (6:48 PM) patient provided an ice pack
-19:27 (7:27 PM) RN B documented, patient taken to a room
-20:15 (8:15 PM) RN B documented, pain level 7
-21:48 (9:48 PM) RN B documented, repeat pain level 5 after administration of pain medication
-22:56 (10:56 PM) RN B documented, patient able to eat one cup of ice chips & requested to get a glass of water
-00:00 (12:00 Midnight) RN B documented, patient refusing last set of vital signs, and refusing to let this RN remove IV "until more pain medication is given to me." Core (Charge RN A) notified.
-00:00 (12:00 Midnight) per Charge RN A, "Pt seen in ED, full workup completed & pt was discharged by ED MD after consulting with infectious disease. When attempting to discharge, PT TELLING RN HE FEELS UNSAFE TO GO HOME DUE TO HIS PAIN AND HIS INFECTION. Pt's mother also called on phone asking to speak to charge RN. Pt's mother states she feels he needs to be admitted, that we are "putting him at risk" by discharging him because "infections can creep up really fast and be fatal." Pt's mother was told that the ED MD spoke with infectious disease and they all said he was okay for discharge and would not be admitting him. Spoke with ED MD on staff, stated he would not be admitting pt and that he was okay to go. Charge Nurse RN into speak with pt, pt states, that "I STILL HAVE PAIN, I HAVE THIS INFECTION, MY WHITE BLOOD CELL COUNT IS UP AND I CAN'T KEEP MY PAIN MEDICATIONS DOWN BECAUSE I KEEP VOMITING." I told pt I would speak with ED MD to see if we can get him another dose of pain meds prior to discharge and a prescription for an additional nausea medication to go home with. ED MD ordered additional dose of IV pain med and would write a rx (prescription) for another nausea medication to have for home so he can keep down his prescribed pain med's. I then told him he would be discharged as discussed." "Charge RN A called mother back, explained same conversation had with pt. Pt's mother stated she was coming to the hospital and demanded to speak with the doctors refusing to admit him come talk to her. Security notified at this time. The Pt's mother came angrily into the room demanding to speak with MD and "those doctors that won't admit him." "Charge RN A informed pt and pt's mother that they had been discharged, and that they can either leave or be escorted out by security. Pt's mother continually telling security that "They're not needed, we're not going to cause a scene."

The evidence in the medical record demonstrated Patient 14 was discharged from the ED despite the patient's signs and symptoms and high risk of recurrent Methicillin-resistant Staphylococcus aureus (MRSA), a very difficult to treat infection which placed him at risk for a life threatening infection. At 5:35 PM on 4/5/22, approximately 12 hours after discharge, the results of the blood culture testing indicated Patient 14 was positive for MRSA. The patient required inpatient admission for the treatment of his infection but had already been admitted to Hospital B. The positive blood culture identifies that Patient 14 has MRSA in his blood stream which is very serious. The treatment for positive blood cultures requires immediate treatment, including hospitalization and PROMPT USE OF IV ANTIBIOTICS. There is a high mortality rate and the high risk of serious complications associated with a bloodstream infection of MRSA.

C. An interview with (Hospital A's) ED MD (Dr H) on 4/20/22 at 2:54 PM revealed, "Yes I remember this patient (Patient 14) from 4/4/22. He presented with fever and generalized pain. He is a sickle cell patient. We gave him IV fluids, morphine, zofran and benadryl. At times he looked comfortable. Before the end of my shift, I went and re evaluated him, reviewed his labs with him. His WBC was 38,000, his procalcitocin was high, but trending down. I consulted Infectious Disease Doctor (Dr J). He also had complained of diarrhea, Dr J suggested ordering a C Diff test, and blood cultures. He had been tachycardic on admission, felt like the fluids had improved that. I spoke with him regarding discharge, I felt the patient was agreeable to this. I did do a non-formal hand off to the oncoming ED MD (Dr I).

D. An interview with (Hospital A's) oncoming ED MD (Dr I) on 4/22/22 at 8:45 AM revealed, "I received a hand off from Dr H that the patient (Patient 14) was still here and may need an additional dose of pain medication prior to leaving. The nurse (Charge RN A) came and asked me for an additional dose of pain medication and something additionally for nausea. I okayed the pain medication and gave a prescription for phenergan as needed for nausea at home. Dr H said that blood cultures had been drawn and we were waiting to see if we could get a stool specimen for the C Diff test. He said he talked to infectious disease (Dr J) and the plan was for the patient to go see them." When asked ED MD (Dr I) if he was aware that he & his Mom wanted him re evaluated and he did not want to go home? Dr I stated, "No, I was not aware of that."

E. An interview with Infectious Disease Dr on call on 4/4/22 (Dr J) on 4/20/22 at 11:02 AM revealed, "The ED MD (Dr H) called me, said that this patient complained of nausea/vomiting and feeling terrible. He had previously been hospitalized 2-3 weeks prior and he felt like his infection was coming back. His WBC was 38.3 and on 3/25/22 his WBC was 29.6. He mentioned that the patient said at home his temp was up to 103° and was having a lot of pain. I reviewed his lab, his Procalcitonin was improving, his lactic acid was normal. Dr H highlighted his GI upset, pain and previous bacteremia. I told (Dr H) that if the attending's physical examination and review of systems were stable, if he discharged to follow up with infectious disease in a few days." Shortly after midnight the patient's mother paged me. She asked me if I could admit (Patient 14) directly to the hospital. I told her I could not, I had not seen and examined the patient, the ED physician assessed him and determined he did not need admission. I recommended to the Mother that if she felt strongly that he needed further evaluation, then she will need to take him to a different ED. If there are any outstanding tests that are pending and show infection, then obviously he will be contacted and managed appropriately."

F. Review of the facility provided videos on the inside of the ED registration waiting area revealed the following:
On 4/4/22 at 2:22 PM the greeter brought Patient 14 into the lobby. He was dressed in a hoodie, sweat pants and had a blanket wrapped around him. He was taken to the registration and moves to the waiting room at 2:31 PM seated in the wheelchair. At 2:55 PM Patient 14 ambulated to the bathroom, when he returned at 3:00 PM he handed the registrar a full emesis bag and gets a new one. At 3:06 PM, lab staff took him to get some blood drawn. The video showed that at 3:13 PM he exited the lab and went to the bathroom, at 3:19 PM he returned to the lobby. At 3:37 PM walked to the bathroom, returned to his wheelchair in the lobby at 3:39 PM. At 3:46 PM the patient wrapped himself up and laid on the floor in front of the wheelchair. Two staff people were sitting at the greeter desk, including the triage RN, which was approximately 3 feet from Patient 14, and neither staff checked on the patient. At 4:19 PM Patient 14 walked to the bathroom and returned at 4:22 PM. At 5:02 PM went to the bathroom, returned to wheelchair at 5:05 PM. At 5:16 PM patient seen fanning himself with papers, then laid on floor until getting up to bathroom at 5:44 PM and returned to floor at 5:36 PM. At 6:00 PM continued to fan self and took off sweat pants, at 6:31 PM he removed his hoodie and continued to fan self. Walked to the bathroom at 6:32 PM and returned at 6:34 PM. He approached the greeter desk at 6:45 PM and asked the nurse for an ice pack, 6:48 PM the nurse brought him an ice bag and he placed it on his neck. Laid down with ice pack on neck until 7:17 PM when he was taken to an ED room. The video lacked staff checking vital signs or speaking to the patient after the initial quick triage, other then when he went for lab and requested the ice pack.

When the patient was interviewed on 4/20/22 at 11:45 AM, and inquired about his to his trips to the bathroom, he said, "I threw up 3-4 times while I was waiting in the lobby, I was also going in there to get wet paper towels for my head. I could feel my fever coming back." When asked why he was laying on floor, he said "I just couldn't stand the pain of sitting up any longer, I just had to lay down." Inquired if anyone came to check on the patient while in the ED Lobby while he was waiting for a room, "No just to register me, draw my lab and they got me an ice bag I asked for, but she didn't even ask why I wanted it."

G. Review of Patient 14's 4/5/22 (Hospital B) ED medical record documentation, revealed Triage VS at 00:52 (12:52 AM) blood pressure 106/67; pulse 131; respirations 18, temperature 102.7°; and oximetry 97%. Chest X Ray showed Patchy right infrahilar consolidation compatible with developing pneumonia. Lab; WBC 37.2 [normal 4-12] and HGB 7.6 [normal 12.5-17.5]. Review of (Hospital B's) ED Dr M examination and workup on 4/5/22 at 00:52 (12:52 AM) -03:45 (3:45 AM) revealed, Patient 14's chief complaint was "hurting all over", complain of joint pain, right knee pain, "hurting all over", emesis, nausea, fever, night sweats, recent MRSA infection from port. Examinations endorses generalized body pain, fevers & chills when he sleeps for the past 4 days, 2 days prior developed nausea, multiple episodes of vomiting with multiple episodes of diarrhea. Stated he was unable to eat or drink and hard to keep fluids down. Patient met SIRS (Systemic Inflammatory Response Syndrome) criteria with tachycardia and temperature on arrival and sepsis bundle was ordered. ED Differential diagnosis included, Sickle Cell Crisis; met SIRS criteria with his tachycardia and temperature status post sepsis bundle with 1 liter IVF (intravenous fluids) along with Vancomycin and Zosyn (IV Antibiotics) especially given history of recent line site MRSA (line/port has been removed). Pain controlled with 8 mg morphine every 3 hours, Benadryl x 1 along with Zofran along with Tylenol for fever. Hospitalist was called for admission for sepsis secondary to viral &/or bacterial pneumonia, sickle cell crisis and pain control.

Review of (Hospital B's) inpatient record from 4/5/22 - until transfer to (Hospital A) for cardiac surgery on 4/17/22. Patient 14 was admitted to Hospital B on 4/5/22 for treatment of Sickle Cell Crisis; Sepsis possibly due to pneumonia; Sickle Cell Anemia; and Hypokalemia (low potassium). Review of 4/12/22 Internal Medicine progress note at 6:35 AM revealed his diagnoses as: Endocarditis (an infection of the heart's inner lining, usually involving the heart valves) with pericardial effusion (extra fluid collects in the sac around the heart); SVC clot (a blood clot in the Superior Vena Cava- the large vein that drains blood away from the head, neck, arms, upper chest and into the heart); MRSA Bacteremia (systemic infection in blood stream that is resistant to methicillin antibiotics); TEE (transesophageal echocardiogram- a test to check the chambers and valves of the heart by sound waves) revealed vegetation on the heart valves. On 4/17/22 the patient was prepped for transfer to (Hospital A's) hospital for an AngioVac Procedure ( a procedure where a cannula is inserted into the right internal jugular vein to the tricuspid valve. The infective vegetation on the heart valves is aspirated and filtered to remove the vegetation) on 4/18/22.