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Based on record review, interview, and policy review the Critical Access Hospital (CAH) failed to follow their policies and procedures and did not provide stabilizing treatment within its capabilities and capacity prior to discharging one patient (patient # 2) out of 20 patients reviewed from January to May 2019 who presented to the emergency department (ED) seeking care for a medical condition.

The failure to provide stabilizing treatment prior to discharge delayed care and placed the patient at significant risk for deterioration in her medical condition.

Findings Include:

Review of the CAH policy titled "EMTALA" with a revision date April 2019, provided the following information: " ...Stabilization and treatment of any emergency medical condition identified will be rendered within the capability and capacity of the medical center ...Components of MSE: (2) Admission and ongoing vital signs (include pain scale as needed) ...Discharge vital signs (include pain scale as needed) (8) Adequate documentation of all of the above including condition at discharge/stability ...emergency medical condition has been stabilized and treated to assure, within reasonable medical probability, that no material deterioration is likely to result, the patient may be dismissed or referred for definitive care ..."

Review of the medical record showed Patient 2 presented to the emergency department (ED) on 5/14/19 at 2:41 PM via emergency medical services (EMS) ambulance with complaints of a fall that occurred 12 hours prior to arrival in the ED. The fall occurred while Patient 2 was walking across the room, ran out of air and fell to the floor. Registered Nurse (RN) A triaged Patient 2 at 2:40 PM, using the Emergency Severity Index (ESI-a triage tool for ED care), as a level 2 (a high-risk patient) due to oxygen dependency, history of desaturation (low oxygen levels), history of sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and presenting with severe pain. RN A documented on the "Trauma Activation Record" the following initial vital signs: temperature of 101.8 Fahrenheit (F), blood pressure of 120/73, heart rate of 105, respiratory rate at 18 and oxygen level at 95% on three liters of oxygen. RN A documented the patient had bilateral (both sides) upper and lower back and neck pain of an 8 at rest and 9 with activity with a goal of a level of 5 (using scale 0-10, with 10 being the most severe) with rest or activity.

Physician Assistant-Certified (PA-C) C examined the patient at 2:47 PM and ordered laboratory testing that included a urinalysis (UA), blood cultures times two, a comprehensive metabolic panel (CMP), a complete blood count (CBC) with differential, and diagnostic imaging of patient # 2's back, pelvis and neck. At 5:41 PM, PA-C C documented a plan to discharge patient # 2 back to her home along with a prescription for Zithromax Z-Pak (antibiotic) 250 milligram (mg) oral tablet, education on back pain and chronic obstructive pulmonary disease (COPD), and instructions to follow up with her family physician in 3 to 5 days.

RN A documented on 05/14/19 at 7:00 PM the patient's vital signs at discharge: "blood pressure 154/77 (normal range 120/80 - 140/90), Pulse Rate 107 (normal range 60-100), Respiratory Rate of 18, an oxygen saturation level of 95% (within normal range), and an elevated temperature of 39.5 C or 103.1 F.

During an interview on 06/04/19 at 10:30 AM, Staff B, RN, ED Director stated that the ED utilizes the ESI (emergency severity index) triage tool when determining the acuity of a patient at time of ED admission. The ED Director said when a patient is triaged at a level 2 the patient is to be monitored every 15 to 30 minutes during the ED stay. The ED Director confirmed Staff A RN, assessed Patient 2's pain at the time of admission and failed to monitor or re-assess the pain during the stay and at time of discharge.

Review of a second medical record showed that patient # 2 returned to the ED by ambulance on 05/15/19 at 2:31 PM, nearly 24 hours after discharge. Documentation in the medical record showed that patient # 2 had suffered another fall at home and continued to have a fever. The ED physician arranged for patient # 2 to be transported by ambulance to another hospital providing a higher level of care at 9:21 PM.

Refer to tag C2407 for further details.

Based on record review and staff interviews the Critical Access Hospital (CAH) failed to provide within its capabilities and capacity treatment to stabilize, one patient (patient # 2) out of 20 patients reviewed from January to May 2019, prior to discharge. The failure to provide further examination and stabilizing treatment delayed the patient's care and placed her at risk for further deterioration in her medical condition after discharge. The failure had the potential to adversely impact all patients who present to the emergency department (ED) and require stabilizing treatment, and ongoing monitoring and re-evaluation of their medical condition prior to discharge.

Findings Include:

Review of Patient 2's medical record showed Patient 2 arrived by emergency medical services (EMS) and was admitted to the ED on 05/14/19 at 2:41 PM with complaints of a fall that occurred 12 hours prior to arrival in the ED. The fall occurred while Patient 2 was walking across the room, ran out of air and fell to the floor sitting on the buttocks. A "Trauma Alert" was initiated at 2:25 PM by Staff A, Registered Nurse (RN) when EMS alerted the ED that an adult patient was being transported to the ED with a fall who was receiving anticoagulation (blood thinner) medication. Staff A, RN triaged Patient 2 at 2:40 PM, using the Emergency Severity Index (ESI-a triage tool for ED care), as a level 2 (a high-risk patient) due to oxygen dependency, history of desaturation (low oxygen levels), history of sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and presenting with severe pain. Staff A, RN documented on the "Trauma Activation Record" the following initial vital signs: temperature of 101.8 Fahrenheit (F), blood pressure of 120/73, heart rate of 105, respiratory rate at 18 and oxygen level at 95% on three liters of oxygen. Staff A, RN documented the patient had bilateral (both sides) upper and lower back and neck pain of an 8 at rest and 9 with activity with a goal of a level of 5 (using scale 0-10, with 10 being the most severe) with rest or activity.

Review of Staff A, RN's assessments for Patient 2 failed to reflect a re-evaluation or on going monitoring of the 8-9 pain level reported at admission to the ED.

Staff C, Physician Assistant-Certified (PA-C) performed the Medical Screening Exam (MSE) at 2:47 PM and ordered laboratory testing that included a urinalysis (UA), blood cultures times two, comprehensive metabolic panel (CMP), complete blood count (CBC) with differential, and diagnostic testing of back, pelvis and neck. Staff C, PA-C noted at 5:41 PM the plan was to discharge the patient to home with a pharmacy prescription of Zithromax Z-Pak (antibiotic) 250 milligram (mg) oral tablet, along with printed education materials on managing back pain and chronic obstructive pulmonary disease (COPD), and instructions to follow up with her family physician in 3 to 5 days.

Staff A, RN documented on 05/14/19 at 7:00 PM the patient discharge vitals: blood pressure 154/77 (normal range 120/80 - 140/90), Pulse Rate 107 (normal range 60-100), Respiratory Rate of 18, SpO2 of 95% on 3 Liters of oxygen by nasal cannula, and an elevated temperature of 39.5 C or 103.1 F.

The evidence in the medical record showed patient # 2 presented to the ED with a fever, an increased heart rate, weakness, and a recent fall in her home. The patient's past medical history included chronic obstructive pulmonary disease and chronic cholecystitis. Her discharge diagnosis included acute cholecystitis (inflamed and swollen gallbladder, which requires immediate medical attention) and acute exacerbation of chronic obstructive pulmonary disease, however no treatment was provided. PA-C C did not re-evaluate the patient or obtain further studies or request evaluation by the on-call ED physician to further assess for sepsis as she continued to have severe signs/symptoms of fever (temperature increased to 103.1 F, an increase of 1.3 degrees F in a four- and half-hour time period), an elevated heart rate, and ongoing complaints of severe pain. Without further examination and stabilizing treatment, the patient had a reasonable medical probability of deteriorating following discharge at 7:00 PM.

During an interview on 06/04/19 at 10:30 AM, RN ED Director said the ED utilizes the ESI (emergency severity index) triage tool when determining the acuity of a patient at time of ED admission. The ED Director said when a patient is triaged at a level 2 the patient is to be monitored every 15 to 30 minutes during the ED stay. The ED Director confirmed Staff A RN, assessed Patient 2's pain at the time of admission and failed to monitor or re-assess the pain during the stay and at time of discharge. The ED Director confirmed the policy is to assess pain at admission/initially and at discharge.

During a phone interview on 06/05/19 at 12:00 PM, Staff C, PA-C acknowledged treating Patient 2 in the ED on 05/14/19. Staff C, PA-C said the decision to discharge Patient 2 was made after reviewing the blood work, x-rays and computed tomography scan (CT) and consulting with the ED on call physician. Staff C, PA-C shared they discussed during the consultation the results of diagnostic testing and labs with the decision to discharge rather than admit because of not having a diagnosis that met admission criteria and explained this was discussed with Patient 2 prior to the discharge. Staff C, PA-C said Patient 2 was stable at the time of discharge, taken home by a friend who the family had arranged to check in on the patient. Staff C, PA-C was aware Patient 2 returned to the ED the next day.

During a Phone interview on 06/05/19 (no time) with Staff H, Medical Director of ED, shared the providers of the ED use an objective Post scoring along with medical diagnosis with vital signs, labs, radiology, chemical, and social factors in determining if the criteria for admission is met.

During an additional phone interview on 06/10/19 at 2:15 PM, the Medical Director verified a patient triaged with an ESI of Level 2 is to be monitored every 15 to 30 minutes. He acknowledged a patient with pain of an 8 or 9 should be reassessed every 30 minutes until pain relief is noted. The Medical Director shared that he assumed RN A reported the discharge vitals to PA-C C, but said he could not verify whether PA-C C re-assessed the discharge vitals.

Review of a second medical record showed Patient # 2 returned to the ED by ambulance on 5/15/19 at 2:31 PM, approximately 24 hours after discharge. Documentation showed that patient # 2 had suffered another fall, continued to have an elevated temperature, and an elevated heart and respiratory rate. The ED physician diagnosed patient # 2 with exacerbation of chronic obstructive pulmonary disease and left lower lobe pneumonia. The ED physician arranged transfer to a higher level of care on 05/15/19 at 9:21 PM.