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Based on document review and staff interview, the critical access hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff followed hospital policies, and provided all available and appropriate stabilizing treatment for 1 of 18 patients (Patient #17) that presented to the ED and requested care from 5/29/2019 through 8/30/2019.

Failure of the CAH's ED staff to provide all available and appropriate stabilizing treatment within its capabilities resulted in staff discharging a patient who complained of significant abdominal pain without performing all necessary testing to determine the source of the pain. This failure resulted in Patient #17 returning to the ED on 8/20/19 approximately 49 hours after discharge with a diagnosis of acute cholecystitis (an infection of the gallbladder), prolonged pain, suffering, and potentially increased perioperative morbidity (complications associated with surgical procedures or interventions).

The CAH's administrative staff identified an average of 345 patient's per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "EMTALA: Medical Screening and Stabilizing Treatment," revised 8/2019, revealed in part, "... the Hospital will provide further medical examination and stabilizing treatment as required to stabilize the medical condition..." "Stabilizing treatment consists of providing medically appropriate treatments within the capabilities of the Hospital necessary to ensure that ... no material deterioration of the patient's condition is likely to occur during ... discharge of the patient."


2. Review of the medical record showed Patient #17 presented to the ED at 12:11 PM on 8/18/19, the second time in 2 days (initial presentment on 8/16/19) complaining of vomiting, constipation and abdominal pain.

The medical record did not contain evidence that the ED provided, within it's capabilities, further examination to determine if Patient #17's emergency medical condition resolved prior to discharge. The ED failed to re-evaluate Patient #17's vital signs to determine if his blood pressure and heart rate had returned to normal, or perform a repeat abdominal examination to determine if it remained painful or not. Without this information, the physician could not be reasonably assured that no intra-abdominal pathology was overlooked or that Patient #17 would not deteriorate after discharge.

Review of a third medical record showed that Patient #17 returned to the ED at 1:47 PM on 8/20/19, two days after discharge on 8/18/19. Documentation showed Patient # 17 appeared ill, in moderate distress, with severe (10 out of 10) abdominal pain, continued abnormal vital signs and abnormal lab test results. A CT scan (special type of x-ray) revealed Patient #17 had an acutely infected gallbladder, which can lead to sepsis, peritonitis, and even death if left untreated, and as a result was transferred to another hospital for emergent surgical intervention.


3 During an interview on 9/17/2019 at 9:15 AM, ED Physician C revealed he would have ordered a CT scan on 8/18/2019 when Patient #17 returned to the ED the second time. The CT scan could have diagnosed the infected gallbladder.

Please see C-2407 for additional information and findings.

Based on document review and staff interviews, the critical access hospital's (CAH) emergency department (ED) staff failed to provide all available and appropriate stabilizing treatment for 1 of 18 patients (Patient #17) that presented to the ED and requested care from 5/29/2019 through 8/30/2019.

Failure of the CAH's ED staff to provide an all available and appropriate stabilizing treatment within it's capabilities resulted in staff discharging home a patient complaining of significant abdominal pain without performing all testing within the hospital's capabilities to determine the source of the abdominal pain. This failure resulted in Patient #17's return to the ED for a 3rd time on 8/20/19, approximately 49 hours after discharge on 8/18/19, with a diagnosis of acute cholecystitis (acute infection of the gallbladder), prolonged pain, suffering, and potentially increased perioperative morbidity (complications associated with surgical procedures or interventions).

The CAH's administrative staff identified an average of 345 patient's per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the medical record showed Patient #17 presented to the ED at 12:11 PM on August 18, 2019, the second time in 2 days (initial presentment on August 16, 2019) complaining of vomiting, constipation and abdominal pain.

At 12:23 PM, the physician working in the ED performed a history and physical which revealed that Patient #17 complained of vomiting and diarrhea and had an abnormally high heart rate (121 beats per minute, normal at rest range is 60 to 100) without a fever, and a high blood pressure 136/108 (normal range 120/80 - 140/90), indicating the presence of an emergency medical condition. The triage nurse documented Patient #17 complained of abdominal pain that the patient rated 8 out of 10 (10 being the most severe pain), but the physician documented the patient had a non-tender, non-distended abdomen. The physician ordered a repeat of the lab tests initially performed when the patient presented to the ED on August 16, 2019, and an abdominal x-ray. The patient received intravenous (IV) fluids and a medication to control his nausea. The repeat lab tests showed continued elevation of the patient's white blood cell count of 13.1 (hospital's normal range 4 - 10.5), a sign of a possible infection, and a continued elevated blood sugar 326 mg/dL (hospital's normal range 74-106 mg/dL). Documentation in the medical record showed the physician determined the patient's disposition - "discharge to home" at 3:12 PM.

The medical record did not contain evidence that the ED provided, within it's capabilities, further examination to determine if Patient #17's emergency medical condition resolved prior to discharge. The ED failed to re-evaluate Patient #17's vital signs to determine if his BP and heart rate had returned to normal, or perform a repeat abdominal examination to determine if it remained painful or not. Without this information, the physician could not be reasonably assured that no intra-abdominal pathology was overlooked or that Patient #17 would not deteriorate after discharge.

Review of a third medical record showed that Patient #17 returned to the ED at 1:47 PM on 8/20/19, two days after discharge on 8/18/19. Documentation showed the patient appeared ill, in moderate distress, with severe (10 out of 10) abdominal pain, continued abnormal vital signs and abnormal lab test results. A CT scan (special type of x-ray) revealed Patient #17 had an acutely infected gallbladder, which can lead to sepsis, peritonitis, and even death if left untreated, and as a result was transferred to another hospital for emergent surgical intervention.

2. During an interview on 9/17/2019 at 9:15 AM, ED Physician C revealed he would have ordered a CT scan (an x-ray image using a form of tomography) on 8/18/2019 when Patient #17 returned to the ED the second time. The CT scan could have diagnosed the infected gallbladder.

3. During an interview on 9/18/2019 at 11:10 AM, Surgeon E revealed, in discussion of the 3 ED visits at MercyOne Oelwein Medical Center, Surgeon E had a rule that if a patient is bad enough to come back in a day or so, the patient should get admitted to see what is going on.

4. During an interview on 9/17/2019 at 4:00 PM, Hospitalist D revealed he would have ordered a CT scan during the second ED visit when Patient #17 indicated they had severe abdominal pain.