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Based on review of the facility policies, review of the Emergency Department (ED) Central Log and Throughput, review of ED medical records, and interviews, the facility failed to provide Stabilizing Treatment within the capabilities of the hospital for 1 (#3) patient of 35 patients reviewed. The facility failed to notify Patient #3 of abnormal diagnostic findings of the Medical Screening Examination (MSE); and failed to provide information and the opportunity to seek further evaluation and treatment.

The findings included:

Refer to A-2407

Based on review of the facility policies, review of the Emergency Department (ED) Central Log and Throughput, review of ED medical records, and interviews, the facility failed to provide Stabilizing Treatment within the capabilities of the hospital for 1 (#3) patient of 35 patients reviewed. The facility failed to notify Patient #3 of abnormal diagnostic findings of the Medical Screening Examination (MSE); and failed to provide information and the opportunity to seek further evaluation and treatment.

The findings included:

Review of the facility's policy, "Triage Acuity", dated 4/2021, showed "...assure timely evaluation of patients...minimize delays for essential care and facilitate patient flow through the Emergency Department (ED)..."

Review of the facility's policy, "Emergency Medical Treatment and Active Labor Policy", dated 10/22, showed "...A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized..."

Review of the ED logs for 8/9/2022 showed:
5:00 PM - 45 patients in ED beds with 16 patients held in the waiting room
6:00 PM - 42 patients in ED beds with 20 patients held in the waiting room
7:00 PM - 45 patients in ED beds with 22 patients held in the waiting room
8:00 PM - 44 patients in ED beds with 19 patients held in the waiting room
9:00 PM - 42 patients in ED beds with 18 patients held in the waiting room

Review of the ED Throughput showed the ED had 34 patient beds and 20 hallway stretchers for patient use on 8/9/2022. During 8/2022 the average length of service for admitted patients was 540 minutes with the average length of service for discharged patients 247 minutes.

Review of the medical record revealed Patient #3 was admitted to the facility's ED on 8/9/2022 at 5:43 PM for complaints of abdominal swelling. Patient #3 had a history of cirrhosis of the liver, weakness, and reported he was unable to eat or drink for the previous 4 days due to difficulty swallowing. Vital signs were obtained at 5:56 PM and showed Temperature 98.1 Fahrenheit (F), Blood Pressure 120/91, Pulse 99, Respirations 20, Oxygen Saturation 100 percent (%) on room air. Pain (abdominal, general) was rated as a '4' out of 1 to 10 (10 being worst pain possible). Diagnostic testing for a Computerized Tomography (CT) of the Abdomen and Pelvis without contrast and lab work, including Basic Metabolic Profile (BMP), Complete Blood Count (CBC) with Differential, Hepatic Function Panel, and a Urinalysis with Reflex was ordered. Patient #3 was triaged with an Emergency Severity Index Score of '3' Urgent.

Review of the medical record showed Patient #3, following triage, was taken to a pre-exam (PEA) for his Medical Screening Examination (MSE). Patient #3 informed the Physician Assistant (PA) he had cirrhosis of the liver and need paracentesis (procedure to remove fluid from the abdominal/peritoneal cavity) for abdominal swelling that began 4 days earlier. Lab work was obtained, and Patient #3 returned to the waiting room. The CT of the abdomen and pelvis was completed on 8/9/2022 at 7:52 PM. Following the CT, Patient #3 returned to the waiting room.

Review of the medical record showed the following laboratory results:
Sodium (NA) - 134 meq/L (milliequivalents/liter) [L] (low). Normal range: 135 - 145 meq/L. A low level may indicate cirrhosis of the liver.
Glucose (BS) - 53 mg/dl (milligrams/deciliter) [L]. Normal range: 70 - 100 mg/dl. A low level may indicate chronic illnesses, anorexia, or insulin overproduction.
Carbon Dioxide (CO2) - 18.6 mmol/L (millimoles/liter) [L]. Normal range: 23 -29 mmol/L. A low level could indicate a problem with the lung or kidney.
Bicarbonate (HCO3) - 17.8 meq/L. [L]. Normal range: 22 - 28 meq/L. Low range may indicate liver failure along with other medical conditions.
Albumin - 3.1 g/dl (grams/deciliter) [L]. Normal range: 3.4 -5.4 g/dl. Low range may indicate liver disease or malnutrition along with other medical conditions.
Total Bilirubin - 3.9 mg/dl High [H]. Normal range: 0.1 - 1.2 mg/dl. High range may indicate liver disease.
Direct Bilirubin - 2.1 mg/dl [H]. Normal: less than (<) 0.3 mg/dl. High levels may indicate liver disease.
Aspartate Aminotransferase (AST) - 135 units/liter (u/L) [H]. Normal range 8 - 33 u/L. High levels may indicate liver disease.
Alkaline Phosphatase (ALK PHOS) - 223 u/L [H]. Normal range 44 - 147 u/L. High levels may indicate liver disease.
Alanine Transaminase (ALT) - 48 u/L [H]. Normal range 4 - 36 u/L. Elevated levels may indicate liver disease.
Neutrophil 80.8% [H]. Normal range 60 - 70%. Elevated range may indicate infection or use of certain medications.
Lymphocytes 9.6 % [L]. Normal range 21 - 51%. A low level may indicate a higher risk of infection.
Absolute Neutrophil 8.94 per microliter (mcL) [H]. Normal range 1.5 - 8.0 mcL. Elevated levels may indicate infection, inflammation, or a stress response in the white blood cells.

Review of the CT of the Abdomen and Pelvis without contrast, dated 8/9/2022 at 7:52 PM, showed "...prominent abdominal ascites, large low-density lesion left lobe of the liver worrisome for neoplasm. Follow-up and evaluation advised. MRI [Magnetic Resonance Imaging] or contrast CT may be helpful for further evaluation. Peritoneal nodularity, stranding, worrisome findings for peritoneal masses/metastases. The lesion left lobe of the liver is a new finding compared to the previous study..."

Review of the medical record showed Patient #3 had vital signs retaken dated 8/9/2022 at 7:58 PM. Temperature 98.0 F, Blood Pressure 125/59, Pulse 89, Respirations 18, Oxygen Saturation 98% room air. Pain was rated as '4', with the location of abdomen, general.

Review of the medical record showed Patient #3 was not located in the waiting room at 9:35 PM when the facility called him to recheck his blood glucose level. At 9:36 PM, the facility was unable to locate Patient #3 in the waiting room. Patient #3 was listed as Discharge Against Medical Advice/Left Without Being Seen (AMA/LWBS).

During a telephone interview on 3/28/2023 at 1:20 PM, Patient #3's daughter stated her brother accompanied Patient #3 to the facility ED on 8/9/2022. She said Patient #3 waited 4 hours in the ED waiting room, had not been placed in a room, and decided to go home. On 8/10/2022, Patient #3 went to an area hospital (located in another state) and he was admitted. She stated she telephoned the facility twice to complain her father had not been placed in an ED bed. She stated she was told patients were seen in order of their severity.

During a review of Patient #3's medical record and interview on 3/28/2023 at 2:55 PM the Chief Medical Officer (CMO) stated the liver lab work was abnormal. He stated he was unaware of the etiology but stated the cause could be either liver disease or cancer. Upon review of the CT of the Abdomen and Pelvis, he stated the nodality and stranding showed either a growth or fluid which occurred with ascites. He stated the ascites would need treatment, but the vital signs were okay, and he did not require paracentesis at that moment stating his ureters were not blocked "...I don't think this needed to be handled immediately...handled as an outpatient...paracentesis is variable...if he truly couldn't swallow, he would have been bumped up to the front of the line...people who can't swallow are miserable, they can't protect their airway and are a choking risk..."

During an email interview on 4/24/2023 at 9:22 AM the Risk Manager stated the facility did not have a policy for notifying patients of abnormal results after discharge from the ED. She stated they did have a process. She stated the Advanced Practice Clinicians (APC) reviewed abnormalities and determined if a follow-up was necessary. If the abnormality was outside the knowledge or scope of the APC, they were to review the abnormal finding with an ED Medical Physician and create and document a treatment plan. The ED physician would then contact the patient with recommended follow-up. The Risk Manager stated Patient #3 had not been assessed by the provider when he left the ED. He had been evaluated in triage by the Provider in Triage (PIT), who initiated diagnostics. Patient #3 returned to the waiting room. She stated the patient chose to leave after his initial triage and that was the end of the provider's involvement in his care. He left without being seen "...and this is why follow-up with the patient did not occur..."