HospitalInspections.org

Based on observation, interviews and record review, the facility failed to ensure an appropriate medical screening exam (MSE) was performed for Patient #1 based on his presenting symptoms and complaint in 1 of 1 patient identified from 21 sampled patients.


A. The facility failed to ensure an appropriate MSE upon patient's initial presentation to the Emergency Department (ED);

B. The facility failed to complete a complete reassessment the patient when he was returned to the ED after discharge.



Findings:


On 06/15/2020 at 1:50 p.m., Patient #1 was observed in his medical surgical room at Hospital (#1).

Observation revealed the patient was alert and oriented to person, place and time but spoke mostly Spanish. The patient had oxygen in place at 2 liters per minute via nasal cannula and a right peripheral line in place. Two nurses were present in the room providing care and services to the patient. At the request of the Surveyor and approval from the patient, the dressings from the patient's wounds were exposed by the nurses:
Observation of the patient revealed the following: Right foot five toes and foot blackened and necrotic. Left foot toes amputated previously, heel with eschar tissue. Buttock/ sacral area pink with broken skin. The nurse assigned to the patient said it was a stage 1 wound.

Pictures attached which were taken by the Quality Manager during the observation on 06/15/2020.

Interview on 06/15/2020 at 2:00 p.m. with the Registered Nurse assigned to the patient revealed the patient was scheduled for a peripheral angiogram and tentatively for amputation of the right foot.


Review of the Patient's clinical record (demographic data) revealed the patient presented to the facility's emergency room at Hospital campus #3 on 06/05/2020 at 18:34 with chief complaint of lower extremity pain. The Patient was triaged as a level 2.


Review of the Patient's Triaged Sheet dated 06/05/2020 at 18:54 revealed the following entry: "Patient just returned from ------ (Long Term acute care hospital) and on the way home, the family became concern about his dressing on his right foot."

Vital signs documented were as follows: Blood pressure 103/74, Temperature 99 F, Pulse 82 beat per minute, Respiration 24 and SpO2 98% 2/L minute. Pain assessment 0/10.

Assessment by the registered nurse in the emergency room revealed the following documentation: "dressing to r foot. Serosangreaous drainage noted."

There was no documentation that the dressing to the patient's wounds were removed and an assessment done by the registered nurse.


Physician's Emergency Room assessment

Review of the patient's clinical record revealed the following assessment dated 06/05/2020 at 19:29 by the hospital's emergency room physician:

"Chief complaint: wound check. Treated in emergency department (today discharged from hospital). The patient has experienced discharge since the procedure was performed. Patient discharged from hospital in -----today/ daughter saw discharge from foot and brought patient in /not aware that there's wound care nursing coming to change dressing in am/patient no pain or fever)."

"Review of systems: No fever, numbness, weakness, headache, or nausea. No vomiting, chest pain or difficulty breathing. All other systems reviewed and are negative."

"History: problems: peripheral arterial occlusive disease, coronary artery disease, diabetes mellitus, congestive heart failure, amputated toe, diabetes mellitus type 2, hypertension."

"Additional Surgeries: amputation, amputation lower extremities, coronary artery bypass graft."

Physical Exam: Appearance: Oriented x 3. Anxious. No acute distress.

CVS: Heart sound normal

Respiratory: Breath sounds normal

Skin: Oozing wound on right foot- with dressing around. No erythema or tenderness.

Neuro: Oriented X 3"

Progress and procedures: Course of care: patient is stable.

Clinical Impression: "Wound Check."

Disposition: Discharged home in stable condition (18:58 Jun 05, 2020). Condition stable

"Instructions: General Warnings: Return or contact your physician immediately if your condition worsens or changes unexpectedly, if not improving as expected, or if other problems arise."

"Follow up: Follow up with your doctor wound care nurse tomorrow as scheduled for wound check. Reason for referral: evaluation and treatment. Summary of care provided to patient and family."

Review of the patient's clinical record revealed no indication that the dressing done previously from the long term acute care hospital to the patient's right foot was removed by the physician and the patient's foot examined during medical screening of the patient in the facility's emergency room.


Emergency Room Visit of 06/09/2020 at 04:17 a.m.

The patient's record revealed the patient returned to the facility's emergency room on 06/09/2020.

Review of the patient's clinical record (Emergency Care Triage Report) revealed, the patient presented to the emergency room at Hospital campus#3 on 06/09/2020 at 04:17 a.m., transported by EMS with chief complaint of being unresponsive at home.

Review of the patient's triage record dated 06/09/2020 at 04:44 revealed the following documentation: "EMS called due to patient being unresponsive; upon arrival BS found to be in the 40s. One-amp D50 given and patient placed on fluid. BS upon arrival 130. "

Vital signs as documented, Blood pressure 132/64, Temperature 97.8 F, Pulse 86 beat per minute, Respiration 18 and SpO2 91%. There was no pain assessment documented.

Review of the Patient's clinical record revealed a Daily Focus Assessment completed by the registered nurse on 06/09/2020 at 04:40 am with the following documentation: "Integumentary Skin warm, Skin dry, skin intact."

There was no documentation of an assessment of wounds to the patient's lower extremities and sacral area.


Physician's Emergency Room Assessment

Review of the patient's clinical record revealed the following assessment dated 06/09/2020 at 04:20 by the hospital's emergency room physician:

"Chief Complaint: CHANGED MENTAL STATUS AND LOW BLOOD SUGAR. This started prior to arrival, patient was witnessed to be last known well and is now gone. The patient is described as having decreased responsiveness. The patient was found unresponsive. Not a nursing home resident. No history of chronic dementia. No change in diabetic routine, alcohol recently or recent drug use. Prior to arrival, the dextro stick was measured by paramedics and found to be very low (40 at home upon arrival) D 50 was given prior to arrival by paramedics. No weakness, numbness or recent fall. No difficulty walking."

The record indicated physical examination was done by the physician with the following findings:

"Appearance: alert. No acute distress.

Head: atraumatic.

Eyes: Pupils equal, round and reactive to light.

ENT: Normal ENT inspection. Airway intact. Moist mucus membranes. Pharynx normal.

CVS: Normal Heart rate and rhythm. Heart sounds normal. Pulses normal.

Respiratory: No respiratory distress breath sound normal

Abdomen: Soft no organomegaly.

Back: Normal inspection

Skin: warm and dry. Normal skin color. No rash. Normal skin turgor

Extremities: Extremities exhibit normal ROM

Neuro: Alert, Oriented X 3. Mood and affect normal. Speech normal. Cranial nerve normal (as tested) No cerebellar findings. No motor deficit. No sensory deficit."


Course of Treatment

The record indicated that the following course of treatment was provided during the visit:

Peripheral intravenous inserted with 20-gauge needle. Peripheral line (started by EMS)
Complete blood count
General chemistry:
Troponin
Metylyte 8 panel
Chest x-ray

AN ECG was performed on the patient at 4:28:37 a.m. with the following diagnosis: Sinus rhythm with PACs vs junctional rhythm. Right bundle branch block, possible old myocardial infarction, prolonged QTc. Abnormal ECG.

Chest X-ray: Result Impression: "Slightly increasing left pleural effusion appearing partially loculated"
There was no documentation that the ECG was reviewed during the visit.

The course of care documented by the emergency room physician were as follows: 04:36 6/9/2020: "return to normal baseline mental status AAOX3. No complaint per patient at this time or complaint by family. Reviewed med list and advised family to discuss DM meds with PCP tomorrow, advised to monitor BG regularly at least q8 hours."

"Pt on home O2, currently 100%. 91% was taken w/no supplemental O2. There is a slight increase in pleural effusion compared to last month. No CP or SOB endorsed. Patient states that he is feeling otherwise back to baseline. Patient currently on antibiotic for recent amputation. Advised follow up with PCP for med recs. Return precaution given to family.

05:22 Patient is stable. Physical exam findings are unchanged. The patient's symptoms are unchanged.
Blood glucose done by laboratory blood glucose performed at 04:36 a.m. 103 /104 mgs / dl.

The record indicated the patient was discharged from the facility to home at 5:50 a.m. Disposition: "Discharged home in good condition. Condition good and stable"

Review of the patient's clinical record revealed no indication that the wounds to the patient's feet were assessed by the physician during medical screening of the patient.


Emergency Room Visit of 06/09/2020 at 11:50 a.m.

Review of the Patient's clinical record revealed the patient returned to the hospital emergency room on 06/09/2020 at 11:50 a.m.

Review of the patient's clinical record (Emergency Care Triage Report), dated 6/09/2020 at 11:50 a.m. revealed, the patient arrived at Hospital Campus #3 via EMS with the following chief complaint by care giver" Patient caregiver at bedside states FSBS has been low all a.m. and they could not get it up. EMS reports that FSBS have ranged from 32- 56. Patient very lethargic. FSBS 32 upon arrival. Patient responds to commands but confused and lethargic."

Vital signs as documented, Blood pressure 155/66, Temperature 98.1 F, Pulse 62 beat per minute, Respiration 16 and SpO2 91%.


Physician's Emergency Room Assessment

Review of the Patient's clinical record revealed the following assessment, dated 06/09/2020 at 12:00 by the hospital's emergency room physician:

"Chief Complaint: DECREASED MENTAL STATUS AND LOW BLOOD SUGAR. This started today and is still present. It was an abrupt onset and is still constant. The patient is described as having decreased responsiveness. The patient was found unresponsive. Not a nursing home resident. No history of chronic dementia. No change in diabetic routine, alcohol recently, recent drug use or medication given prior to arrival. Prior to arrival, the dextro stick was low. The patient has had weakness. No numbness or recent fall. No difficulty walking."

Past Medical History: Coronary artery disease, congestive heart failure, hypertension, peripheral vascular disease, pulmonary hypertension, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, moderate renal failure.

Surgeries: amputation of lower extremity (Partial left foot) coronary artery bypass surgery.

The record indicated physical examination was done by the physician with the following findings:

"Vital signs have been reviewed as normal and appear to be correct.

Appearance: alert. No acute distress.

Head: Head atraumatic.

Eyes: Pupils equal, round and reactive to light.

ENT: Normal ENT inspection. Airway intact. Moist mucus membranes. Pharynx normal.

Neck: Normal inspection. Neck supple

CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal.

Respiratory: No respiratory distress. Breath sound normal

Abdomen: Soft and nontender. No organomegaly

Back: Normal inspection

Skin: Warm and dry. Normal skin color. No rash. Normal skin turgor

Extremities: Extremities exhibit normal ROM. No lower extremity edema.

Neuro: Alert, Oriented X3. Mood/ affect normal. Speech normal. Cranial nerve normal (as tested) No cerebellar findings. No motor deficit. No sensory deficit. Reflexes normal."


Course of Treatment

The record indicated that the following course of treatment was provided during the visit:

11:55 a.m.: Peripheral intravenous inserted with 18 -gauge needle. Peripheral line (started by RN)

12:02 D50 bolus administered on arrival.

12:11 p.m. D10 started on pump at 100 mls/ hour. 250 mls administered. Patient is more awake and oriented. FSBS 132. Family at bedside.

15:20: D50, 50 mls administered

15:20: D10, 250 mls administered

Complete blood count.

Metylyte 8 panel

Glucose Testing

Glucometer testing


Review of measurement report:

Review of the patients record revealed the following blood glucose results documented in the emergency room:

06/09/2020 at 11:59 a.m. blood glucose level 32 mg/ dl

06/09/2020 at 12:18 p.m. blood glucose level 132 mg/ dl

06/09/2020 at 12:56 p.m. blood glucose level 89 mg/ dl

06/09/2020 at 13:49 p.m. blood glucose level 79 mg/ dl

06/09/2020 at 15:08 p.m. blood glucose level 68 mg/ dl

Blood glucose done by laboratory, blood glucose performed at 12:49 p.m. 75 mgs / dl.


Review of the physician's progress and procedure documentation revealed the following entry: "15:12 Evaluation after repeat exam. IV fluids and glucose. Patient is stable. Physical exam findings are improved. Symptoms better. "

Disposition: Hypoglycemia without coma- associated with type 2 diabetes and use of oral hypoglycemic."
The patient was discharged to home on 06/09/2020 at 15:20.

There was no indication in the registered nurse's assessment that a complete skin assessment including the wounds on the patient's feet were assessed.

There was no documentation that a complete skin assessment, including the wounds to the patient's feet was done by the physician during medical screening of the patient in the emergency room. The physician documented the following : " Extremities exhibit normal ROM. No lower extremity edema."


Admission 06/09/2020 at 17:21 p.m.

Review of the patient's clinical record revealed the patient was taken to Hospital campus #1 on 06/09/2020 at 17:21 p.m .

Review of the patient's clinical record (Physician assessment) revealed the patient presented to the emergency room at Hospital Campus #1 on 06/09/2020 at 17:21 via ambulance, accompanied by family with chief complaint of hypoglycemia. The patient was admitted from home.

Blood glucose level performed via Glucometer at 17:53 indicated a blood glucose level of 48 mgs/ dl.

The record indicated the Patient was admitted to the telemetry unit at 18:51 p.m. with clinical impression of hypoglycemia without coma- associated with type 2 diabetes and use of oral hypoglycemia and elevated Troponin.


Review of History and Physical

Review of the patient's clinical record revealed a history and physical completed by the nurse practitioner dated 06/10/2020 at 13:32 with the following documentation:

"Patient is a poor historian most of his history is obtained from chart review and from Granddaughter over the phone. As per her, pt's blood sugar has been dropping and he was taken to "Campus #3 ER" and was sent home after stabling his blood sugar. Over the weekend his blood sugar stayed low and patient was taken to the ER again on 6/9/2020. His blood sugar was 48. As per family, patient takes only Metformin and was held, his Po intake was also poor. Patient was admitted here at OBMC in beginning of May, his stay was complicated with cardiac arrest, patient was eventually discharged to "LTAC". As per granddaughter patient came home on 6/5/2020 from "LTAC".

"On assessment Pt's right foot toes are black in color, cold to touch and right lower legs with draining wounds. Per granddaughter she is unsure if he had any vascular surgery evaluation after he left OBMC, states it was black in color with draining wounds when he came from "LTAC"."


"Physical Exam

Extremities: LT foot with TMA, RT foot all toe black in color. Unable to palpate pulse, draining wound in lower leg toes cold to touch, edema1+.

Assessment and plan:

Hypoglycemia possibly related to acute infection from right foot

Sepsis POA with hypoglycemia and cellulitis right foot.

Ischemic right toe with open wounds, history of PAD

Elevated Troponin with history of coronary artery disease

Hypertension, congestive heart failure

Chronic kidney disease

Anemia of chronic disease

Deep vein thrombosis


Wound Care Assessment

Review of a wound care assessment, completed on 06/11/2020 at 18:10 revealed the following documentation:

"Wound care consultation 6/11/2020. 78-year-old male in bedside chair with c/o BLE diabetic ulcers. Left heel DFU3x2 5X0. I cm partial thickness denuded skin, small serosangreaous, no odor. Macerated. left TMA site wound 7x1.1 x0.2 cm, fibrin dried, no drainage diminished pulses to left foot. Right leg diabetic ulcer noted., posterior leg ulcer 8.5 x 7.9 x 0.1 cm red slough eschar edges pale pink, cool. Small serosangreaous drainage, no odor painful for patient to be touched. Right anterior leg ulcer 7.5 x 3.58 x 0. 1 cm pink crusted edges cool. Right heel DFU 5.5 x 5x0.1 CM denuded skin peri wound, moderate Serosangreaous drainage, eschar covering ulcer, edges macerated and cool. RT foot has severe mixed ischemic arterial diabetic foot ulcer, Wagner grade 5, measuring 16.5 x 26 X 0.2 cm, dorsal foot has pale pink tissue denuded skin, slough and eschar noted to areas, maceration on plantar surface of wound that is circumferential of whole foot. No palpable pulse, foot cold moderate serosangreaous drainage. Unable to assess cap refill. Gangrenous changes to 1- 5th toes to right foot hard, black tissue to all toes, non-viable. Toes also included in wound measurement. base of toes cold, moist denuded tissue, ischemic skin changes. No odor."

"Recommendation: (1) cleans with NS 20 betadine paint all wounds, cover with gauze, kerlix daily and PRN soiling 30 consult podiatry: Dr ----consult vascular surgeon, Dr -----) right foot may not be salvageable. Dr ------."


Review of Physician K's progress notes

Review of the patient's record revealed a physician's progress note dated 06/15/2020 with the following documentation:" Impression: Right foot cellulitis with concern for dry gangrene. Patient has clinical and radiographic osteomyelitis.

Plan: Awaiting for podiatry's recommendation. Patient will require Transmetatarsal amputation or below knee amputation."


Interviews

Dr F (Emergency Room Physician)

An interview was conducted with Dr F (Emergency Room Physician) via the telephone, on 06/18/2020 at 8:54 a.m.

During the interview, he stated that saw the patient on 06/09/2020 at the Hospital Campus #1 emergency room. He said the patient had hypoglycemia and had been discharged from the Hospital Campus #3.

He said during the patient's assessment, he focused on the patient's presenting symptom of hypoglycemia because his blood sugar was low. He said he did not see the wounds, but he believed there were dressing on it.

He said the patient was not stable in terms of his sugar (hypoglycemia)." The main thing was his hypoglycemia. I wanted to keep him because of his hypoglycemia and secondary his elevated Troponin."

He said he did not mention anything about the wounds except the amputation. Dr (K) said he had not seen the patient since the emergency room visit because he is busy with COVID 19 patients.

When asked about the admission on 06/05/2020, he said he did not remove the dressing to the patient's foot during his assessment.


Interviewed Dr G (Emergency Room Physician)

During an interview via the telephone on 06/18/2020 at 9:07 a.m. with Dr (G), revealed, he said the patient came to the Hospital campus #3 campus emergency room with hypoglycemia. He said the patient had dressings on his leg, but he did not see the wounds because he was told by the family that it had just been dressed, and so he did not remove the dressings. He said the patient had already taken his medication and may have taken a double dose or had not eaten. He said there was a granddaughter present who told him the patient does not eat at nights. He then instructed the granddaughter that the patient should not be taking hypoglycemic medication if the patient was not eating.

He said he instructed the daughter that the patient needed a quick follow up in the morning with his primary care physician, and should return to the emergency room if needed. He said the patient was already on antibiotic and up and talking so he did not see the need for in- patient admission.

He said if patients warranted in- patient admission then he calls the bed manager and then a decision is made to transfer the patient to the Hospital Campus #2 or Hospital Campus #1. He said if there is no capability or capacity to admit patients to those campuses them another hospital is consulted.

Subsequent interview via the telephone on 06/18/2020 at 2:52 p.m. with DR (G)regarding the ECG report indicating abnormal ECG. Doctor (G) said he had reviewed the ECG report, but since the patient did not have presenting symptom of shortness of breath, cardiac event and elevated Troponin, he wrote no acute process.

The Surveyor informed him that the ECG result provided indicated it was not reviewed. Dr G said he signs and review all ECG results but the computer sometime spits out extra copies and the staff throws away the signed copy at times.


Interviewed Nurse Practitioner ( I).

During an interview via the telephone on 06/18/2020 at 9:18 a.m. with Registered Nurse Practitioner (I) revealed, she saw the patient at Hospital Campus #1 on 6/10/2020. She said the granddaughter told her that the patient was transferred from LTAC with the blackened wound that was draining. She said the patient had a dressing on and she opened it and it was blackened in color.


Interviewed Registered Nurse (E)

During an interview via the telephone on 06/18/2020 at 11:10 a.m. with Registered Nurse (E) who said he was the Emergency Room Director for all three campuses, he saw the patient on 06/05/2020 at the Hospital Campus #3 emergency room. He said the family was concern about the wound on the patient's right foot but was more concern about discharge planning and whether Dr (K) had seen the patient prior to discharge at (LTAC). He said he spoke with Dr (K) and the staff at the LTAC about the patient's concern.
He said the wound was slightly visible and he could see part of the wound, but he did not remove the dressing.

The Surveyor informed him that he had documented that there was serosangreaous drainage on the right foot. Registered Nurse (E) stated that the dressing was not soaked or saturated. It was at the base of the foot that there was drainage.

He said the Patient's granddaughter had pictures of the wound as they were dressing it at the LTAC.


Interviewed Registered Nurse (D)

During an interview on 06/18/2020 at 2:35 p.m. with Registered Nurse (D) revealed she has being working at the facility for approximately two years. She said she took care of the patient on 6/9/2020 on the night shift. She said the patient came in with low blood sugar and she conducted a focus assessment. She said she cannot recall if the patient had a dressing. She said as a nurse in the emergency room, she is responsible for triaging, assessing the patient and drawing laboratory samples.

She said she focused on neurological assessment, the patient was Spanish speaking but Dr G said the patient's blood sugar dropped because he did not eat snacks.

The Surveyor informed her that she had documented on her assessment that the patient's skin was intact, but patient had wounds to his buttocks and feet Registered Nurse (D) said "I did not fully undress him. I don't remember if the patient had dressings."


Interviewed Registered Nurse (M)

During an interview via the telephone on 06/18/2020 at 3:18 p.m. with Registered Nurse (M), revealed she provided care to the patient on 06/09/2020 in the emergency room. She said the patient was fully assist, his blood sugar was low, and he was not speaking. The patient's primary language was Spanish. She said she changed him because he was wet, administered D50 to the patient and had him on a drip of D5.

She said the patient's granddaughter who was present, told her the patient was not eating and had difficulty swallowing that morning. She said she gave him some juice x 3 to get his blood sugar up.

She said the patient had duoderm to his bottom. She said the granddaughter said he had home health. She stated "she asked me to do the dressing, but I told her wound care would be done by the wound care nurse at home, since he had home health. I did not unwrap the wound. From what I was told we do not need to unwrap the wound. I need to slow down."


Interviewed Dr (H)

During an interview via the telephone on 06/22/2020 at 8:55 a.m. with Dr (H)revealed, he saw the patient at Hospital Campus #3. He said the patient was brought in accompanied by caregiver. He said the patient responded a little slow, his sugar was 40s and so he gave him dextrose 50 and he started responding.

He said the patient stayed in the emergency room for approximately 3 - 4 hours and finger stick were done hourly. He said the last finger stick was approximately 78. The patient was eating and drinking all the juice given to him.

He said he was told by the caregiver that the patient was taking Metformin 1000 mgs daily and so he told the caregiver to skip the medicine.

The Surveyor asked the physician about the condition of patient's right foot. He said he cannot recall how the patient's foot looked, but the patient did not complain of his foot. He said the patient's vital signs were stable on discharge.

Based on observation, interview and record review, the facility failed to stabilize a patient with an emergency medical condition, who presented to the hospital's emergency room in that the patient presented to the facility's emergency room on two separate dates at numerous times without facility's staff providing necessary treatment and stabilized the patient's emergency medical condition. This contributed to a delay in treatment and stabilization of the patient's medical condition, in 1 of 1 patient identified from 21 sampled patients.

[citing Patient #1]

Findings:



On 06/15/2020 at 1:50 p.m. Patient #1 was observed in his medical surgical room at Hospital (#1).

Observation revealed the patient was alert and oriented to person, place and time but spoke mostly Spanish. The patient had oxygen in place at 2 liters per minute via nasal cannula and a right peripheral line in place. Two nurses were present in the room providing care and services to the patient. At the request of the Surveyor and approval from the patient, the dressings from the patient's wounds were exposed by the nurses:
Observation of the patient revealed the following: Right foot five toes and foot blackened and necrotic. Left foot toes amputated previously, heel with eschar tissue. Buttock/ sacral area pink with broken skin. The nurse assigned to the patient said it was a stage 1 wound.

Pictures attached which were taken by the Quality Manager during the observation on 06/15/2020.

Interview on 06/15/2020 at 2:00 p.m. with the Registered Nurse assigned to the patient revealed the patient was scheduled for a peripheral angiogram and tentatively for amputation of the right foot.


Patient's Visit 6/05/2020

Review of the Patient's clinical record (demographic data) revealed the patient presented to the facility's emergency room at Hospital campus #3 on 06/05/2020 at 18:34 with chief complaint of lower extremity pain. The Patient was triaged as a level 2.

Review of the Patient's Triaged Sheet dated 06/05/2020 at 18:54 revealed the following entry: "Patient just returned from ------ (Long Term acute care hospital) and on the way home the family became concern about his dressing on his right foot."

Vital signs documented were as follows: Blood pressure 103/74, Temperature 99 F, Pulse 82 beat per minute, Respiration 24 and SpO2 98% 2/L minute. Pain assessment 0/10.

Assessment by the registered nurse in the emergency room revealed the following documentation: "dressing to r foot. Serosangreaous drainage noted."

There was no documentation that the dressing to the patient's wounds were removed and an assessment done by the registered nurse.


Physician's Emergency Room assessment

Review of the patient's clinical record revealed the following assessment dated 06/05/2020 at 19:29 by the hospital's emergency room physician:

"Chief complaint: wound check. Treated in emergency department (today discharged from hospital). The patient has experienced discharge since the procedure was performed. Patient discharged from hospital in -----today/ daughter saw discharge from foot and brought patient in /not aware that there's wound care nursing coming to change dressing in am/patient no pain or fever)."

"Review of systems: No fever, numbness, weakness, headache, or nausea. No vomiting, chest pain or difficulty breathing. All other systems reviewed and are negative."

"History: problems: peripheral arterial occlusive disease, coronary artery disease, diabetes mellitus, congestive heart failure, amputated toe, diabetes mellitus type 2, hypertension."

"Additional Surgeries: amputation, amputation lower extremities, coronary artery bypass graft."

Physical Exam: Appearance: Oriented x 3. Anxious. No acute distress.

CVS: Heart sound normal

Respiratory: Breath sounds normal

Skin: Oozing wound on right foot- with dressing around. No erythema or tenderness.

Neuro: Oriented X 3"

Progress and procedures: Course of care: patient is stable.

Clinical Impression: "Wound Check."

Disposition: Discharged home in stable condition (18:58 Jun 05, 2020). Condition stable

"Instructions: General Warnings: Return or contact your physician immediately if your condition worsens or changes unexpectedly, if not improving as expected, or if other problems arise."

"Follow up: Follow up with your doctor wound care nurse tomorrow as scheduled for wound check. Reason for referral: evaluation and treatment. Summary of care provided to patient and family."

Review of the patient's clinical record revealed no indication that the dressing done previously from the long term acute care hospital to the patient's right foot was removed by the physician and the patient's foot examined during medical screening of the patient in the facility's emergency room.

The Facility's staff not examining the patient's wounds at the time of assessment caused a delay in treatment to the patient.


Emergency Room Visit of 06/09/2020 at 04:17 a.m.

The patient's record revealed the patient returned to the facility's emergency room on 06/09/2020.

Review of the patient's clinical record (Emergency Care Triage Report) revealed, the patient presented to the emergency room at Hospital campus#3 on 06/09/2020 at 04:17 a.m., transported by EMS with chief complaint of being unresponsive at home.

Review of the patient's triage record dated 06/09/2020 at 04:44 revealed the following documentation: "EMS called due to patient being unresponsive; upon arrival BS found to be in the 40s. One-amp D50 given and patient placed on fluid. BS upon arrival 130. "

Vital signs as documented, Blood pressure 132/64, Temperature 97.8 F, Pulse 86 beat per minute, Respiration 18 and SpO2 91%. There was no pain assessment documented.

Review of the Patient's clinical record revealed a Daily Focus Assessment completed by the registered nurse on 06/09/2020 at 04:40 am with the following documentation: "Integumentary Skin warm, Skin dry, skin intact."

There was no documentation of an assessment of wounds to the patient's lower extremities and sacral area.


Physician's Emergency Room Assessment

Review of the patient's clinical record revealed the following assessment dated 06/09/2020 at 04:20 by the hospital's emergency room physician:
"Chief Complaint: CHANGED MENTAL STATUS AND LOW BLOOD SUGAR. This started prior to arrival, patient was witnessed to be last known well and is now gone. The patient is described as having decreased responsiveness. The patient was found unresponsive. Not a nursing home resident. No history of chronic dementia. No change in diabetic routine, alcohol recently or recent drug use. Prior to arrival, the dextro stick was measured by paramedics and found to be very low (40 at home upon arrival) D 50 was given prior to arrival by paramedics. No weakness, numbness or recent fall. No difficulty walking."

The record indicated physical examination was done by the physician with the following findings:

"Appearance: alert. No acute distress.

Head: atraumatic.

Eyes: Pupils equal, round and reactive to light.

ENT: Normal ENT inspection. Airway intact. Moist mucus membranes. Pharynx normal.

CVS: Normal Heart rate and rhythm. Heart sounds normal. Pulses normal.

Respiratory: No respiratory distress breath sound normal

Abdomen: Soft no organomegaly.

Back: Normal inspection

Skin: warm and dry. Normal skin color. No rash. Normal skin turgor

Extremities: Extremities exhibit normal ROM

Neuro: Alert, Oriented X 3. Mood and affect normal. Speech normal. Cranial nerve normal (as tested) No cerebellar findings. No motor deficit. No sensory deficit."


Course of Treatment

The record indicated that the following course of treatment was provided during the visit:

Peripheral intravenous inserted with 20-gauge needle. Peripheral line (started by EMS)

Complete blood count
General chemistry:
Troponin
Metylyte 8 panel
Chest x-ray

AN ECG was performed on the patient at 4:28:37 a.m. with the following diagnosis: Sinus rhythm with PACs vs junctional rhythm. Right bundle branch block, possible old myocardial infarction, prolonged QTc. Abnormal ECG.

Chest X-ray: Result Impression: "Slightly increasing left pleural effusion appearing partially loculated"
There was no documentation that the ECG was reviewed during the visit.

The course of care documented by the emergency room physician were as follows: 04:36 6/9/2020: "return to normal baseline mental status AAOX3. No complaint per patient at this time or complaint by family. Reviewed med list and advised family to discuss DM meds with PCP tomorrow, advised to monitor BG regularly at least q8 hours."

"Pt on home O2, currently 100%. 91% was taken w/no supplemental O2. There is a slight increase in pleural effusion compared to last month. No CP or SOB endorsed. Patient states that he is feeling otherwise back to baseline. Patient currently on antibiotic for recent amputation. Advised follow up with PCP for med recs. Return precaution given to family.

05:22 Patient is stable. Physical exam findings are unchanged. The patient's symptoms are unchanged. Blood glucose done by laboratory blood glucose performed at 04:36 a.m. 103 /104 mgs / dl.

The record indicated the patient was discharged from the facility to home at 5:50 a.m. Disposition: "Discharged home in good condition. Condition good and stable"

Review of the patient's clinical record revealed no indication that the wounds to the patient's feet were assessed by the physician during medical screening of the patient. The Facility's staff not examining the patient's wounds at the time of assessment caused a delay in treatment to the patient.


Emergency Room Visit of 06/09/2020 at 11:50 a.m.

Review of the Patient's clinical record revealed the patient returned to the hospital emergency room on 06/09/2020 at 11:50 a.m.

Review of the patient's clinical record (Emergency Care Triage Report), dated 6/09/2020 at 11:50 a.m. revealed, the patient arrived at Hospital Campus #3 via EMS with the following chief complaint by care giver" Patient caregiver at bedside states FSBS has been low all a.m. and they could not get it up. EMS reports that FSBS have ranged from 32- 56. Patient very lethargic. FSBS 32 upon arrival. Patient responds to commands but confused and lethargic."

Vital signs as documented, Blood pressure 155/66, Temperature 98.1 F, Pulse 62 beat per minute, Respiration 16 and SpO2 91%.


Physician's Emergency Room Assessment

Review of the Patient's clinical record revealed the following assessment, dated 06/09/2020 at 12:00 by the hospital's emergency room physician:

"Chief Complaint: DECREASED MENTAL STATUS AND LOW BLOOD SUGAR. This started today and is still present. It was an abrupt onset and is still constant. The patient is described as having decreased responsiveness. The patient was found unresponsive. Not a nursing home resident. No history of chronic dementia. No change in diabetic routine, alcohol recently, recent drug use or medication given prior to arrival. Prior to arrival, the dextro stick was low. The patient has had weakness. No numbness or recent fall. No difficulty walking."

Past Medical History: Coronary artery disease, congestive heart failure, hypertension, peripheral vascular disease, pulmonary hypertension, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, moderate renal failure.
Surgeries: amputation of lower extremity (Partial left foot) coronary artery bypass surgery.

The record indicated physical examination was done by the physician with the following findings:

"Vital signs have been reviewed as normal and appear to be correct.

Appearance: alert. No acute distress.

Head: Head atraumatic.

Eyes: Pupils equal, round and reactive to light.

ENT: Normal ENT inspection. Airway intact. Moist mucus membranes. Pharynx normal.

Neck: Normal inspection. Neck supple

CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal.

Respiratory: No respiratory distress. Breath sound normal

Abdomen: Soft and nontender. No organomegaly

Back: Normal inspection

Skin: Warm and dry. Normal skin color. No rash. Normal skin turgor

Extremities: Extremities exhibit normal ROM. No lower extremity edema.

Neuro: Alert, Oriented X3. Mood/ affect normal. Speech normal. Cranial nerve normal (as tested) No cerebellar findings. No motor deficit. No sensory deficit. Reflexes normal."


Course of Treatment

The record indicated that the following course of treatment was provided during the visit:

11:55 a.m.: Peripheral intravenous inserted with 18 -gauge needle. Peripheral line (started by RN)

12:02 D50 bolus administered on arrival.

12:11 p.m. D10 started on pump at 100 mls/ hour. 250 mls administered. Patient is more awake and oriented. FSBS 132. Family at bedside.

15:20: D50, 50 mls administered

15:20: D10, 250 mls administered

Complete blood count.
Metylyte 8 panel
Glucose Testing
Glucometer testing


Review of measurement report:

Review of the patients record revealed the following blood glucose results documented in the emergency room:

06/09/2020 at 11:59 a.m. blood glucose level 32 mg/ dl
06/09/2020 at 12:18 p.m. blood glucose level 132 mg/ dl
06/09/2020 at 12:56 p.m. blood glucose level 89 mg/ dl
06/09/2020 at 13:49 p.m. blood glucose level 79 mg/ dl
06/09/2020 at 15:08 p.m. blood glucose level 68 mg/ dl

Blood glucose done by laboratory, blood glucose performed at 12:49 p.m. 75 mgs / dl.

Review of the physician's progress and procedure documentation revealed the following entry: "15:12 Evaluation after repeat exam. IV fluids and glucose. Patient is stable. Physical exam findings are improved. Symptoms better. "

Disposition: Hypoglycemia without coma- associated with type 2 diabetes and use of oral hypoglycemic."
The patient was discharged to home on 06/09/2020 at 15:20.

There was no indication in the registered nurse's assessment that a complete skin assessment including the wounds on the patient's feet were assessed.

There was no documentation that a complete skin assessment, including the wounds to the patient's feet was done by the physician during medical screening of the patient in the emergency room. The physician documented the following : " Extremities exhibit normal ROM. No lower extremity edema."

The Facility's staff not examining the patient's wounds at the time of assessment caused a delay in treatment to the patient.



Admission 06/09/2020 at 17:21 p.m.

Review of the patient's clinical record revealed the patient was taken to Hospital campus #1 on 06/09/2020 at 17:21 p.m .

Review of the patient's clinical record (Physician assessment) revealed the patient presented to the emergency room at Hospital Campus #1 on 06/09/2020 at 17:21 via ambulance, accompanied by family with chief complaint of hypoglycemia. The patient was admitted from home.
Blood glucose level performed via Glucometer at 17:53 indicated a blood glucose level of 48 mgs/ dl.

The record indicated the Patient was admitted to the telemetry unit at 18:51 p.m. with clinical impression of hypoglycemia without coma- associated with type 2 diabetes and use of oral hypoglycemia and elevated Troponin.


Review of History and Physical

Review of the patient's clinical record revealed a history and physical completed by the nurse practitioner dated 06/10/2020 at 13:32 with the following documentation:

"Patient is a poor historian most of his history is obtained from chart review and from Granddaughter over the phone. As per her, pt's blood sugar has been dropping and he was taken to "Campus #3 ER" and was sent home after stabling his blood sugar. Over the weekend his blood sugar stayed low and patient was taken to the ER again on 6/9/2020. His blood sugar was 48. As per family, patient takes only Metformin and was held, his Po intake was also poor. Patient was admitted here at OBMC in beginning of May, his stay was complicated with cardiac arrest, patient was eventually discharged to "LTAC". As per granddaughter patient came home on 6/5/2020 from "LTAC".

"On assessment Pt's right foot toes are black in color, cold to touch and right lower legs with draining wounds. Per granddaughter she is unsure if he had any vascular surgery evaluation after he left OBMC, states it was black in color with draining wounds when he came from "LTAC"."


"Physical Exam
Extremities: LT foot with TMA, RT foot all toe black in color. Unable to palpate pulse, draining wound in lower leg toes cold to touch, edema1+.
Assessment and plan:

Hypoglycemia possibly related to acute infection from right foot

Sepsis POA with hypoglycemia and cellulitis right foot.

Ischemic right toe with open wounds, history of PAD

Elevated Troponin with history of coronary artery disease

Hypertension, congestive heart failure

Chronic kidney disease

Anemia of chronic disease

Deep vein thrombosis


Wound Care Assessment

Review of a wound care assessment, completed on 06/11/2020 at 18:10 revealed the following documentation:

"Wound care consultation 6/11/2020. 78-year-old male in bedside chair with c/o BLE diabetic ulcers. Left heel DFU3x2 5X0. I cm partial thickness denuded skin, small serosangreaous, no odor. Macerated. left TMA site wound 7x1.1 x0.2 cm, fibrin dried, no drainage diminished pulses to left foot. Right leg diabetic ulcer noted., posterior leg ulcer 8.5 x 7.9 x 0.1 cm red slough eschar edges pale pink, cool. Small serosangreaous drainage, no odor painful for patient to be touched. Right anterior leg ulcer 7.5 x 3.58 x 0. 1 cm pink crusted edges cool. Right heel DFU 5.5 x 5x0.1 CM denuded skin peri wound, moderate Serosangreaous drainage, eschar covering ulcer, edges macerated and cool. RT foot has severe mixed ischemic arterial diabetic foot ulcer, Wagner grade 5, measuring 16.5 x 26 X 0.2 cm, dorsal foot has pale pink tissue denuded skin, slough and eschar noted to areas, maceration on plantar surface of wound that is circumferential of whole foot. No palpable pulse, foot cold moderate serosangreaous drainage. Unable to assess cap refill. Gangrenous changes to 1- 5th toes to right foot hard, black tissue to all toes, non-viable. Toes also included in wound measurement. base of toes cold, moist denuded tissue, ischemic skin changes. No odor."

"Recommendation: (1) cleans with NS 20 betadine paint all wounds, cover with gauze, kerlix daily and PRN soiling 30 consult podiatry: Dr ----consult vascular surgeon, Dr -----) right foot may not be salvageable. Dr ------."


Review of Physician K's progress notes

Review of the patient's record revealed a physician's progress note dated 06/15/2020 with the following documentation:" Impression: Right foot cellulitis with concern for dry gangrene. Patient has clinical and radiographic osteomyelitis.
Plan: Awaiting for podiatry's recommendation. Patient will require Transmetatarsal amputation or below knee amputation."


Interviews

Dr F (Emergency Room Physician)

An interview was conducted with Dr F (Emergency Room Physician) via the telephone, on 06/18/2020 at 8:54 a.m.

During the interview he stated that saw the patient on 06/09/2020 at the Hospital Campus #1 emergency room. He said the patient had hypoglycemia and had been discharged from the Hospital Campus #3.

He said during the patient's assessment, he focused on the patient's presenting symptom of hypoglycemia because his blood sugar was low. He said he did not see the wounds, but he believed there were dressing on it.

He said the patient was not stable in terms of his sugar (hypoglycemia)." The main thing was his hypoglycemia. I wanted to keep him because of his hypoglycemia and secondary his elevated Troponin."

He said he did not mention anything about the wounds except the amputation. Dr (K) said he had not seen the patient since the emergency room visit because he is busy with COVID 19 patients.

When asked about the admission on 06/05/2020, he said he did not remove the dressing to the patient's foot during his assessment.


Interviewed Dr G (Emergency Room Physician)

During an interview via the telephone on 06/18/2020 at 9:07 a.m. with Dr (G), revealed he said the patient came to the Hospital campus #3 campus emergency room with hypoglycemia. He said the patient had dressings on his leg, but he did not see the wounds because he was told by the family that it had just been dressed, and so he did not remove the dressings. He said the patient had already taken his medication and may have taken a double dose or had not eaten. He said there was a granddaughter present who told him the patient does not eat at nights. He then instructed the granddaughter that the patient should not be taking hypoglycemic medication if the patient was not eating.

He said he instructed the daughter that the patient needed a quick follow up in the morning with his primary care physician, and should return to the emergency room if needed. He said the patient was already on antibiotic and up and talking so he did not see the need for in- patient admission.
He said if patients warranted in- patient admission then he calls the bed manager and then a decision is made to transfer the patient to the Hospital Campus #2 or Hospital Campus #1. He said if there is no capability or capacity to admit patients to those campuses them another hospital is consulted.

Subsequent interview via the telephone on 06/18/2020 at 2:52 p.m. with DR (G)regarding the ECG report indicating abnormal ECG. Doctor (G) said he had reviewed the ECG report, but since the patient did not have presenting symptom of shortness of breath, cardiac event and elevated Troponin, he wrote no acute process.

The Surveyor informed him that the ECG result provided indicated it was not reviewed.
Dr G said he signs and review all ECG results but the computer sometime spits out extra copies and the staff throws away the signed copy at times.


Interviewed Nurse Practitioner ( I).

During an interview via the telephone on 06/18/2020 at 9:18 a.m. with Registered Nurse Practitioner (I) revealed, she saw the patient at Hospital Campus #1 on 6/10/2020. She said the granddaughter told her that the patient was transferred from LTAC with the blackened wound that was draining. She said the patient had a dressing on and she opened it and it was blackened in color.


Interviewed Registered Nurse (E)

During an interview via the telephone on 06/18/2020 at 11:10 a.m. with Registered Nurse (E) who said he was the Emergency Room Director for all three campuses, he saw the patient on 06/05/2020 at the Hospital Campus #3 emergency room. He said the family was concern about the wound on the patient's right foot but was more concern about discharge planning and whether Dr (K) had seen the patient prior to discharge at (LTAC). He said he spoke with Dr (K) and the staff at the LTAC about the patient's concern.

He said the wound was slightly visible and he could see part of the wound, but he did not remove the dressing.

The Surveyor informed him that he had documented that there was serosangreaous drainage on the right foot. Registered Nurse (E) stated that the dressing was not soaked or saturated. It was at the base of the foot that there was drainage.

He said the Patient's granddaughter had pictures of the wound as they were dressing it at the LTAC.


Interviewed Registered Nurse (D)

During an interview on 06/18/2020 at 2:35 p.m. with Registered Nurse (D) revealed she has being working at the facility for approximately two years. She said she took care of the patient on 6/9/2020 on the night shift. She said the patient came in with low blood sugar and she conducted a focus assessment. She said she cannot recall if the patient had a dressing. She said as a nurse in the emergency room, she is responsible for triaging, assessing the patient and drawing laboratory samples.

She said she focused on neurological assessment, the patient was Spanish speaking but Dr G said the patient's blood sugar dropped because he did not eat snacks.

The Surveyor informed her that she had documented on her assessment that the patient's skin was intact, but patient had wounds to his buttocks and feet Registered Nurse (D) said "I did not fully undress him. I don't remember if the patient had dressings."


Interviewed Registered Nurse (M)

During an interview via the telephone on 06/18/2020 at 3:18 p.m. with Registered Nurse (M), revealed she provided care to the patient on 06/09/2020 in the emergency room. She said the patient was fully assist, his blood sugar was low, and he was not speaking. The patient's primary language was Spanish. She said she changed him because he was wet, administered D50 to the patient and had him on a drip of D5.
She said the patient's granddaughter who was present, told her the patient was not eating and had difficulty swallowing that morning. She said she gave him some juice x 3 to get his blood sugar up.

She said the patient had duoderm to his bottom. She said the granddaughter said he had home health. She stated "she asked me to do the dressing, but I told her wound care would be done by the wound care nurse at home, since he had home health. I did not unwrap the wound. From what I was told we do not need to unwrap the wound. I need to slow down."


Interviewed Dr (H)

During an interview via the telephone on 06/22/2020 at 8:55 a.m. with Dr (H)revealed, he saw the patient at Hospital Campus #3. He said the patient was brought in accompanied by caregiver. He said the patient responded a little slow, his sugar was 40s and so he gave him dextrose 50 and he started responding.

He said the patient stayed in the emergency room for approximately 3 - 4 hours and finger stick were done hourly. He said the last finger stick was approximately 78. The patient was eating and drinking all the juice given to him.
He said he was told by the caregiver that the patient was taking Metformin 1000 mgs daily and so he told the caregiver to skip the medicine.

The Surveyor asked the physician about the condition of patient's right foot. He said he cannot recall how the patient's foot looked, but the patient did not complain of his foot. He said the patient's vital signs were stable on discharge.


Review of Facility's current policy and procedure.

Review of the facility's current policy and procedure on Emergency Medical Treatment and Patient Transfer (effective 7/1/1990 and reviewed 2/2019 ) directed staff as follows: " the term stabilize means with respect to an emergency medical condition to provide with medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from the transfer of the individual from the facility or with respect in labor, that the woman has delivered (including the placenta) .

The term "transfer" means the movement ( including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by ( affiliated or associated, directly or indirectly with the hospital) but does not include a movement of an individual who has declared dead or leaves the facility without permission of any such person."