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Based on review of 39 Emergency Department (ED) Records, review of documentation and interviews, it was determined that the Hospital failed to provide appropriate medical screening examinations to Patient #1 during 2 consecutive visits occurring at ED (A) on 12/15/12 and 12/16/12.

Findings include:

ED VISIT #1 AT ED (A)

Triage documentation dated 12/15/12 at 8:35 P.M. indicated Patient #1 was brought to ED (A) by a group home caregiver (Caregiver #1) because Patient #1 was refusing to eat, drink and take medications. The Triage documentation indicated Patient #1 was alert, non-verbal and agitated. The Triage documentation indicated Patient #1 would not allow vital signs to be taken.

The Physician who evaluated Patient #1 on 12/15/12 (Physician #1) was interviewed at 2:00 P.M. on 1/30/13. Physician #1 said Patient #1 was known by the majority of the ED staff and had numerous visits to the ED. Physician #1 said Patient #1 demonstrated that he/she has a medical problem by displaying agitation, refusal to eat, drink and take medications.

Physician Notes completed by ED Physician #1 on 12/15/12 (time not recorded) indicated Patient #1's history included mental retardation, cerebral palsy, seizures, Dilantin (anti-seizure medication) toxicity, urinary tract infection (UTI) and pneumonia. The Physician Notes indicated Caregiver #1 said that Patient #1 did not have a cough or urinary problems. The Physician Notes indicated a physical examination did not identify neurological, respiratory or abdominal abnormalities.

The Physician Notes did not indicate that Patient #1 had indwelling intravenous (IV) and urinary catheters.

The Medication Administration Record dated 12/15/12 indicated Patient #1 was medicated with Ativan (anti-anxiety medication) at 9:05 P.M.

Physician Orders dated 12/15/12 at 11:14 P.M. indicated ED Physician #2 ordered 1 liter intravenous (IV) fluid for Patient #1.

Nursing Notes dated 12/16/12 at 1:42 A.M. indicated that 1 liter of IV fluid was administered.

The Nursing Notes dated 12/15/12 and 12/16/12 did not indicate urine output was measured and recorded as required per Hospital policy. The ED policy/procedure titled "Triage, Initial Nursing Assessment and Reassessment of ED Patients" indicated intake and output measurements are to be recorded for all patients who receive IV fluids and have an indwelling urinary catheter.

Review of the medical record did not indicate that patency of the urinary catheter was evaluated.

ED RN #2 was interviewed at 11:30 A.M. on 1/29/13. ED RN #2 said Patient #1 had pre-existing indwelling IV and urinary catheters. ED RN #2 said he administered the IV infusion and changed Patient #1's urinary drainage leg collection bag (a small urine collection drainage bag that is attached to the patient's leg using a Velcro strap to allow for ambulation and privacy/dignity) to a constant drainage bag (a larger urine collection bag that drains by gravity, measures urine output and was attached to the side of a bed or chair).

ED RN #2 said he clamped Patient #1's urinary catheter in order to obtain a urine sample and then gave report to ED RN #3 who assumed care of the Patient. ED RN #2 said there was no urine in Patient #1's constant drainage bag when he clamped the catheter.

Nursing Notes completed by ED RN #2 on 12/15/12 indicated Patient #1's urinary catheter was attached to the constant drainage bag at 10:30 P.M. and the catheter was clamped at 11:33 P.M (to obtain urine for analysis).

ED RN #3 said a urine sample was not sent for urinalysis because Patient #1's catheter did not drain urine (indwelling urinary catheter output of less than 30 milliliters/hour is abnormal). ED RN #3 said he did not think it was unusual that Patient #1 had no urinary catheter output for more than 3 hours. ED RN #3 said he did not palpate (feel) Patient #1's bladder area to determine if it was distended or perform a bladder scan (diagnostic test to determine the estimated amount of urine in the bladder and is done to diagnose urinary retention which can be an emergency medical condition).

Review of the medical record did not indicate patency of the urinary catheter was evaluated. (Evaluation of catheter patency was important to validate if the catheter was draining urine properly. A procedure called "flushing" validates catheter patency.)

The ED Director was interviewed during a tour of the ED at 9:30 A.M. on 1/31/13. The ED Director said that the ED staff have access to a bladder scanner and the bladder scanner is located on one of the medical/surgical units.

ED Physician #2 said he did not recall being informed that Patient #1 did not have any urine output or that urine was not sent for urinalysis.

The Nursing Note completed by ED RN #3 on 1/16/13 at 1:43 A.M. indicated Patient #1 was discharged home at 1:43 A.M.

The Nursing Note did not include a urine output measurement or discharge vital signs.

The ED policy/procedure titled "Triage, Initial Nursing Assessment and Reassessment of ED Patients" indicated that:
(1) any change in patient condition is to be immediately reported to the ED physician,
(2) vital signs are to be assessed upon arrival and at least every 2 hours throughout the ED visit and at discharge and
(3) intake and output measurements are to be recorded for all patients who receive IV fluids and have an indwelling urinary catheter.

Review of the medical record indicated that the ED policy/procedure was not followed.
(1) The ED Physician was not informed that Patient #1 did not have any urine output or that the urine was not sent for urinalysis.
(2) Patient #1's vital signs were not taken at least every 2 hours and at discharge.
(3) Patient #1's urine output was not monitored and recorded in the ED medical record.

Review of the medical record indicated that patency of the urinary catheter was not evaluated and that a bladder scan was not performed to determine if the bladder was full and the volume of urine in Patient #1's bladder.



ED VISIT #2 AT ED (A)

ED documentation on 12/16/12 indicated that Patient #1 returned to ED (A) at 11:59 A.M. [approximately 10 hours after discharge from ED (A) for visit #1].

Triage documentation dated 12/16/12 at 12:15 indicated Patient #1 returned to the ED (A) accompanied by Caregiver #3 because Patient #1 did not have urine output overnight.

Triage documentation did not indicate that a bladder scan was performed.

ED RN #4 was interviewed at 1:45 P.M. on 1/29/13. ED RN #4 said Patient #1 had an indwelling urinary catheter and when they undressed Patient #1 for an examination, they noted that one of the legs of the sweatpants was wet with urine and the catheter was attached to a constant drainage bag with the drainage spout open. ED RN #4 said the urine did not smell foul. ED RN #4 said he did not think a bladder scan was necessary because Patient #1's sweatpants were wet with urine and the drainage bag spout was open.

ED RN #2 said he examined Patient #1's urinary catheter and did not find urine leaking from around the catheter. ED RN #2 said he informed ED Physician #3 about the sweatpants wet with urine and the open drainage bag spout.

ED Physician #3 said that based on his experience with Patient #1, he/she was uncooperative when not feeling well. ED Physician #3 said Patient #1 was cooperative for the 12/16/12 examination and an abdominal examination was within normal limits. ED Physician #3 said that if Patient #1's bladder was full, he/she would have been agitated during the abdominal examination.

ED Physician #3 and ED RNs #2 and #4 said they concluded that Patient #1 did not have urine output overnight was because the constant drainage bag spout was open and the urine drained onto Patient #1's clothing and bedding (The urine output that wet Patient #1's sweat pants was difficult to estimate or measure).

Review of the medical record did not indicate that patency of the urinary catheter was evaluated or that a bladder scan was performed to determine if the bladder was full and the volume of urine in Patient #1's bladder.

Evaluation of catheter patency was important to validate if the catheter was draining urine properly. A procedure called "flushing the catheter" validates catheter patency.

The Nursing Note completed by ED RN #2 indicated Patient #1 was discharged home at 1:14 P.M. on 12/16/12.

The ED policy/procedure titled "Triage, Initial Nursing Assessment and Reassessment of ED Patients" indicated that:
(1) vital signs are to be assessed upon arrival and at least every 2 hours throughout the ED visit and at discharge
(2) output measurements are to be recorded for all patients who have an indwelling urinary catheter.

Review of the medical record indicated that the ED policy/procedure was not followed.
(1) Patient #1's vital signs were not taken every 2 hours and at discharge
(2) Patient #1's urine output was not recorded and he/she had an indwelling urinary catheter.

ED VISIT #3 AT ED (B)

The ED Record obtained from Hospital (B) (ED visit #3) indicated Patient #1 presented to Triage at 3:19 P.M. on 12/16/12 with the complaint of urine leaking around his/her indwelling urinary catheter.

Patient #1 was discharged from ED (A) visit #2 at 1:14 P.M. on 12/16/12 and presented to ED (B) at 3:19 P.M. on 12/16/12 (approximately 2 hours later).

Patient #1's ED (B) medical record dated 12/16/12 indicated that the bladder scan demonstrated greater than 760 ml volume of retained urine. Urology was consulted and the urinary catheter changed. Patient #1 had a urine output of 1400 ml in 3 hours (normal urine output). Patient #1 was started on an antibiotic for his/her UTI and discharged home at 8:48 P.M.