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Based on policy review, patient and staff interviews, the hospital inappropriately discharged 1 (Patient 2) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether or not an Emergency Medical Condition (EMC) existed, in accordance with the facility's "Emergency Medical Treatment and Transfer Policy." Patient 2 presented to the Emergency Department seeking medical care via Ambulance from the Nursing Home she resides. The Nursing Home Staff reported, "the patient has not been to dialysis in nearly one week because she had not felt well enough to go." The pt's hands and face appear "puffy and the pt is more confused than normal." They reported increasing generalized weakness/ fatigue and concerned may need emergent dialysis. The Emergency Department staff failed to provide the patient an appropriate MSE. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause a patient harm or death due to a delay in treatment.

Findings are:

See also A 2406.

A. Review of facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department EMTALA (Emergency Medical Treatment and Active Labor Act)- Immanuel" last revised 1/2019 states, "A medical screening examination is the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted to the extent necessary, by physicians and/or other QMP's (Qualified Medical Person),to determine whether an EMC exists. The extent of the MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board.

B. The hospital failed to follow the policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department EMTALA (Emergency Medical Treatment and Active Labor Act)- Immanuel" and did not provide a medical screening exam sufficient for Patient 2 when she presented to the dedicated emergency department with complaint of being more confused than normal, generalized weakness and refusing dialysis. Patient 2 was discharged at 2:10 AM back the the Nursing Home.

C. An interview with Patient 2's Power of Attorney on 2/10/22 revealed that Patient 2 was taken to dialysis later in the day and demonstrated stroke-like symptoms and altered mental status and was taken by ambulance to Hospital B. The patient was admitted to Hospital B for a urinary tract infection, viral infection and abnormal electrolytes and was discharged from Hospital B on 1/20/22.

D. Review of Hospital B's ED record revealed that the patient was admitted to the ED department 1/12/22 and dismissed 1/20/22. ED Doctor B documented, "Chief Complaint, pt was half way through dialysis when she became confused, Pt is alert but confused." "She started her run and about half way through she became confused. She also had a low grad fever & generalized tremors. She missed dialysis on Monday & Friday so has not received dialysis in one week. She did present to the ED at [Hospital A] on Monday evening due to generalized weakness, but was discharged without dialysis." "She is altered and oriented only to self." Pt 2 daughter reports she is typically oriented x 3 and able to discuss current events and recognize her loved ones. "Given the available information her Altered Mental Status is most likely uremic encephalopathy. Given UA results showing bacteruria, pyuria, hematuria and proteinuria; viral panel showed positive for Human Metapneumovirus, infectious sourse could also contribute or complicate. She was given Rocephin for UTI and a urine culture is pending. Internal Medicine was consulted for admission." Preliminary diagnosis: delirium, concern for uremia, viral respiratory infection, UTI.

Based on policy review, patient and staff interviews, the hospital inappropriately discharged one (Patient 2) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether or not an emergency medical condition (EMC) existed. The total sample of 20 patients were reviewed. This failure has the potential for all patients presenting to the Emergency Department (ED) to have an untreated MSE which could result in harm or death due to delay in treatment. According to the facility provided information the ED sees an average of 2963 patients per month.

Findings are:

A. In an interview with Patient 2's power of attorney (POA), on 2/10/22 at 9:30 AM, revealed the Nursing Home sent Pt 2 to the emergency department on 1/11/22 at 12:02 AM, for increased confusion, generalized weakness, puffy hands and face. The POA said that Patient 2 had refused 2-3 scheduled hemodialysis due to not feeling well. The patient was brought to the ED via ambulance from the Nursing Home. The patient was returned to the Nursing Home 2 hours later after the physician ran some blood work and told the Nursing Home to make sure the patient went to her next scheduled dialysis session. The POA said that during Patient 2's dialysis session on 1/12/22 she demonstrated stroke-like symptoms and an altered mental status. The dialysis center sent her via ambulance to (Hospital B) and was admitted for "extremely bad" electrolytes, a urinary tract infection and a viral infection and was discharged on 1/20/22.

B. Review of Patient 2's 1/11/22 (Tuesday) ED medical record at Hospital A showed Patient 2 arrived at 12:02 AM, the patient's vital signs (VS) were 98.2 (temperature), heart rate 89, respirations 16, blood pressure 143/58, oximetry (measurement of oxygen) 97%. The ED Doctor examined Patient 2 and ordered a Complete Metabolic Profile (CMP); Complete Blood Count (CBC); and Magnesium and Phosphorus levels. The CMP revealed, a Blood Urea Nitrogen 69 [BUN-test to check how kidneys are functioning, normal 6-24]; Creatinine 12.40 [Creatinine is the waste product of muscle use and is found in the bloodstream, the functioning kidneys then filter out the creatinine and it is excreted in the urine- normal range 0.50-1.10]; Potassium 5.5 [an electrolyte in your body to help you heart and muscles work, normal 3.7-5.1]. The CBC showed Hemoglobin 9.8 [a test to show how much hemoglobin protein is present in red blood cells to carry oxygen, normal range 12-16]. The ED physician documented that the patient was scheduled for Hemodialysis each Monday, Wednesday and Friday at the Dialysis Center and has missed her session this past Friday (1/7/22) and Monday (1/10/22). She is awake and alert but has confusion due to underlying dementia. The Care Facility reported "increasing generalized weakness and fatigue so they called squad in case she needs emergent dialysis. No other specific complaints reported." The ED Doctor's Differential diagnosis included: End-stage renal disease, electrolyte disorder, and anemia. The ED Doctor's ED Course & Medical Decision Making included: "Serum labs significant for mildly elevated potassium & highly elevated creatinine." "Patient needs to undergo outpatient dialysis as currently scheduled." The Patient's next scheduled outpatient dialysis sessions was scheduled on 1/12/22 at 8:00 AM, approximately 28 hours after discharge. The medical record did not contain evidence that the patient received an appropriate medical screening examination sufficient to determine that an EMC did not exist. There were no baseline or previous lab results documented for comparison, an EKG was not obtained to assess the patient for cardiac arrhythmias given the patient's mildly elevated potassium level, and no consultation with the on-call nephrologist to discuss further evaluation and management of the patient prior to the next scheduled hemodialysis appointment, which was approximately 28 hours after discharge.

C. On 2/16/22 at 8:15 AM an interview with Hospital A's ED provider that provided Patient 2 care on 1/11/22, verified that he was aware that the patient received hemodialysis on M-W-F at a dialysis center locally. He verified that the patient had skipped dialysis on the previous Friday (1/7/22) and Monday (1/10/22). When asked if the ED had a Nephrologist on call and if the provider contacted him, the Provider stated, yes they have a Nephrologist on call but did not contact the on call provider.

D. Review of Hospital A's on call ED schedule for 1/11/22 verified that there was a Nephrologist on call and a phone number was available to call from 10:00 PM-8:00 AM. The Nephrologist group on call identified the physician as Nephrologist B. (Nephrologist B was Patient 2's Nephrologist)

E. Interview with Patient 2's Nephrologist (Nephrologist B) on 3/2/22 at 4:00 PM revealed that Patient 2 has been a dialysis patient since 2018 is familiar with this patient. The Nephrologist was aware of the patient missing sessions in January and also being transferred to [Hospital B] in January from the dialysis center. Review of the circumstances related to patient 2's ED visit on 1/11/22 was reviewed. The Nephrologist revealed that "ideally the nursing facility the patient lives in would call the on call physician for the group, also the on-call physician was available to the ED physician once the patient got to the ED. "The ED's across Omaha have been educated on how to reach us if one of our patients come in, and can consult with us." "With the patient's Potassium being 5.5, we would have suggested giving the patient Localma, [a medication given to lower Potassium] and asked them to hold the patient until they can call the dialysis center in the morning to get the patient fit in." The Nephrologist stated, "this patient is aware and insightful about her condition and need for dialysis." The patient is routinely scheduled for dialysis at this center Monday- Wednesday -Fridays at 7:00 AM.

F. Review of the Prehospital Care Report for Patient 2 dated 1/12/22. The Prehospital Care Ambulance report identified that Patient 2 was at the Dialysis clinic and they called 911 when the patient began having an altered level of consciousness. The patient was asked her name and was unable to tell (ambulance staff). The Cincinnati stroke scale was done and was negative. The Patient became alert, was moved outside. The patient had only finished 1/2 of her dialysis. The ambulance was enroute at 8:30 AM, arrived at Dialysis clinic at 8:32 AM and arrived at Hospital B at 8:41 AM. The ambulance identified the patient's blood pressure was 180/79, pulse 100, respirations 14.

G. Review of Hospital B's ED and inpatient record revealed that the patient was seen in the ED department 1/12/22 at 8:41 AM and admitted to the hospital as an inpatient, she was dismissed on 1/20/22. Hospital B's ED Doctor documented, "Chief Complaint, pt (patient) was half way through dialysis when she became confused, Pt is alert but confused." "She started her run and about half way through she became confused. She also had a low grade fever & generalized tremors. She missed dialysis on Monday & Friday so has not received dialysis in one week. She did present to the ED at [Hospital A] on Monday evening due to generalized weakness, but was discharged without dialysis." "She is altered and oriented only to self." Pt 2's daughter reports she is typically oriented x 3 and able to discuss current events and recognize her loved ones. "Given the available information her Altered Mental Status is most likely uremic encephalopathy (a confused state caused by an accumulation of toxins as a result of chronic renal failure). Given UA results showing bacteruria (bacteria in the urine), pyuria (pus in urine), hematuria (blood in urine) and proteinuria (protein in urine); viral panel showed positive for Human Metapneumovirus (a respiratory virus), infectious source could also contribute or complicate. She was given Rocephin (an antibiotic) for UTI (Urinary tract infection) and a urine culture is pending. Internal Medicine was consulted for admission." Preliminary diagnosis: delirium, concern for uremia, viral respiratory infection, UTI. Vital signs in ED Blood Pressure 156/138; Pulse 87; Respirations 18; Temperature 97.0; Oximetry 97%. Review of the inpatient Admission history and physical showed that the UA in the ED is consistent with cystitis (bladder inflammation). Her Procalcitonin (a test to check the level of infection in the body) was elevated at 1.63; her viral screen was positive for metapnuemoviris and stated has had a cough and headache for 5 days. She has hemodialysis but does produce urine. Her altered mental status with acute agitation required haldol (medication for agitation) in the ED. Urine microscopy with bacteria, WBC & RBC's. Afebrile, normal white count. Creatinine was 8.59; BUN 46; Potassium 4.4; magnesium 1.9 and Phosphorus 3.8.