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Based on a medical record review, a review of policy and procedures, and interviews with staff, it was determined that the facility failed to conduct an appropriate medical screening exam (MSE) and stabilizing treatment for one (P#1) out of twenty sampled patients. Specifically, the facility failed to update medications during triage or during the MSE to include anticoagulants (blood thinners). Additionally, the facility failed to assess P#1's wound for bleeding prior to discharge from the Emergency Department (ED). P#1 returned to the ED the same day and was admitted to the facility. P#1 underwent multiple blood transfusions during her inpatient admission.

Findings:

Cross-reference 2406 as it relates to the facility's failure to provide an appropriate MSE.

Cross-reference 2407 as it relates to the facility's failure to provide stabilizing treatment.

Based on a medical record review, interviews with staff, and a review of policy and procedures, it was determined that the facility failed to provide an appropriate Medical Screening Exam (MSE) within the capability of the Emergency Department (ED) for one (P#1) out of twenty sampled patients. Specifically, the facility's ED failed to update P#1's medication list to include blood thinners.

Findings:

A review of the facility's policy titled "Emergency Center Assessment and Reassessment" policy #10439829, revised 12/19, revealed that ED assessments were divided into a primary and secondary surveys. Surveys would be initial and ongoing. The primary survey involved a brief, rapid assessment to identify actual or potential life-threatening illness or injury. A secondary survey involved a more focused and detailed evaluation of the patient to identify other, less severe illness or injury. The secondary survey included vital signs, head to toe assessment of body systems, past medical/surgical history, and current medications. A complete list of the patients' medications would be documented in the chart, if available.

A review of the facility's policy titled, "EMTALA - Definitions, General Requirements, External Transfers" policy #10440009, revised 8/21, revealed that the hospital would provide an appropriate medical screening examination (MSE) to any individual who came to the Emergency Department (ED), within the capability of the ED, to determine if the individual had an emergency medical condition (EMC).

A review of the medical record (MR) revealed that P#1 arrived at the ED on 10/25/22 at 10:19 a.m. by emergency medical services (EMS) after falling and hitting her head. P#1 was triaged at 10:20 a.m. P#1 MSE was initiated by Medical Doctor (MD) AA on 10/25/22 at 10:28 a.m. which revealed a large amount of matted blood on P#1's right scalp. A small laceration (cut) on the back of P#1's scalp was explored and irrigated (washed out). The laceration was closed with three sutures (stitches).

A review of the medication list revealed that P#1 was on Chlorthalidone (treat high blood pressure and fluid retention), metoprolol (treat high blood pressure), risedronate (prevent bone breakdown), and Simvastatin (lower cholesterol). The medications had been recorded and confirmed on 12/31/2015, and the MSE notes failed to reveal that the medications or allergies had been updated during the MSE on 10/25/22.

A review of the discharge medication list failed to reveal that P#1 was on anticoagulants (medications specifically prescribed to thin blood or prevent clots or medications known to decrease clotting times). P#1 was discharged home on 10/25/22 at 3:48 p.m.

Further review of the MR failed to reveal whether P#1's laceration site was examined before discharge and whether the site was bleeding at discharge.

A review of a Prehospital Care Report by EMS revealed that EMS was dispatched on 10/25/22 at 6:31 p.m. to respond to P#1, who had passed out but was breathing. Medications listed on the EMS report were clopidogrel (to prevent clotting), famotidine (decreases stomach acid production), metoprolol, levothyroxine (treat underactive thyroid), Asmanex (inhaler to treat asthma symptoms), levocetirizine (relieves allergy symptoms), and Simvastatin. P#1 arrived at the ED on 10/25/22 at 7:45 p.m.

An additional medical record review revealed that P#1 arrived at the ED by EMS on 10/25/22 at 8:00 p.m. with a chief concern of syncope (fainting). A review of an MSE by MD CC on 10/25/22 at 9:03 p.m. revealed that P#1 was seen in the ED earlier on 10/25/22 and still had mild bleeding from her scalp from a laceration that had been repaired. Further medical record review revealed that 'No Known Allergies' (NKA) was verified on 10/25/22 at 8:38 p.m. P#1 was admitted to hospital on 10/26/22 at 2:54 a.m.

A review of the list of home medications revealed that daily aspirin (blood thinner) and clopidogrel had been recorded and confirmed on 10/26/22.

A telephone interview was conducted with MD AA on 12/14/22 at 10:22 a.m. MD AA stated nurses would try to contact patients' families to get an update on current medications. Hospital pharmacists would also run medication records from local pharmacies. MD AA said he would usually find out what medications a patient was on from a previous visit note.

An interview took place with the ED Nurse Manager (RN) EE on 12/15/22 at 9:35 a.m. RN EE said that the MD would do the initial assessment, one nurse would start the IV, and the primary nurse would do a focused assessment, which included questions about allergies, home medications, and a description of what occurred. If a patient were not able to provide information, the information would be obtained from the family. The family or the primary contact would be called to verify medications and allergies if the patient was at the facility alone. There was a selection on the computer for "unable to obtain." When a patient had been to the facility previously, the medications would show in the system but not be verified. The hospital pharmacy could contact the listed pharmacy to verify medications. P#1 had not been at the facility previously and did not have a listed pharmacy. RN EE said patient medications were required to be verified before a patient was admitted to the hospital from the ED. RN EE further said that when a patient fell, the staff would need to note if the person was on blood thinners because of additional concerns. Whenever a patient was on blood thinners and hit their head, there would be a concern about a potential bleed. RN EE verified from P#1's MR that medications imported automatically said "no changes," and medications were not updated on the first ED visit on 10/25/22. The requirements were to verify all home medications and allergies. RN EE further said that the nurses' notes would have included if a patient was on blood thinners.

An interview was conducted with the complainant on 12/16/22 at 12:33 p.m. The complainant said she was not present at the hospital until the following day after P#1's initial ED visit. The complainant said P#1's wound was still bleeding when she arrived the following afternoon. There was a clean bandage on the wound, but the complainant observed blood oozing down the back of P#1's neck onto a towel. The towel was changed multiple times after becoming saturated with blood. The complainant said P#1 was bleeding profusely. The complainant said that although she was not present the first time P#1 was discharged, she was told by a family member that after P#1 was brought to the front of the ED, P#1 was taken back to have the dressing changed prior to P#1 being released. The bandage had become saturated with blood. The complaint said that she was on the phone with the nurse during the time P#1 was being discharged from the ED, and the complainant asked the nurse why P#1 was being discharged while on blood thinners. The nurse informed the complainant that a head CT was normal, so P#1 was being discharged. The complainant said it appeared the nurse was not aware that P#1 was on blood thinners.

Based on a medical record review, interviews with staff, and a review of policies and procedures, the facility failed to stabilize an emergency medical condition (EMC) within the facility's capability for one (P#1) out of twenty sampled patients. The facility failed to assess P#1's wound for bleeding prior to discharge from the Emergency Department (ED). P#1 returned to the ED on the same day and was admitted to the facility. P#1 underwent multiple blood transfusions during her inpatient stay.

Findings:

A review of the facility's policy titled, "EMTALA - Definitions, General Requirements, External Transfers" policy #10440009, revised 8/21, revealed that the hospital would provide an appropriate medical screening examination (MSE) to any individual who came to the Emergency Department (ED), within the capability of the ED, to determine if the individual had an emergency medical condition (EMC). If an EMC were determined to have existed, the hospital would provide any necessary stabilizing treatment or an appropriate transfer.

A medical record (MR) review revealed that P#1 arrived at the ED on 10/25/22 at 10:19 a.m. by emergency medical services (EMS) after falling and hitting her head. P#1 was triaged at 10:20 a.m. P#1 MSE was initiated by Medical Doctor (MD) AA on 10/25/22 at 10:28 a.m. A small laceration (cut) on the back of P#1's scalp was explored and irrigated (washed out). The laceration was closed with three sutures (stitches). A review of the procedure report failed to reveal that P#1's scalp was shaved prior to suturing the site. Deep structures of the scalp were found to be intact.

P#1 was discharged home on 10/25/22 at 3:48 p.m. Discharge instructions failed to include education regarding lacerations or sutures. In addition, a review of the discharge medication list failed to reveal that P#1 was on anticoagulants (medications specifically prescribed to thin blood or prevent clots or medications known to decrease clotting times). P#1 was discharged home on 10/25/22 at 3:48 p.m.

Further review of the MR failed to reveal whether P#1's laceration site was examined before discharge and whether the site was bleeding at discharge.

A review of a Prehospital Care Report by EMS revealed that EMS was dispatched on 10/25/22 at 6:31 p.m. to respond to P#1, who had passed out but was breathing. The back of P#1's head was still bleeding. EMS placed dressings on P#1's head and transported P#1 back to the hospital. A review of the medications listed on the EMS report included clopidogrel (brand name Plavix - used to thin blood and prevent clotting). P #1 arrived at the ED on 10/25/22 at 7:45 p.m.

An additional medical record review revealed that P#1 arrived at the ED by EMS on 10/25/22 at 8:00 p.m. with a chief concern of syncope (fainting). A review of an MSE by MD CC at 9:03 p.m. revealed that P#1 was seen in the ED earlier on 10/25/22 and still had mild bleeding from her scalp from a laceration that had been repaired.
P#1 was admitted to hospital on 10/26/22 at 2:54 a.m.

A review of the list of home medications revealed that daily aspirin (blood thinner) and clopidogrel had been recorded and confirmed on 10/26/22.

An interview was conducted with the ED Nurse Manager (RN) EE on 12/15/22 at 9:35 a.m. RN EE stated that the physicians and nurses would remove the dressing after a laceration repair to assess the site. If no interventions were necessary, the staff would re-cover the wound and assess the dressing on the next shift. RN EE said P#1 was admitted to the hospital after her second ED visit due to age, a recent fall, and syncope. RN EE further stated that when a patient had a fall, the staff would need to note if the person was on blood thinners because of additional concerns. Whenever a patient was on blood thinners and hit their head, there would be a concern about a potential bleed. RN EE further said that after the doctor sutured a wound, the nurses would clean and bandage the laceration repair. RN EE said it was possible to suture a small wound on the scalp by moving the hair around, and the scalp would not always need to be shaved. The bandage would not be taped if it was in the hair, but the wound would be cleansed. RN EE said it was not uncommon for a laceration to bleed a little after a laceration repair. RN EE said patients would be given discharge instructions on maintaining and cleaning the sutured area and what to expect, including bleeding, adverse reaction, and follow-up care. RN EE confirmed that the only instructions given to P#1 were 'Preventing Falls in Older Adults,' and P#1 should have gotten instructions about laceration repair during the first ED visit.

An interview was conducted with the complainant on 12/16/22 at 12:33 p.m. The complainant said she was not present at the hospital until the following day after P#1's initial ED visit. The complainant said P#1's wound was still bleeding when she arrived the following afternoon. The complainant said that although she was not present the first time P#1 was discharged, she was told by a family member that after P#1 was brought to the front of the ED, P#1 was taken back to have the dressing changed prior to P#1 being released. The bandage had become saturated with blood. The complaint said that she was on the phone with the nurse during the time P#1 was being discharged from the ED, and the complainant asked the nurse why P#1 was being discharged while on blood thinners. The nurse informed the complainant that a head CT was normal, so P#1 was being discharged. The complainant said it appeared the nurse was not aware that P#1 was on blood thinners.