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Based on record review and interview the facility failed to provide stabilizing treatment to 1 (P6 (patient)) out of 10 (P1-P10) patients being reviewed for stabilizing treatment. This deficient practice is likely to lead to patients leaving the emergency department (ED) in unstable condition.

The findings are:

A. Record review of facility's undated procedure titled "Nursing CAUTI [Catheter Associated Urinary Tract Infection] Prevention Protocol" stated "Discontinue the catheter [tube that drains urine], document and perform the following assessment and interventions: Ensure the patient is spontaneously voiding [urinating on their own]: record on intake and output time and amount of each void [urine output] for 24 hours following the removal of the catheter or as ordered by a patients physician"

B. Record review of facility's policy titled "EMTALA Stabilization" dated 03/05/2021 under the section "Policy " stated "Patients being transferred or discharged will be stabilized as required under EMTALA."

C. Record review of P6's medical record under "ED Events" indicated that P6 arrived to the emergency department on 09/08/24 at 4:31 AM by ambulance with a chief complaint of abdominal pain. Review of the section "Provider note" indicated P6 had urinary retention (when a person cannot urinate and the urine is retained) requiring a catheter. A foley catheter (indwelling tube that drains urine) was ordered for insertion at 4:45 AM. This order stated "Acute urinary retention (requires providers order to remove)." P6's flowsheets revealed at 8:46 AM, P6 had 2500 mL (milliliters) of output from the Foley catheter. The provider note stated "Patient is hopeful did not need the Foley catheter but understands that he does need this." Indicating that the Foley catheter is needed. The sections titled "Flowsheets" indicated that the catheter was removed at 10:31 AM. The record did not contain any documentation of urinary output following the removal of the Foley catheter. The section "ED events" revealed P6 was discharged at 10:33 AM, 2 minutes after the removal of the Foley catheter. The record did not contain any order in place for discontinuation of the Foley catheter. The record did not contain any assessment of the patients ability to void following the removal of the foley catheter.

D. Record review of P6's discharge instructions under "Acute Urinary Retention" stated "Acute Urinary Retention is when a person cannot pee (urinate) at all, or can only pee a little. This can come on all of a sudden. If it is not treated, it can lead to kidney problems or other serious problems.

E. During an interview on 09/12/24 at 11:10 AM with S(staff)4, Clinical Staff member, when asked how soon after the removal of a Foley catheter a patient can be discharged, S6 explained that he would wait until the patient can "urinate on their own" to discharge them.