HospitalInspections.org

Based on Medical Record Review, policy review, and interviews, the facility failed to provide adequate stabilizing treatment as required that was within the capabilities of the staff and facilities available at the emergency department prior to discharge for an individual with an emergency medical condition, for one patient (Patient #19) of twenty-one patients reviewed.

Please refer to findings in A-2407.

Based on review of facility policy, review of Emergency Room (ER) Logs, medical record review, and interview, the facility failed to maintain an accurate ER log for two (#11, #12) of twenty-one sampled patients.

The findings included:

Review of facility policy Number: PC.ED.5.02 last revised in May 2012, revealed, "...This is a department specific policy applicable to (facility's) Emergency Department (ED)...The (ED) will maintain a central log of individuals...and indicate whether these individuals refused treatment, denied treatment, were treated, admitted, stablized, and/or transferred or discharged...will be completed by ED Registration staff...Disposition and patient condition will be completed on the log based on the medical record documentation...Refused Tx (treatment) - all patient leaving as AMA (against medical advice), LWBS (left without being seen) and/or ELOPED...Discharged - all patients treated and released from the ED setting...Transferred - patients treated in the ED setting and transferred to an outside facility..."

Review of an ER Log dated November 2, 2012, revealed Patient #11 presented to the ER and included, "...Refused treatment..." Continued review revealed "Refused treatment" was circled, a line was drawn through "Refused treatment." Continued review revealed, "...error...(and an individual's initials written above "error")...discharged..."

Medical record review of an Emergency Provider Record dated November 2, 2012, revealed, "...chief complaint CP (chest pain) on and off one month worse over past 3 days...Pt (patient) requesting to leave before next set of enzymes. Advised of possible worsening status including death. Please see AMA form...Clinical Impression Chest Pain Disposition AMA..."

Medical record review of a Request for Discharge Against Medical Advice form dated November 2, 2012, revealed the patient's signature and included, "...I am being discharged against the advice of the attending physician..."

Interview with the Chief Nursing Officer on January 23, 2013, at 11:00 a.m., in an administration conference room, confirmed the facility failed to accurately maintain the ER Log for Patient #11.


Review of an ER Log dated November 4, 2012, revealed Patient #12 was transferred.

Medical record review of an Emergency Nursing Record dated November 4, 2012, revealed, "...chief complaint: suicidal thoughts...now reports would not hurt self...transferred...stable..." Continued review revealed the document was signed by Medical Doctor (M.D. #4).

Interview with M.D. #4 on January 24, 2013, at 2:13 p.m., in an administration conference room, revealed the physician discussed the patient's care with the patient and the family. M.D. #4 stated, "...said (patient) would not harm self, not suicidal at the time...I documented the wrong disposition. I should have circled discharged and it resulted in the ER Log being inaccurate."

Based on Medical Record Review, policy review, and interviews, the facility failed to provide adequate stabilizing treatment as required that was within the capabilities of the staff and facilities available at the emergency department prior to discharge for an individual with an emergency medical condition, for one patient (Patient #19) of twenty-one patients reviewed.

The findings included:

Medical record review of an ambulance service Patient Care Report, dated December 26, 2012, revealed Patient #19 presented to the Emergency Department (ED) of Hospital #1, on December 26, 2012, at 5:50 a.m., with complaints of, " Flu-like symptoms...Nausea...Vomiting...Fever...".

Medical record review of an Emergency Room Nursing Record (Hospital #1) dated December 26, 2012, at 5:56 a.m., revealed, "...Triage (assessment by a nurse to determine a patient's medical priority need)...Level 3 (1=Most Emergent, 5=Least Urgent) ... Chief complaint N/V (nausea and vomiting) started 4 hours ago...vomiting 3 times...vitals BP (blood pressure) 181/92 ... Pulse 93 ... RR (respiratory rate) 20 ... temperature 102.7 (oral) ... pain scale...8/10...no acute distress...abdomen...distended...nausea/vomiting..."

Medical record review of Hospital #1 laboratory reports, dated December 26, 2012, revealed a White Blood Count (WBC, a lab test to measure the amount of white blood cells present) with elevated result of "15.6" (normal 4.0 - 11.0). There was no documented evidence that the elevated WBC was addressed or treated prior to discharge from the emergency department. Hemoglobin (hemoglobin in the blood carries oxygen from the respiratory organs (lungs) to the rest of the organs in the body) "11.1 L (low) (hospital normal reference range- 12.0 to 15.5), Hematocrit (is the volume percentage (%) of red blood cells in blood), "32.6 (L) (hospital reference range 35.0 to 45.0), an elevated blood Creatinine (measure kidney function and hydration) level of "6.6" (normal 0.5 - 0.9), an elevated blood potassium level (measurement of the potassium electrolyte) collected/drawn at 7:40 a.m. with results released at 8:05 a.m. of "7.7 C (critical)" (normal 3.5 - 5.0). Further review of the medical record indicated that at 8:44 a.m. another blood potassium level was collected/drawn with results released at 9:04 a.m. of 6.6 (C). A physician order written at 9:10 a.m. revealed that an order for Kayexalate (medication to treat high potassium) of 30 gram po (by mouth) was ordered and administered." There was no way to determine if patient #19's critical hyperkalemic status was within normal range as evidenced by no potassium levels were drawn after the kayaexalate was administered prior to discharge. An elevated Blood Urea Nitrogen (BUN/measures kidney function) level of "66" (normal 6 - 22), and an elevated Blood Glucose (amount of sugar in the blood) level of "169" (normal 70-99).

Medical record review of an Emergency Provider Record dated December 26, 2012, authored by Medical Doctor #1 (MD #1), revealed, "...Time Seen 6 a.m...chief complaint: vomiting, today severity: moderate...associated symptoms: diarrhea, nausea... counseled patient regarding: results diagnosis Clinical Impression Vomiting/Diarrhea...Hyperkalemia (Hyperkalemia is a condition caused by high concentration of potassium in the blood. Abnormally high levels of potassium in the blood or urine usually suggest the presence of another underlying medical condition. Potassium helps to regulate muscle activity, including the activity of the heart; hyperkalemia needs to be taken seriously)...Disposition Decision Time 11:45 (a.m.) ...Disposition Home Stable."


Medical record review of an Emergency Room Nursing Record dated December 26, 2012, revealed Patient #19 was discharged at 12:15 p.m. with, "...Disposition discharged home...accompanied by brother. Discharge Vitals ... B/P 151/76 ... HR 98 ... RR 20 ... Temp 99.8 ...pain level at discharge 4/10 ... Condition Stable... Depart Time 12:15 p.m...W/C..." The facility failed to ensure that patient #19 received adequate stabilizing treatment on 12/26/2012, as evidenced by failing to adequately stabilize the critical hyperkalemia value and address and or treat the elevated WBC prior to discharge.


Medical record review of a Hospital #2's ED Record, dated December 26, 2012, revealed, Patient #19 presented to the ED there at 4:13 p.m. with"...Acuity Level - Urgent...Triage...(4:13 p.m.) chief complaint description: flu like symptoms...arrived...from...Dialysis Clinic...(4:16 p.m.)...101.3...90...22..120/71...HPI text...presents with nausea vomiting and diarrhea as well as fever...in moderate distress secondary to persistent nausea and pain..." Review of a nurse's note, from Hospital #2, dated December 26, 2013, at 4:23 p.m., revealed, "...complaining of flu-like symptoms...had a cardiac workup and it was negative...pt not happy with what they told her...now at (Hospital #2) with flu like symptoms...Diagnosis Infection - urinary tract Renal Failure Hyperkalemia Nausea and vomiting Diarrhea...Nursing Disposition is admitted..."

Medical record review of a History and Physical (Hospital #2) dated December 26, 2012, revealed, "...did not have fever until today...did have some chest pain but only in the setting of ...vomiting...At dialysis...complain of chest pain so they sent ... to (Hospital #1)...worked ...up for a couple of hours and gave her ...Kayexelate (medication to treat high potassium) for high potassium, did an EKG and some labs and thought this was non-cardiac and sent ... back to dialysis ... continued to feel terrible at dialysis so they sent ...over to the emergency room...I do worry about flu even in the setting of a negative flu swab. I am going to empirically cover gram positives in the blood given ...dialysis status with Vancomycin (anti-biotic)... EKG is really not helpful at this time...Problem list: Fever...End stage renal disease..."

Medical record review of a Nephrology Consultation, at Hospital #2, dated December 27, 2012 revealed, "...very well known to our service...went to the (Hospital #1) Emergency Room and was evaluated over there and discharged...went to the outpatient dialysis clinic but thirty minutes into the treatment ...developed chest pain and could not continue the dialysis so she was sent to the emergency room...Impression...End stage renal disease...Hypertension...Fever...Coronary artery disease...Anemia...admitted for further evaluation and treatment of fever...Antibiotics will be addressed by the admitting physician..."

Review of a Discharge Summary from Hospital #2 revealed Patient #19 was admitted to Hospital #2 on December 27, 2012 and discharged on January 3, 2013, with principal diagnosis of: Fever, Methicillin Sensitive Staphylococcus Aureus Bacteria (infection), End Stage Renal Disease, Hypokalemia (low potassium level), Anemia, Hypertension (High blood pressure), Diabetes Mellitus, Coronary Artery Disease, and Hyponatremia (low sodium).

Review of Hospital #1's Policy number "LDR.AD.023", titled, "Transfer of Emergency Patients", approved August 2009, revealed, " ...Each Emergency Department will ...perform the emergency medical screening examination and initially stabilize the patient ..."

Telephone interview with M.D. #1 on January 24, 2013, at 10:45 a.m., revealed MD #1 treated the patient at Hospital #1 on December 26, 2012. Continued interview revealed Patient #19 presented with vomiting, fever, and had missed the dialysis treatment that morning. Continued interview revealed the patient wanted to be admitted and the physician discussed the patient's care with two nephrologists (patient's) and they were made aware of the elevated white count. Continued interview revealed MD #1 attributed the symptoms to a viral syndrome and the patient's temperature came down before discharge. Continued interview revealed the patient resisted leaving and the patient called personal cardiologist and some other unknown doctors requesting admission. Continued interview revealed after discussion with the two nephrologists, the plan was to return the patient to the dialysis clinic and the patient would be admitted if unable to be dialyzed