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Based on interview and record review, the hospital failed to comply with the provisions of CFR 489.24 when one of 20 patients (Patient 1) did not receive an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether or not an emergency medical condition (EMC) existed when:

Patient 1 (Pt 1) presented to the Emergency Department (ED) on 6/9/18 at 10:13 a.m. via private vehicle with the chief complaint of shortness of breath (SOB) and difficulty breathing and was discharged to the parking lot of the hospital and returned back to the ED within 25 minutes in worse respiratory condition than on arrival. The ED Medical Director (MD) 1 performed an MSE at 12:54 p.m. and discharged the patient to the parking lot of Hospital 1 at 6:55 p.m. Pt 1's respiratory status deteriorated in the parking lot while in her vehicle. Pt 1 was brought back into the ED at 7:20 p.m. in severe respiratory distress, 25 minutes after being discharged. Pt 1 was intubated (tube placed in the windpipe) with ventilator (machine that supports breathing) support and transferred to a higher level of care to another acute care hospital (Hospital 2).

The cumulative effect of this problem resulted in the hospital failure to provide care in a safe setting in the Emergency Department. (refer to A 2406)

Based on interview and record review, the hospital failed to ensure one of 20 patients (Patient 1) received an appropriate medical screening examination (MSE) within the hospital's (Hospital 1) capabilities to determine whether or not an emergency medical condition (EMC) existed when Patient 1 (Pt 1) presented to the Emergency Department (ED) on 6/9/18 at 10:13 a.m. via private vehicle with the chief complaint of shortness of breath (SOB) and difficulty breathing and was discharged to the parking lot of the hospital and returned back to the ED within 25 minutes in worse respiratory condition than on arrival. The ED Medical Director (MD) 1 performed an MSE at 12:54 p.m. and discharged the patient to the parking lot of Hospital 1 at 6:55 p.m. Pt 1's respiratory status deteriorated in the parking lot while in her vehicle. Pt 1 was brought back into the ED at 7:20 p.m. in severe respiratory distress, 25 minutes after being discharged. Pt 1 was intubated (tube placed in the windpipe) with ventilator (machine that supports breathing) support and transferred to a higher level of care to another acute care hospital (Hospital 2).

This failure resulted in the hospital not utilizing its full capabilities to determine an EMC existed, discharged the patient in an unstable condition which led to Pt 1's deteriorated respiratory status and mechanical respiratory support and emergent transport to Hospital 2 and required 5 days of hospitalization.

Findings:

On 9/25/18 at 2:13 p.m., during a concurrent interview and record review of Pt 1's electronic health record (EHR) from Hospital 1, Emergency Department Manager (EDM) validated Pt 1 arrived via private vehicle on 6/9/18 at 10:13 a.m., with a chief complaint of SOB. EDM stated the ED did not have a standardized protocol (a standardized procedure for completing a task) for patients exhibiting symptoms of SOB. The EHR indicated RN 1 assessed Pt 1 at 10:16 a.m., and determined the emergency severity index (ESI - a tool used in the ED to identify and prioritize patient illness) was 3 (moderate severity - on a scale of 1 to 4, 1 being the most severe). The next documentation of contact with Pt 1 was at 12:54 p.m., during an MSE. The EHR indicated the care for Pt 1 included a blood draw for laboratory tests, a chest x-ray, and placement of intravenous (directly in the vein) access. Administration of medications included levalbuterol and ipratropium bromide (medications used to open the airways of the lungs), sodium chloride (a fluid given for hydration [the process of causing something to absorb water], methylprednisolone sodium (a medication used to decrease inflammation), ceftriaxone (a drug given for bacterial infection), and hydrochlorothiazide (a drug given to reduce fluid retention). The record indicated final lab values for brain natriuretic peptide (BNP - a blood test used to determine heart failure) was 594 pg/ml (a unit of measurement) (normal levels are 0.0-300), and erythrocyte sedimentation rate (ESR - a blood test that detects and monitors inflammation in the body) was 80 ml/hr (one thousandth of a liter-per hour) (normal levels are 0.0-18.0). The EHR indicated MD 1 documented the following: "Progress and Procedures, ... patient had intense panic episodes causing secondary severe SOB and wheezing. She had several [panic episodes] [while] IN ER [ED] -in front of me- and when told to calm down-she MARKEDLY improved.", [The EHR indicated this entry by MD 1 was input at 12:56 a.m. on 6/10/18 after Pt 1 was discharged and transferred] The EHR indicated RN 1 documented the following: "Disposition / Discharge: Departure time: late entry - 18:55 [6:55 p.m.] 06/09/18; condition at departure: improved and stable ..." The EHR indicated RN 1 documented at 7:21 p.m., the following, "Pt was brought back into ED by Emergency Medical Technician (EMT) 1, Pt 1 was in her car and was brought back to room E-1 via wheel chair."

The EHR indicated, and EDM validated, Pt 1 returned to the ED on 6/9/18 at 7:20 p.m. During the subsequent MSE, MD 1 documented the following: "History of Present Illness ... she sat in her car in ER parking lot-and became progressively short of breath with much anxiety. After about 20-25 minutes-she was returned to ER-LOW 02 Sats (oxygen saturation is a measurement of the fraction of oxygen in the blood) and altered mentation and in SEVERE RESPIRATORY DISTRESS, and is still present. The dyspnea [difficulty breathing] is severe ..." From 7:20 p.m. to 9:52 p.m., the EHR indicated the care for Pt 1 included blood draw for laboratory tests, a chest x-ray, placement of intravenous access, intubation, ventilator support, central line placement (a tube placed in a great vein or artery), and a Foley catheter (sterile tube inserted into the bladder to drain urine). Administration of medications including oxygen, succinylcholine (a drug used to relax muscles to prepare for intubation), midazolam (a drug used to relieve anxiety), rocuronium bromide (a drug used to relax muscles to prepare for intubation). The EHR indicated, at 7:20 p.m., MD 1 documented the following: "Course of Care ... Transfer Center notified- will transfer to Higher level of care [Hospital 2] ...accepted patient ...will fly patient..."

Pt 1's medical record from Hospital 2 (accepting hospital for transfer) was reviewed. The document titled, "History and Physical Critical Care Note" dated 6/9/18, indicated, " ...[Pt 1] was seen at [Hospital 1] for shortness of breath and wheezing ...about 30 minutes after discharge, patient was brought back into the ED in severe respiratory distress and hypoxic (low oxygen in the blood) ... [Pt 1] was subsequently intubated, and was transferred to [Hospital 2] via airlift for higher level of care." Hospital 2's medical record for Pt 1 titled "Assessment" dated 6/9/18, indicated "Acute respiratory failure with hypoxia [condition in which the body is deprived of oxygen] and hypercapnia [condition in which the body has excessive carbon dioxide, a colorless, odorless gas formed as a byproduct of respiration] in the blood."

On 7/2/18 at 4:00 p.m., during an interview, Pt 1 stated she went to the ED because her rescue inhaler (a drug used to open the airways of the lungs) was not working. In the ED of Hospital 1 Pt 1 stated she received two doses of medication to help with her breathing and was informed by MD 1 her shortness of breath was related to anxiety. Pt 1 stated at the time of discharge from the Hospital 1's ED, RN 1 assisted her to the parking lot in a wheel chair. Pt 1 stated RN 1 then assisted her to her car. Pt 1 stated she commented to RN 1 that she did not feel well and wanted to sit in her car until she felt better. Pt 1 stated "I tried to call the facility (Hospital 1), but I could not speak, I honked my car horn to get help and someone came out to help..."

On 7/3/18 at 10:50 a.m., during an interview, RN 1 stated he was the assigned nurse for Pt 1 on 6/9/18 when Pt 1 came into the ED with SOB. RN 1 stated he triaged Pt 1 as an ESI of 3 and implemented the protocol for asthma, even though the chief complaint was SOB. RN 1 stated the hospital did not have a protocol for SOB. RN 1 stated at the time of discharge he assisted Pt 1 to the parking lot in a wheel chair. RN 1 stated he helped Pt 1 into her car and stated to her, "Is there someone waiting for you at home, you're not looking too well?" RN 1 stated he was aware Pt 1 was brought back into the ED shortly after discharge, but was not the assigned nurse once Pt 1 was brought back into the ED.

On 9/26/18 at 9:40 a.m., during a concurrent interview with Chief Nursing Officer (CNO) and EDM, they were asked about the discharge process for Pt 1. EDM stated the expectation for RN 1 was to have used professional judgement (the process of arriving at a sound conclusion following observation, reflection and analysis of observable or available information or data) at the time of discharge for Pt 1. EDM stated, and CNO agreed, RN 1 should have used professional judgement to determine if the discharge was appropriate and safe for Pt 1.

On 9/26/18 at 10:43 a.m., during an interview and record review of Pt 1's first and second ED visits, the Chief of Staff (MD 2) stated regarding the expectation of care for Pt 1 in the ED on 6/9/18. "Eyes would be placed on the patient right away to determine if the patient was in any distress." When MD 2 was asked to discuss the delay of an MSE for Pt 1, MD 2 stated she expected a faster MSE to be performed. When asked about RN 1's statement that Pt 1 did not look well at discharge, MD 2 stated RN 1 should have brought Pt 1 back to the ED and notified the physician.

On 9/26/18 at 11:38 a.m., during a telephone interview, the Emergency Medical Technician (EMT) was asked about Pt 1's condition when he saw her in her vehicle in the parking lot on 6/9/18. EMT stated he was alerted that someone needed help in the parking lot. EMT stated, when he arrived at Pt 1's vehicle, she was breathing rapidly and could not speak. EMT stated he immediately got her out of her vehicle and brought her back into the ED via wheelchair.

On 9/26/18 at 1:03 p.m., during a telephone interview, Pt 1 stated she went to the ED on 6/9/18 because she had difficulty breathing. Pt 1 stated she received two breathing treatments in the ED. Pt 1 stated she got up to use the restroom after the second breathing treatment. PT 1 stated she had to use the ED walls for support because she had a hard time walking. Pt 1 stated every time she told the ED staff she was SOB she was told it was anxiety. Pt 1 stated, "Yes, I was anxious because I couldn't breathe! They wouldn't believe me." Pt 1 stated she felt the ED staff ignored her and she was discharged from the ED. Pt 1 stated RN 1 took her to her truck and she told RN 1 "I don't know how I'm getting in the house. He [RN 1] seemed frustrated." Pt 1 stated, "I sat in my car and I couldn't breathe. I tried to call the hospital but I couldn't talk. I honked my horn, but no one came out [of the ED]. I saw two people sitting on a bench. They came over and then ran inside to get someone." Pt 1 stated someone put her in a wheelchair and took her back into the ED, but she did not know who. Pt 1 stated, "Then I got inside [the ED] and I heard someone say, "She's coding [medical emergency in which the heart beat and or breathing stops]." Then I passed out. This whole experience made me feel terrible. I was doubting myself and no one would listen. It made me feel like I'm crazy."

On 9/26/18 at 1:50 p.m., during an interview, MD 1 was asked to explain why the time for Pt 1's MSE was 12:54 p.m., over two hours after Pt 1 arrived. MD 1 stated the time listed [for the MSE] in the medical record was inaccurate. MD 1 was then asked how Pt 1 presented before discharge. MD 1 stated according to the record, Pt 1 was stable. When asked if he interacted with Pt 1 before discharge, MD 1 stated he could not recall an interaction with Pt 1 prior to discharge on 6/9/18.

On 9/27/18 at 9:21 a.m., during an interview, RN 3 was asked to discuss Pt 1's second ED admission after she returned to the ED from the parking lot on 6/9/18. RN 3 stated Pt 1 was brought back into the ED via wheelchair in severe respiratory distress. RN 3 stated, when Pt 1 arrived back into the ED, she was in critical condition (very sick or injured and likely to die). RN 3 stated all of her focus was on keeping Pt 1 alive. RN 3 stated Pt 1 required to be intubated; required ventilator support; and needed to be transferred to a higher level of care. RN 3 stated the actual time Pt 1 was in the parking lot could not have been much more than ten minutes after discharge from the ED.

On 9/27/18 at 12:25 p.m., during a second interview with MD 1 and MD 2 present, MD 1 stated Pt 1 arrived on 6/9/18 at 10:13 a.m., was placed in a room at 12:47 p.m., and an initial MSE was performed at 12:54 p.m. MD 1 stated Pt 1's care included laboratory tests, breathing treatments, antibiotics, and fluids. When asked to discuss Pt 1's discharge, MD 1 stated Pt 1 was stable and was observed over six hours in the ED. When asked how Pt 1 presented when she returned to ED, MD 1 stated a significant change had occurred during the minutes she was in the parking lot. When asked if he would have discharged Pt 1 knowing she could not walk or drive, MD 1 stated, "Absolutely no question she would be admitted."
Hospital 1's document Interfacility Transfer Summary indicated the date of transfer was 6/9/18, and named Hospital 2 as the receiving hospital and the time receiving physician was contacted as 8:45 p.m. The reason for the transfer was listed as comprehensive or specialty services needed and in the section Other, the following comment was handwritten: "higher level of care - ICU." The form indicated "the patient is stable and transfer poses no significant medial risk .. the benefits of treatment at the receiving facility outweigh risks of emergency transfer." The physician's orders section of the form indicated transport via Air Ambulance. The discharge time was documented as 10:10 p.m.

The Air Ambulance company form Prehospital Care Report Summary indicated the call for transport was received at 9:25 p.m. on 6/9/18, was on scene at Hospital 1 at 9:44 p.m., Patient contact occurred at 9:45 p.m., arrived at destination (Hospital 2) at 10:55 p.m. and the transfer of care occurred at 11:10 p.m.

The EDM and CNO were asked for a policy or protocol for triaging patients presenting to the ED with SOB. The EDM and CNO stated the hospital did not have any policies or protocols pertaining to SOB.

The ED document Standard of Care- Acute Status Asthma dated 6/1/00 indicated under "Policy - Patients with acute status asthma will be classified as immediate patients and receive appropriate care. Procedure - The patient arriving at the [ED] with acute status asthma will receive the following care: 1. Assure a patent airway; 2. Assist with ventilation, as needed; 3. Recognize the need for potential intubation; 4. Administer oxygen high-flow; 5. Establish IV access; 6. Place on pulse oximetry and cardiac monitor; 7. Prepare patient for respiratory breathing treatments, ABG's and medication; 8. Monitor respiratory status continuously; 9 Documentation shall include , but is not limited to: a) initial lung sounds; b) initial vital signs; c) oxygen saturation; d) lung sounds after treatments; e) vital signs after treatments or prior to discharge; f) response to treatments."

The ED Policy and Procedure for Assessment of the ED Patient indicated under "Policy: all patients will receive initial triage assessment and ongoing assessments throughout their stay in the [ED] ..." and under "Procedure: A. All patients presenting to the [ED] will be triaged and categorized as Emergent, Urgent, or non-Urgent ..."

The ED Policy and Procedure for Triage indicated under "Policy: The triage area shall be an area or room, with a telephone, next to the Emergency Department with direct access to the Emergency Department. The triage area shall a have privacy for an initial assessment and vital signs. Procedure: The registered nurse will evaluate and categorize each patient upon arrival to the Emergency department into either resuscitative, emergency, urgent, semi-urgent or routine categories ...Emergency Severity Index (ESI): Resuscitative (Level 1) -immediate care, life-threatening conditions ...Emergency (Level 2) - major injury or illness but stable; treatment and reassessment should occur within five (5) to 15 minutes ... Urgent (Level 3)- treatment and reassessment should occur in 15-45 minutes ...Semi-Urgent (Level 4) - treatment and reassessment should occur in one to two (1-2) hours ..."