HospitalInspections.org

Based on policy reviews, Emergency Department (ED) Logs, ED Medical Record reviews, Medical Staff Rules and Regulations, Physician On-Call Schedules, and interviews, the facility failed to provide, within its capability, an adequate medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC), for one patient (#1) out of 24 sampled ED records reviewed from February 2018 through August 29, 2018, that presented to the ED seeking care.

The facility had the capacity and capability to perform an adequate MSE, which included additional laboratory studies, radiology, cardiology (related to the heart) and other specialty consults, when the patient, who had an mechanical heart valve (structure placed in the heart that prevents backward flow of blood), a history of blood clots, and took regular doses of Coumadin (anticoagulant, prevents blood clots from forming, an increases the risk of bleeding), presented with chest pain, shortness of breath, anxiety, restlessness and agitation. The patient was at high risk for cardiopulmonary (heart, lungs and entire vascular [pertaining to blood flow] system) related events or bleeding, due to the patient's history and current presentation.

Refer to A2406 for additional information.

Based on interview, record review and policy review, the facility failed to provide, within its capability an adequate medical screening examination (MSE), to include laboratory/radiology studies and/or consults to determine if there was an emergency medical condition (EMC) for one patient (#1) that presented the facility's Emergency Department (ED) seeking care out of 24 sampled ED patients selected from February 01, 2018 through August 29, 2018. The patient, who had an mechanical heart valve (structure placed in the heart that prevents backward flow of blood), a history of blood clots, and took regular doses of Coumadin (anticoagulant, prevents blood clots from forming, an increases the risk of bleeding), presented with chest pain, shortness of breath, anxiety, restlessness and agitation. The patient was at high risk for cardiopulmonary (heart, lungs and entire vascular [pertaining to blood flow] system) related events or bleeding, due to the patient's history and current presentation. This failed practice had the potential to affect all patients that presented to the ED seeking care and treatment for an EMC. The facility ED saw an average of 3,120 cases per month.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment and Active Labor Act-EMTALA Requirements," reviewed 07/08/15, showed:
- An EMC is any condition that is a danger to the health and safety of the patient if not treated in the foreseeable future.
- The MSE must determine if any further medical examinations and/or treatment may be required.
- The patient should be offered treatment, as required, and may not be discharged with an EMC.
- Documentation of the MSE must include use of all available testing resources.

Review of the facility's completed Database Worksheet, Exhibit 286, dated 08/30/18, showed the facility was capable providing an adequate MSE of to Patient #1's, through specialty physicians, laboratory, radiology, and cardiology (related to the heart).

Review of Patient #1's discharged ED medical record showed that:
- The patient presented to the ED 06/11/18 at 7:30 PM, by ambulance, with complaints of anxiety, shortness of breath, restlessness, agitation, and resting chest pain of 2 (rated on a scale with 10 being the worst pain).
- The patient had these symptoms for two hours prior to arrival in the ED.
- The patient had used aspirin long-term (used to prevent heart attacks and blood clots).
- The patient had used Coumadin long-term.
- The patient had a long-term cardiac history of mechanical heart valve placement and deep vein thrombosis (blood clots) of the lower extremities (legs), as well as a history of obesity and anxiety.
- The MSE, completed at 7:38 PM, showed the patient was five feet two inches tall, and weighed 198 pounds. The patient was nervous and anxious. The only laboratory tests performed were a Prothrombin time (PT, laboratory test to determine how long it takes blood to clot) and International Normalized Ratio (INR, laboratory test to determine how well Coumadin is working to prevent blood clots). The PT/INR were both elevated, with a PT of 42.5 (normal 12.3-14.9) and INR of 4.3 (normal 0.9-1.1). The physician's documentation showed the patient had no chest pain reported.
- There was no evidence of further laboratory tests or other diagnostic studies or consults.
- At 7:49 PM, the ED nurses' notes showed the patient continued to rate her chest pain at "2," even though the ED physician showed the patient had no chest pain eleven minutes prior.
- No further chest pain assessment was documented in the record.
- The patient was given Ativan, (medication that reduces anxiety) at 8:19 PM.
- The patient was discharged at 9:07 PM with directions to follow-up with her primary care physician (PCP) as needed.

There was no documented evidence the ED physician knew the patient complained of chest pain, no evidence of further examination into the cause of the elevated PT/INR, and no further laboratory, radiology or cardiopulmonary studies were completed, or consults to specialty physicians, as related to the patients risk factors and presentation.

During an interview on 08/30/18 at 6:47 AM, Staff B, ED Registered Nurse (RN), stated that she did not recall the patient's level of chest pain at discharge or if the patient's chest pain was assessed prior to discharge, and did not recall any treatment or orders related to the increased PT/INR or chest pain.

Review of the patient's Warfarin (Coumadin) Flow Sheet, via the anticoagulation clinic, with entries from 05/25/17 through 05/31/18 showed:
- Patient #1's INR target range was 2.5-3.5 because of her mechanical heart valve.
- The highest INR the patient had, in the prior seven months (10/10/17-05/31/18) was 4.2, and the intervention for this level was to skip one dose of Coumadin, continue with the regimen and return to the clinic in two weeks for follow-up.
- Her INR remained in target range from 12/28/17 through 05/31/18.

During an interview on 08/30/18 at 8:17 AM, Staff C, ED physician, stated that he did not feel his MSE showed any reason for further testing or consult, and was not concerned about the patient's elevated PT/INR because the INR was not greater than 5 and because the patient had a mechanical heart valve.

During an interview on 08/30/18 at 10:35 AM, Staff H, Vice President of Cardiology Services, stated that he would expect the ED physician to assess Patient #1 for signs of bleeding in his MSE on 06/11/15, both physically and through patient interview.

2. Review of Patient #1's PCP, and group home (residence) documentation, from 06/14/18 to 06/15/18 showed the following:
- On 06/14/18, at 9:19 AM, the group home where Patient #1 resided, called the patient's PCP and reported severe gas-like pains since about 4:00 AM, loose stools, pain all over the lower abdomen, flank (left and right sides, mid-back area) pain and lower back pain.
- The PCP saw her on 06/14/18 at approximately 3:00 PM. The patient reported a poor appetite, severe abdominal pain that was worse with movement or touching. She had a sickly/distressed appearance, was anxious, lying on her side holding her abdomen. There was tenderness and guarding (to tense the stomach muscles as a reaction to pain) in all areas of the abdomen. The white blood cell count (WBC, blood cells that increase when something is wrong in the body) was elevated at 11.4 (normal 4.0-9.8). The patient's hemoglobin (hgb, part of the red blood cells that transport oxygen throughout the body, and decreases with bleeding or blood loss) was low at 9.2 (normal 11.8-14.8) and red blood cell (RBC, carries hgb, and decreases with bleeding or blood loss) count was low 2.77 (normal 3.90-4.90), both can be indicative of bleeding. The group home staff were notified to watch for signs of bleeding. No INR/Protime was evaluated at this visit.
- On 06/15/18 at 8:42 AM, the patient still experienced nausea (to feel as if you will throw up) and had no appetite.
- On 06/15/18 at 1:38 PM, the patient had abdominal pain, would not eat, and lied in bed crying.
- On 06/15/18 at 2:40 PM, the patient became unresponsive and an ambulance was called. The patient stopped breathing and cardiopulmonary resuscitation (CPR, life saving measures when a patient's heart stops, or they stop breathing) was started by ambulance staff.

Review of a second ED visit dated 06/15/18 showed the following:
- The patient presented at 3:18 PM, by ambulance, unresponsive.
- The patient was placed on life-support (medical equipment used to continue life, what a person cannot continue life on their own).
- The patient died, with final diagnoses of hemoperitoneum (bleeding into the area around the stomach and intestines) and anoxic brain injury (lack of oxygen/blood flow to the brain, which kills brain tissue).

During an interview on 08/30/18 at 6:32 AM, Staff D, ED physician on duty when Patient #1 returned to the ED on 06/15/18, stated that he had no knowledge of the patient's previous visit or what caused the patient's death.

During an interview on 08/30/18 at 7:30 AM, Staff E, Cardiologist (doctor who specializes in heart and its function), stated that:
- He provided primary physician care for Patient #1 for the previous eight to nine years.
- If he had seen Patient #1 in his office with an increased PT/INR, similar to the ED results on 06/11/18, he would have directed Patient #1 to hold her Coumadin for one day and have her PT/INR re-checked before she resumed normal dosages.
- He was unaware of the two visits to the ED until 06/15/18, when the patient's mother notified him Patient #1 had returned to the ED. .
- Bleeding was always a concern with a young patient on anticoagulants.
- He was initially concerned that Patient #1 was bleeding, and that the bleeding had gone on for some time prior to 06/15/18..
- He stated that the bleeding caused the patient's blood pressure to decrease, which caused the brain to not have enough oxygen, and lead to anoxic brain injury.

The facility failed to provide a thorough MSE prior to discharging Patient #1 back to a group home on 06/11/18. The patient continued to experience significant abdominal and back pain, a poor appetite, nausea and anxiety and was distressed. The patient died four days later related to bleeding, a side effect of elevated PT/INR.