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Based on record review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [relative to posting of signage and stabilizing of patients]. See A2402 and A2407.

An Immediate Jeopardy was identified. See A2407

Based on observation and interview, it was determined that the facility failed to post the rights of patients under the Emergency Medical Treatment and Labor Act (EMTALA) in an area that would be visible to all patients receiving emergency medical treatment. Findings include:

Upon entrance to the facilities emergency department (ED) on 08/20/2012 at 0900, an observation in the emergency department revealed that the only postings in regards to EMTALA was in the ED waiting room.

During an interview on 08/20/2012 at 1000 with the Director of the Emergency Department, when asked about how patients or family/visitors are informed of their rights under EMTALA she stated that they have it posted in the waiting room. When further asked if all patients that come to the ED go into the waiting room she stated "No." When further questioned as to how patients that do not go into the waiting room or for patients that come in through the ambulance entrance are informed about their EMTALA rights she stated "That's a good question" but did not give an answer.

During the investigation, it was determined that an Immediate Jeopardy (IJ) existed. The determination for the IJ was based upon record reviews and interviews which revealed the Hospital failed to provide stabilizing treatment for a patient, Pt. #1, who presented with a migraine headache. This was the second Emergency Department (ED) presentation in 24 hours. The Hospital failed to monitor the patient's medical condition sufficiently and discharged the patient from the ED. The patient was found deceased at home the next morning.
This failure posed an immediate threat to the health and safety of Patient #1 and has the potential to effect ALL patients that present to the ED with an emergency medical condition. The immediate jeopardy is cited at 42 CFR 489.24(d)(e).


Based on record review, policy review and interview, the facility failed to stabilize 1 of 4 (#1) patients reviewed presenting to the emergency department with a diagnosis of headache from a total of 27 records reviewed. Findings include:

During a review of the medical records for patient #1 on 08/22/2012 at 1100 revealed that the patient had presented to the emergency department on 04/16/2012 at 23:31 with a complaint of " migraine. " Patient was first seen in triage at 23:48 with a documented pain rating of 10 out of 10, pain documented as constant and onset being 3 days ago. A nursing assessment was completed on the patient at 23:56 with documented vital signs (VS) of Blood Pressure 112/53, Pulse 103, Respirations 16, Temperature 98.1 and oxygen saturation 96 % on room air. A medical screen examination was completed on the patient at 0113 by the ED physician (staff F). At 01:09 on 04/17/2012 during the ED visit, the physician wrote orders for the patient to receive Phenergan 25 mg intra-muscular (IM) and Dilaudid 2 mg IM. Final Primary Diagnosis documented at 01:10 as " Migraine headache." At 01:10, the physician wrote a discharge order for the patient to be discharged to home. At 01: 11, the documentation reads that the patient was given discharge instructions. The medications were administered by the RN on 04/17/2012 at 01:23 (after the patient had been given discharge instructions) and the patient was discharged at 01:36 to home (13 minutes after the pain medication had been administered).
During an interview with the director of the Emergency Department on 08/20/2012 at 13:25, when asked about a re-evaluation of the patient she stated "There is no documented evidence in the medical record of a re-evaluation of the patient's vital signs or pain level after medication administration at 01:23."

A review of the facilities policy/procedure titled Patient Assessment and Vital Signs #43.02.09 revised 07-2009 reads Purpose "Provision of guidelines for the minimal standard of care for patient assessment and re-assessment, which includes vital signs. "Policy"All emergency patients will have assessment and re-assessment appropriate to presenting complaint and condition so that optimal care can be provided."
Procedure 9. "Any patient receiving IM, IV or SQ medication will be observed for adverse reaction for 20 minutes before discharge."
Procedure 11."Patients presenting with a complaint of pain at a level of 4 or greater on the 1-10 scale will have their pain level reassessed, including after pain medication, and upon discharge/ transfer/admission."
The medical record for the patient from the 04/16/2012 visit does not contain any follow-up re-assessment of the patient's pain or vital signs prior to discharge on 04/17/2012 at 01:36.

The patient returned again to the ED on 04/17/2012 at 07:18 with an admitting diagnosis of headache vomiting. The documentation shows that the patient was seen in triage at 07:43. Documented vital signs at this time BP 144/77, pulse 115, respirations 24, temperature 100.8, Pain 10 of 10, constant, with onset of 4 days ago and oxygen saturation of 95 % on room air. A medical screen examination was completed on the patient by the physician at 07:44. The physician entered medication orders for the patient at 08:27 consisting of Tylenol 975 mg, Toradol 30 mg, Zofran 4 mg and Dilaudid 1 mg. The medications are documented as being given by the RN at 09:05. There is documentation that at 09:12 the patient 's family states that patient felt hot so they took her temperature which was 101. The record goes on to contain documentation at 10:02 of BP 112/67, Pulse 107, Respirations 16 Pain: sleeping 7, oxygen saturation 91 % with oxygen. Nursing note documentation entered at 10:03 reads "Pt. pulse ox low at 88% so O2 applied at 2L NC. "At 10:04, a re-evaluation by the physician reads "Pt is feeling better but has slurred speech and is sleepy. Will monitor for a while." Nursing documentation at 11:32 reads "Pt. continues to be sleepy with slurred speech while awake. Pt cannot stay awake to have a full conversation." A physician 's note entered at 12:20 reads "Pt is more awake and feeling better." At 12:21, the physician wrote an order to discharge the patient to home "Condition:Stable." The documentation states discharge instructions at 12:21 but does not define who the instructions were given to or if that person voiced understanding of them. A discharge note entered at 12:52 the RN states "First contact with patient was at time of discharge. Patient on cart, awake and easily conversive." The documentation also reads that "Family state she is incoherent" "and this nurse observes no such findings." The patient was then discharged from the ED on 04/17/2012 at 12:59.

During an interview on 08/ 20/2012 at 1450 with the attending physician at the time of the ED visit, an inquiry was made about the re-assessment that took place at 12:20 and what the physician had actually based the documentation on. The physician stated that "I physically examined the patient; the patient was on a constant monitor and that the patient was awake."

When asked about the concerns voiced by the family she stated, "I was never made aware by the nursing staff that the family had any concerns. If they (Nursing staff) had said something I would have been more than happy to go and discuss them with the family."

The record does not contain any further documentation of vital signs after 10:02. There was no further documented re-assessment after the oxygen was removed from the patient. The last documented oxygen saturation was 88% at 10:03.

During an interview with the Director of the Emergency Department (staff C, RN) on 08/20/2012 at 1600, she confirmed that the medical record does not contain any re-assessments on the patient after 10:02. She stated that "the nurses failed to document any further vital signs or reassessment of the pain scale prior to the patient being discharge." When inquiry was made as to if she would have discharged the patient based on the available documentation she stated "No."