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Based on record review, patient/family interview, staff interview, physician interview, document review and policy review, the facility (Hospital #2) failed to provide Patient #19, one (1) of 20 Emergency Room patients reviewed at Hospital #1, an appropriate transfer without delay.


Findings Include:


Cross Refer to A2411 for the facility's failure to provide an appropriate transfer within the capabilities of the hospital for Patient #19 on 02/23/13.

Based on record review, patient interview, physician interview, staff interview, family interview and policy review, Hospital #2 failed to accept Patient #19 from referring Hospital #1, an appropriate transfer of an individual who required such specialized capabilities or facilities when the receiving hospital had the capacity to treat. Patient #19, one (1) of 20 patients reviewed.


Findings Include:


On 03/26/13 the State Agency received a potential EMTALA complaint alleging that on 02/23/13 Hospital #2 and Hospital #4 refused to take transfer of Patient #19, a 64 year old patient who was triaged as "emergent" by Hospital #1, because she was a resident of Louisiana. The patient was accepted, then airlifted and treated by the emergency department at Hospital #3.


Hospital #1

Record review revealed that Patient #19 arrived at Hospital #1's Emergency Department (ED) on 02/23/13 at approximately 15:33 (3:33 p.m.) by personal transportation accompanied by her brother. The patient's chief complaint was shortness of breath that became severe. Initial vital signs revealed a pulse of 213. She was triaged as a Level 2 (two). Level 2 patients are classified as "emergent". (unstable, vital signs compromised, if left untreated situation will quickly deteriorate). Interview with Patient #19 on 04/05/13 at 9:20 a.m., per telephone at her brother's house, revealed that she was visiting her mother when she became very sick and couldn't breathe well so her brother took her to an area hospital (Hospital #1). She discussed her helicopter ride to Hospital #3 then stated, "The first thing they did was to draw off this fluid so I could breathe better. I stayed there (Hospital #3) for four (4) or five (5) days and they told me I had heart failure. I'm supposed to be on medicine, but can't afford it. I can't remember real well these days."



Review of Patient #19's 02/23/2013 Emergency Record and Emergency Nursing Record from Hospital #1 revealed that her general appearance was of moderate to severe distress. She was anxious and had edema of the lower extremities. She had tachycardia with a rapid pulse rate of > (greater than) 200 and periods of confusion. The patient's Electrocardiogram (ECG) interpretation stated: "Atrial Fibrillation, Ventricular Rate about 180, Nonspecific ST-T Abnormality." Laboratory tests performed revealed Patient #19's Sodium, Glucose, Creatinine, Blood Urea Nitrogen (BUN), AST/SGOT and Bilirubin were reported as H (high). A Chest X-Ray revealed a large right Pleural Effusion (increased fluid in the pleural space). The patient was placed on telementry related to her rapid heart rate. An Intravenous (IV) line was placed, as well as a Foley catheter. Diagnoses included: 1. Rapid Afib (Atrial Fibrillation) 2. Pleural Effusion 3. UTI (Urinary Tract Infection) and 4. CHF (Congestive Heart Failure). Medications, given for the problems identified, were documented as Verapamil 5 mg (milligram) IV X2, Lovenox 80 subcutaneous (SQ), Zaroxolyn 5 mg. po (by mouth), Digoxin 0.25 mg. intramuscular (IM), Duoneb treatment, Rocephin 1 gm (gram) IV, and Lasix 80 mg IV. Documentation on the patient's ED record stated that Patient #19 had not been seen by a doctor in 20 to 30 years. Past medical history was unknown.



Interview with Hospital #1's ED Physician on 04/02/13 from 3:00 p.m. to 3:45 p.m. revealed the following description of events from the time Patient #19 came to Hospital #1's ED on 02/23/13 at 3:33 p.m. until she was transferred out to Hospital #3 at 6:00 p.m.:
Patient #19 moved to the area in December 2012 to stay with her mother. She became very ill and her brother brought her to the ED. Upon examination, she was found to be very short of breath, in supraventricular tachycardia (SVT) at 240, decreased pulse oximetry at 80%, and rapid atrial fibrillation. She was placed on a cardiac monitor and an IV was started. Verapamil was administered to decrease her heart rate and lab work was ordered. A Chest X-Ray was performed that showed her whole right lung was white out (Pleural Effusion) and diuretics were administered. "This was a critical patient and needed to get out of there. She also had a urinary tract infection." There was a lack of prophylactic care and the family had to encourage her to come to the ED. Family said that she had not seen a doctor in many years and that she may have Paranoid Schizophrenia. "I called (Hospital #2). (A specialized Unit - Patient Placement Center) takes all calls involving transfers into (Hospital #2). I explained to the person who answered the phone that the Louisiana resident was here visiting and became very ill. The operator stated that she was reading from a new declaration sent to them about three weeks ago that stated that they do not accept Louisiana patients. I explained that the patient was critical and needed an immediate higher level of care. The operator would not let me speak to any doctor. I called (Hospital #2) again and the same operator answered the phone and verified that they would not accept Louisiana residents.
The physician stated that he then called (Hospital #4) to request a transfer for the patient and Hospital #4 also refused the transfer. He then asked the family about a hospital in Louisiana where Patient #19 may have been a patient in the past. They told him to call (Hospital #3). The ED physician contacted Hospital #3 and was able to speak with a physician there who accepted Patient #19 in transfer.
The ED physician stated that Hospital #3 called him back after receiving Patient #19 via airlift and agreed with the medical care the patient had received prior to transfer, stated that their diagnoses for Patient #19 were the same ones she was sent there with, and that they had removed over a liter of fluid from Patient #19.


Interview on 04/02/13 between 3:55 p.m. and 4:10 p.m. with Registered Nurse (RN) #1 from Hospital #1 revealed, "I was supposed to be off that day (Saturday 02/23/13), but a nurse called in. Then, (RN #3) came in to be the triage nurse and give medications. (Patient #19) came in with shortness of breath and the first emergency room was open so we took her straight into that room. The ER (Emergency Room) physician wanted to get her transferred out for a higher level of care. We have a red phone in the ER that automatically goes to (Hospital #2) when picked up. (A Patient Placement Center unit) answers in the ER at (Hospital #2). I heard the ER physician here talking to a person there. He repeated out loud what was said on the other end of the phone. "They're not accepting Louisiana residents. She said that the patient had to go to the doctor where she was from." Later, the ER Physician called back to (Hospital #2). The same operator answered and told him the same thing as before. I also heard him calling other hospitals to see if they could take her in transfer. No one would accept her. The ER physician asked her family if she had used a hospital in Louisiana. The brother said that she had been to (Hospital #3). The ER physician called there and they accepted her in transfer."



On 04/08/13, between 2:45 p.m. and 2:55 p.m., interview by telephone with Licensed Practical Nurse (LPN) #1 from Hospital #1 revealed that she remembered Patient #19. The LPN stated that she could remember the ER physician calling two different hospitals. "He called (Hospital #4) and stated that they wouldn't accept her. Then he called (Hospital #2) and they wouldn't take her because she lived in Louisiana."



Interview by telephone with RN #3 from Hospital #1 on 04/08/13 between 3:15 p.m. and 3:45 p.m. revealed that she was the RN who triaged Patient #19 in the ED on Saturday afternoon 02/23/13. RN #3 stated that the patient described her problem as "my heart is running off." RN #3 stated that the ED physician called several hospitals trying to get Patient #19 transferred for a higher level of care. "He called (Hospital #2) first, where he was told that they had a new policy that they didn't take Louisiana patients anymore. He stayed on the phone telling them that she (the patient) had been here (Mississippi) a couple of months taking care of her mother when she became really sick. He became very frustrated and repeated out loud what the person at (Hospital #2) was saying. He tried to explain that this patient needed to be transferred immediately. They just stated that they were not accepting Louisiana patients and he was not allowed to speak with a doctor there. After a little while he called back to (Hospital #2) to make sure he heard them correctly. He had heard them correctly. They would not accept the transfer because she was a Louisiana resident." RN #3 stated that the ER physician called Hospital #4 and they also refused to accept the transfer. "After talking with her family he (the ER physician) called (Hospital #3). They accepted the patient and she left by helicopter."



On 04/09/13 from 6:00 p.m. to 6:15 p.m. interview by telephone with the brother of Patient #19 revealed, "They (Hospital #1) did not have the capacity to treat her there. The doctor called several hospitals in Mississippi and none would accept her in transfer. One hospital told him that they did not take residents of Louisiana. She was not living in Louisiana, but her address was listed as Louisiana."


Review of Hospital #1's undated "Transfer From Emergency Services" policy revealed: "Policy: No patient shall be transferred until his medical condition is stabilized to a degree that allows for safety during transport...
Patients critically ill and beyond (Hospital name) licensing and treatment capabilities shall be transferred to an appropriate hospital..."


Review of Hospital #1's ED documentation for 03/23/13 revealed that Physician #1 spoke with Patient #19 and her family then contacted Hospital #3 about transfer. Hospital #3 accepted the patient and she was airlifted to Hospital #3 after a delay due to the weather.



Hospital #4


On 04/03/13 at 9:15 a.m. the Chief Nursing Officer (CNO/RN #1) at Hospital #4 was interviewed regarding the alleged call made by Hospital #1's ED Physician to request they take transfer of Patient #19. The CNO stated that she has no knowledge of a call coming in from Hospital #1 requesting a transfer on 02/23/13, that no log was kept to document potential patients requesting transferring to Hospital #4 and that their ED physician's were all contract and that each unit kept their own daily census. She also said that she would contact the three (3) RNs on duty on 02/23/13.


On 04/03/13 at 11:35 a.m. the Chief of Emergency Department Services was asked how Hospital #4 processes request for transfers into their ED. He stated, "The doctor from the transferring hospital would call the ER doctor here. If an ICU (Intensive Care Unit) bed is needed the ER doctor would contact the Nursing Supervisor. The Nursing Supervisor would call Hospital #4's ER doctor back (regarding any vacant ICU beds). Then Hospital #4's ER doctor would call the transferring ER doctor back (to state whether they could take the transfer or not). When he was asked whether they ask about insurance coverage he stated, "No... We can take patients when specialist are on call. We are a Level 4 Emergency Department. Our contract ER physicians come in the evenings."


On 04/03/13 at 12:00 p.m. the House Supervisor (RN #2) stated that the process for a hospital calling for a transfer into Hospital #4's ER depended mainly on staffing, bed availability and if a specialist was needed. She stated that she did not remember talking to a doctor at Hospital #1 about a transfer (on 02/23/13). "When a call comes in for a transfer, the nurse in ER calls the supervisor. I don't recall anyone calling about the availability of a cardiologist and a pulmonologist."


04/08/13 at 3:00 p.m. via telephone, the CNO stated that she had talked to the three (3) RNs that were on duty on 02/23/13. "(RN #3) stated that she doesn't remember, but that she has never turned down a transfer. (RN #4) stated that she did not talk to anybody about a transfer that day. (RN #5) said that she doesn't know anything about a call from a doctor in the ED of (Hospital #1) on 02/23/13."


On 04/12/13 at 5:35 p.m. via telephone interview, ED Physician at Hospital #1 was told that no one at Hospital #4 would acknowledge a call from him on 02/23/13. He again stated, "I call (Hospital #4). I can't remember the name of the nurse I spoke to." The name of the nurse the ED Physician stated he thought he spoke with did coincide with one of the nurses interviewed at Hospital #4 who had denied the call.




Hospital #2

Review of Hospital #2's "Continuum Of Care - Access To Appropriate Care" policy (effective date 9/96; review/revision date 12/11) revealed:
"I. Purpose: To provide and insure medically indicated appropriate care to all patients admitted to (Hospital #2) without regard to race, age, creed, sex, national origin, ethnicity, culture, language, religion, physical or mental disability, socioeconomic status, source of payment for care, sexual orientation, gender identity or expression, within the capabilities of the institution and its resources.
II. Policy: ...Although the hospital serves as a general hospital for its immediate area it is primarily a state referral center designated to aid referring physicians in the management of both ambulatory patients and inpatients.
III. Procedure: ... B. Determination is made as to whether or not a patient may be admitted to (Hospital #2) for medical care based on need, meeting the hospital approved medical necessity program, bed availability, services available... C. A financial review will be made for each patient prior to or at the time of admission to determine the source of payment of the patient's account and to identify third party resources which may be available to defray a patient's hospitalization cost. No one will be denied medically necessary care because of his inability to pay. D. Patient Catagories - Defined: 1. Emergency - An emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would significantly increase such danger.
2. Urgent - Urgent is defined as a condition in which the patient is in need of immedite attention (with-in forth [forty]-eight hours) and which any prolonged delay in administering treatment would jeopardize the health of the patient. This catagory includes those so designated by the attending practitioner and shall be reviewed as necessary. ..."


Review of Hospital #2's "Transfer Patients From Another Facility" policy (effective date 04/04; review/reviswion date 1/10) revealed:
"I. Purpose: To establish guidelines for communication between Emergency Department physicians, nurses, EMS dispatchers and/or any ancillary staff regarding a pending transfer patient and to ensure that the information provided by the referring physician/facility regarding a pending transfer patient is communicated to the staff. ...
V. Procedure: When a transfer call comes into the ED the following should occur; 1. EMSD (Emergency Medical System Dispatcher) obtains information which should be written on the transfer sheet to include: ... c. confirm the patient is in the ED of the referring facility ... f. the ED physician is notified and a three-way connection is established. The EMSD listens and records the information on the transfer sheet. ..."


Review of Hospital #2's "Admission To The Adult Emergency Department" policy (effective date: 9/96; review/revision date: 8/07, 11/11) revealed:
"... II. Policy: The AED accepts all patients who enter (Hospital #2) AED and accepts referrals from outside organizations unless the AED is on diversion. (Hospital #2) will not deny services to anyone requiring treatment based on denial or care conflicts regarding care, services or inability to pay in accordance with current EMTALA regulations. ..."


Review of Hospital #2's "Admission Policy, Patient" policy (effective date: 1/90; review/revision date: 8/2011) revealed:
"I. Purpose: The purpose of this policy is to define access to the care and services provided by (Hospital #2). As the only teaching hospital for the State of Mississippi...is an acute general hospital and a state referral center designed to aide referring physicians in the management of both ambulatory patients and inpatients.
II. Policy: ... C. Four primary factors are considered when a determination is being made as to whether or not a patient may be admitted to (Hospital #2). These are: 1. medical necessity; 2. bad availability; and 3. physician on hospital attending staff acceptance of the patient. 4. availability of services to meet the patient needs. ... E. Emergency care is provided regardless of ability to pay. ... F. Patient Catagories - Defined: 1. Emergency - An emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would significantly increase such danger.
2. Urgent - Urgent is defined as a condition in which the patient is in need of immedite attention (with-in forty-eight hours) and which any prolonged delay in administering treatment would jeopardize the health of the patient. This catagory includes those so designated by the attending practitioner and shall be reviewed as necessary. ..."


Review of Hospital #2's "Medical Staff Bylaws Part 1: Governance" (approved: March 2, 2009; revised 4/1/11, 9/9/11,3/2/12) revealed:
"2.1.2 Admission Priority - Patients will be admitted on the basis of the following order of priorities:
a. Emergency - An emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would significantly increase such danger.
b. Urgent - Urgent is defined as a condition in which the patient is in need of immedite attention (with-in forty-eight hours) and which any prolonged delay in administering treatment would jeopardize the health of the patient. This catagory includes those so designated by the attending practitioner and shall be reviewed as necessary...
2.2 Unassigned Emergency Patients - ...the Hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to, determine whether or not an emergency medical condition exists. ...
2.3 Transfers 2.3.1 Transfers From Other Acute Care Facilities - Transfers from other acute care facilities must meet the following criteria: a. The patient must be medically stable for transfer;
b. The patient's condition must meet medical necessity criteria for inpatient admission;
c. The patient must require, and (Hospital #2) must be able to provide, a higher level of care or a specific inpatient service not available at the transferring facility; ...
e. The transfer must be approved by the appropriate Hospital representative with authority for accepting transfers. ..."



Interview with Employee #1 from Hospital #2 on 04/04/13 at 11:30 a.m. revealed that she was the person over the Patient Placement Center area. (This is the area that takes all transfer-in requests) She stated, "Recordings are kept of all calls coming into the Patient Placement Center. There are two shifts per day and the phones are answered by Emergency Medical Technicians and Paramedics. The unit has an 800 phone number. The physician calls that number. Many small hospitals have a red phone in their ER and all they have to do is pick it up and the call goes through. The staff can accept certain diagnoses for adults. Other specialties have to be notified. Patients are not accepted if the hospital is on diversion. The hospital has had issues with Louisiana Medicaid, but the patient is not denied to my knowledge. There were meetings with Senior Leadership to develop practices to make sure Louisiana residents have exhausted what Louisiana has available." During the interview Employee #1 provided a tour of the area.


On 04/04/13 between 12:00 Noon and 12:15 p.m. an interview was held with Hospital #2's Departmental Chairman, Physician #1. The Physician stated, "There were Telemedicine hook-ups to 15 emergency departments in the state and several of these are in Critical Access Hospitals. It is not our policy to not accept Louisiana residents and the hospital never asks about insurance up front." He emphasized, "Our acceptance is patient-centered. It is about what is best for the patient."


On 04/04/13 from 12:20 p.m. to 12:50 p.m. Employee #2 (the operator who took both calls from Physician #1 at Hospital #1) was interviewed. The operator handwrote a document in her own words regarding the hospital's new process/policy for potential patients from Louisiana and her conversations during both calls from ER Physician #1 from Hospital #1 on 02/23/13. When asked for a copy of the new process/policy, Employee #2 stated that there was no policy because the information came in as an email. She did not submit a copy of the email prior to the exit conference.


Employee #2 wrote, dated, timed and signed the following statement:
"We were asked to start asking all transfers if the patient was a LA (Louisiana) resident. If so we were asked to document that the patient was a LA resident and ask if the sending hospital has contacted any hospitals in the LA area. We are to document if the sending hospital had contacted any LA hospitals and document why the patient was denied care at the LA hospital. If those area hospitals had been contacted and did not have the care needed to provide patient then (Hospital #2) would accept patient.
Dr. (doctor) called for a transfer and I asked was the pt. (patient) a LA resident and he said yes and I asked if he could/had called LA first for the patient care. The doctor was very polite, as I explained the above with the LA hospitals. The doctor said he would call LA. I did tell the doctor that if he had any other issues he could call us back. Several minutes later the doctor called back and said you know by not accepting this patient for her insurance is EMTALA violation. I explained to the doctor that I had nothing to do with patient insurance and that we were not denying the patient, only asking if you could try LA hospital first since pt. was a LA resident, and her doctors were in LA. I told the doctor that if he had any issues getting her accepted to call me back and we would accept the patient here. We would document the hospitals he called in LA and document why the patient was refused from her own residential hospitals. The Dr. said OK he would call LA if he had any issue he would call us back. The doctor never called back so I assumed he did get her accepted to LA hospital. The Dr. never stated it was family or patient request to come to (Hospital #2). If this had been said in the beginning I never would have asked him to call LA hospitals as all pts requesting (Hospital #2) are never denied unless we have no beds available...4/4/2013 12:50 p.m."


On 04/04/13 between 1:00 p.m. and 1:10 p.m. an interview was held with Physician #2. This was the Hospital #2 physician contacted by the operator who spoke with ER Physician #1 from Hospital #1. Physician #1 from Hospital #2 was present during the interview process. Physician #2 stated that the Operator had contacted him about a patient. He described the patient's problems, which included a fast heart rate (160's), and a large Pleural Effusion. He stated that at the time, he thought it would be better if a closer hospital could accept her. "This patient was unstable and would require a long transport time. The transfer was never refused." He stated that he had received extensive training on never to refuse anything.


Review of verbal recordings of two (2) calls made by Physician #1 from Hospital #1 to Hospital #2 revealed:
1. 02/23/13 (no time) Operator asked the ER Physician (Hospital #1) for the patient's name, date of birth, and what was going on with her? After giving the patient's name and date of birth the ER Physician stated, "She is short of breath, visiting from Louisiana since December, has a humongous Pleural Effusion, and SVT (Supraventricular Tachycardia) with a rate of 180-200. I gave her Verapamil. The rate is stable at 100 now. She's in Atrial Fibrillation."
The Operator stated, "She is from Louisiana? I hate to tell you this. You have to call a Louisiana hospital to see if she can go there. If they don't have a bed it must be documented. We have had so many problems with Louisiana hospitals not paying our hospital. We do not accept Louisiana insurance here.
The ER physician (Hospital #1) stated, "I will call back if I run into problems."


2. 02/23/13 (no time) The ER Physician (Hospital #1) called back to Hospital #2. The same Operator answered again. The ER Physician stated that he was on hold with Hospital #3. "They seem to think this is a major EMTALA violation." The Operator stated, "No, she must go to Louisiana because she is a Louisiana resident. They must go to their hospital."


Review of Hospital #2's February 2012 Employee Schedule revealed that the operator who was present in the Patient Placement Center area on 02/23/13 and took the call regarding Patient #19 was on the schedule for that day from 7A to 7P. She had been employed by Hospital #2 for seven (7) years.


Review of the Patient Placement Center area's Transfer Acceptance Policy revealed:
Transferring ED physician or Nurse Practitioner contacts the Patient Placement Center area. If the patient is stable and uncomplicated, they are accepted per Transfer Protocol.
OR
Patient Placement Center staff refer to ED Faculty: sending Physician/Nurse Practitioner Request - (Hospital #2's) Clinic Physician/Nurse Practitioner - Diversion, Refusal, No Service Available - Overdose Patients for Psych Services - Unstable, Complicated and/or Patient Placement Center discretion - Vascular,
OR
Patient Placement Center to appropriate Faculty before acceptance - Hand Service - Ortho - Cardiology.



Review of 20 records of in-coming calls for Hospital #2 revealed that 15 of the 20 patients were accepted/transferred to Hospital #2. Two (2) of the patients refused were from Louisiana. One (1) patient was not received due to their Psych Diversion; One (1) patient was not accepted because Hospital #2 does not perform re-implantation (left hand caught in machinery); Two (2) Telemedicine Consultations were done; and one (1) patient from Louisiana staying with her mother in Mississippi at the time was not accepted in transfer from Hospital #1.



Hospital #3

Review of Hospital #3's ED documentation revealed that Patient #19 was accepted for transfer from Hospital #1 on Saturday, 02/23/13 and airlifted in. She was seen in the ED for a documented medical emergency, treated as needed, then taken to a Special Procedures Room for Thoracentesis with 1700 ccs (cubic centimeters) of fluid removed from her right lung. She was then admitted to Hospital #3 by a Cardiologist. Continued review revealed that the critical conditions addressed in the ED for impending deterioration included respiratory, cardiovascular and metabolic. Associated risk factors included hypoxia, dysrhythmia and metabolic changes. Diagnoses included Acute Congestive Heart Failure, cute Urinary Tract Infection, Atrial Fibrillation, Dyspnea and Plural Effusion, large, right. Review of the patient's Emergency Severity Inex (ESI) revealed she was triaged as a 3 (three) with danger zone vitals and a need for many resources.

Review of Patient #19's History and Physical dated 02/23/13 revealed that the patient reported she had shortness of breath after walkiong less than 50 feet, which had been on-going since January, 2013 and had progressively worsened over the last week. She was only able to do minimal activity and had noticed leg swelling. Bilateral lower extremities were noted to have 2+ pitting edema. She had positive rales to right lower lobe (of lung) with decreased air entry bibasilar. An EKG performed 02/23/13 at 7:45 p.m. revealed atrial fib with a rate of 140 beats per minute. Echocardiogram preliminary report revealed diastolic dysfunction. Her right plural effusion was noted to be notably decreased after a thoracentesis done in the ER where they removed 1.7 liters of fluid.


During a telephone interview on 04/10/13 from 11:30 a.m. to 11:45 a.m. Patient #19's sister stated, "I met the helicopter bringing my sister to (Hospital #3) They took her to the Emergency Room first. My sister was bad off. They drew off a lot of fluid from her and they gave her medicines. She was taken to a room between 3:00 a.m. and 4:00 a.m., but didn't sleep at all and complained of bad leg cramps. She had three episodes that first night. The nurse called her doctor and she was given pain medication and potassium. I think that she has a mental problem. At times she was talking out of her head. Some of it may be because of her medicine, but not all of it. I stayed with her mainly at night. She was discharged on that next Wednesday (02/27/13) and is staying with one of our brothers."


Patient #19 was discharged from Hospital #3 on 02/26/13. Her discharge diagnoses were: Diastolic Heart Failure, acute; Pleural effusion; Congestive Heart Failure; Atrial Fibrillation; Essential Hypertension; Disorder of magnesium metabolism; and family history of Ischemic Heart Disease. Review of her discharge summary revealed that during her hospital stay she had put out a total of 10 liters of urine since admission. Her discharge condition was listed as stable.