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Based on review of facility policy, medical record review and interviews, the facility failed to ensure an accurate and complete medical screening examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) for lightheadedness and fatigue of 22 records reviewed.

The findings include:

Patient #1 presented to the ED on 6/14/2024 by Emergency Medical Services (EMS) with lightheadedness and fatigue. The patient reported her family checked her blood pressure and it was low. The patient had previous history of Atrial fibrillation. EMS started an intravenous line and gave the patient a fluid bolus. The patient was triaged and evaluated by the ED Provider where diagnostic laboratory and radiology testing was completed. Diagnostic testing did not show findings suggestive of Sepsis, however, a urinalysis was ordered and was not completed prior to the patient being discharged. Later on 6/14/2024, the patient presented to Facility B with worsening symptoms. The patient had an elevated White Blood Count, elevated Lactic Acid, and her urine showed findings suggestive of a Urinary Tract Infection. She was started on intravenous antibiotics and given IV fluids with improvement. The patient was admitted with the diagnosis of Sepsis. On 6/15/2024 the preliminary results for the blood cultures, completed at Facility A, showed gram negative rods and E.coli. The patient remained at Facility B until 6/17/2024 when she was discharged home on oral antibiotics.

Refer to A-2406

Based on review of facility policy, review of an Emergency Medical Services (EMS) run report, medical record review and interviews, the facility failed to ensure an accurate and ongoing medical screening examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) with lightheadedness, fatigue, low grade fever and failed to complete diagnostic testing ordered by the physician of 22 records reviewed.

The findings include:

Review of the facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA)" last revised on 2/5/2021, showed "...a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part... Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists, or a woman is in labor. Such screening must be performed by qualified medical personnel...and within the hospital's capacity and capability. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred..."

Review of an EMS run report dated 6/14/2024, showed EMS was requested related to Patient #1 being lightheaded while at home with nausea. The patient had complaints of feeling lightheaded and a "funny feeling" with nausea and muscle cramps. She had a previous history of Atrial fibrillation. Her vital signs were as follows: blood pressure 108/68, pulse 82, respirations 18, pulse oximeter 98%, and temperature 98.5®F (degrees Fahrenheit). During transport, an intravenous (IV) line was started, the patient was given 1000 milliliters of Normal Saline, 4 milligrams (mg) of Zofran (medication used for nausea) and started on oxygen at 2 liters/min via nasal cannula. The patient was transported to Facility A's ED.

Medical record review of an ED Nursing Triage record, dated 6/14/2024 at 1:45 PM, showed the patient presented via EMS with complaints of lightheaded and dizziness which started the same day. EMS had established an IV and given IV fluids. The patient's vital signs were as follows: blood pressure 97/70 with a mean arterial pressure of 79, pulse 100, respirations 18, pulse oximetry 96% on room air, and temperature 99®F. The patient was triaged with an Emergency Severity Index (ESI) score of a 2, indicating urgent needs.

Medical record review of an ED Physician record, dated 6/14/2024 at 2:05 PM, showed Patient #1 presented with generalized fatigue, lightheadedness and nausea intermittently over the past week and "while eating a sandwich" got nauseous and thought the nausea caused the lightheadedness which lasted 5-10 minutes and resolved on its own. She denied chest pain, shortness of breath, cough, congestion, runny nose, headaches, change in vision, focal neuro deficits, abdominal pain, vomiting, or urinary or bowel complaints. The patient had previous history of Atrial fibrillation. A urinalysis (UA) was ordered but was not completed for the patient prior to discharge.

Medical record review of an ED Physician's Discharge note, dated 6/14/2024 at 5:05 PM, showed the patient's diagnoses included nausea and fatigue. The patient was instructed to follow-up with her Primary Care Physician in 1-2 days or return to the ED sooner if symptoms persist, worsen or concerns. No prescriptions were given to the patient and no antibiotics were provided.

Medical record review of a Discharge Disposition Summary, dated 6/14/2024 at 6:41 PM, showed the patient was discharged.

Medical record review of a Microbiology report from Facility A, dated 6/15/2024 at 7:35 AM, showed the patient's blood culture showed Gram Negative Rods. The results were called to the ED Provider. On 6/17/2024 at 7:58 AM, the blood culture showed growth of Escherichia Coli.

Medical record review of an ED Physician's note, dated 6/15/2024 at 10:00 AM, showed "...called and spoke to patient. She is currently at [name of Facility B] ED being evaluated. She will communicate with them that she had two positive blood cultures here..."

Medical record review of an ED Physician's Note, dated 6/20/2024 at 3:19 PM, showed "...blood culture results reviewed and positive for E.coli. Upon chart review from ED visit on 6/14/2024, she did not receive any antibiotics and no urinalysis was performed. I spoke with patient on the phone number listed on her facesheet and she reports that she was seen at [Facility B's] ED 2 times since her visit here at [Facility A] and has been treated with Amoxicillin and Cefdinir [antibiotics] and feels better..."

Medical record review of an ED Nursing Triage Record from Facility B, dated 6/14/2024 at 10:54 PM, showed the patient presented to the ED with complaints of hypotension. The patient had been discharged from Facility A's ED the same day. The patient presented lethargic, she had right lower extremity edema, and generalized weakness. Her vital signs were as follows: Blood pressure 109/56, Pulse 100, Respirations 17, and Temperature 101®F.

Medical record review of an ED Physician's Record from Facility B, dated 6/14/2024 at 11:02 PM, showed the patient presented with general weakness and light headedness. She had gone to Facility A's ED where she was given IV fluids and blood work was obtained. She was discharged home. Later she continued to not feel well and had a low blood pressure in the 80's.

Medical record review of a Urinalysis report from Facility B, dated 6/15/2024, showed the urine showed trace amounts of ketones, small amount of leukocytes, small amount of blood, 8 UR WBC's (normal 0-2), 5 UR RBC's (normal 0-2), and mucus strands. A reflex culture was not completed.

Medical record review of a Hospitalist Progress Note, dated 6/16/2024, showed the patient's diagnoses included Sepsis, possible Urinary Tract Infection (UTI), Bacteremia (bacteria in the urine) with elevated WBC (22 on admission now 6.9), fever, elevated Lactic Acid, and low blood pressure...The patient was on Zosyn and had received Vancomycin and "...suspect this is UTI source, could be GI tract source without clear symptoms and bland UA here..." The patient reported urinary frequency and having to get up at night to urinate which had recently occurred just prior to admission.

Medical record review of a Discharge Summary, dated 6/17/2024 at 11:40 AM, showed the patient's primary discharge diagnosis was E.coli and Sepsis likely due to UTI. The patient was placed on an oral 3rd generation cephalosporin (antibiotic) for 7 days. The patient confirmed urinary frequency. She was discharged home in stable condition.

During a telephone interview on 6/24/2024 at 3:50 PM, with the complainant stated the patient passed out at home and it was thought to be related to a low blood pressure. EMS transported the patient to Facility A for evaluation and the patient was unable to walk. The patient had a fever of 101®F and had previous history of Atrial fibrillation. The facility 'ran some test' including blood work, chest x-ray, and an EKG and within 3 hours she was sent home. Upon discharge at Facility A the family took her to Facility B the same day, where her blood pressure was better and she got IV fluids. Within 1-2 hours the patient met the sepsis criteria, she was given IV antibiotics, and she was admitted to Facility B with Sepsis. He stated Facility A called the patient on 6/15/2024 and told her the blood cultures were positive, the patient had Sepsis, and they wanted her to return to the ED. The patient had already been admitted to Facility B where she remained for 4 days and was discharged.

During an interview on 6/25/2024 at 3:15 PM, ED Physician #1 stated he evaluated the patient on 6/14/2024 and stated the patient presented to the ED with complaints of lightheadedness and fatigue for the past week. The patient did not complain of chest pain, shortness of breath, or urinary symptoms. The patient's vital signs were stable. He stated, related to sepsis, the patient did not meet sepsis criteria but on admission her heart rate was 100. He stated "...she did not trigger the sepsis protocol based on her presentation, but I ordered many of the labs for sepsis. Her WBC and Lactic Acid were normal. IV fluids were started by EMS and she was given a liter bolus of Normal Saline. We drew 2 blood cultures but did not have those results prior to discharge. The urine was ordered but not collected prior to discharge. Based on the labs, chest x-ray, and clinical presentation, I did not feel the patient needed antibiotics and she had a primary care provider. She was not hypotensive. The blood culture results came back positive for Gram Negative Rods and E.coli. The Physician's Assistant called the patient and was told the patient was at [Facility B] being treated. It looks like she got treated with Amoxicillin and Cefdinir. Based on the lab findings and the patient's clinical presentation, antibiotics were not indicated at that time. There was no primary source of infection..."

During an interview on 6/26/2024 at 11:35 AM, ED Nurse Manager #1 stated the sepsis protocol would be triggered related to the patients' vital signs. The sepsis protocol would be initiated if 2 or more of the criteria triggered for a patient. The only trigger for the patient was a heart rate greater than 90 but the patient's EKG showed the heart rate was trending downward. The Nurse Manager confirmed the urinalysis was ordered, but was not completed prior to discharge.

During a telephone interview on 6/26/2024 at 2:00 PM, ED Physician #2 stated the standard of care was not to give antibiotics without an identifiable source. The patient did not meet sepsis criteria related to her vital signs and no urinary complaints. Diagnostic testing was completed to include a chest x-ray, CBC, CMP, and Lactic Acid which showed no acute findings. A urinalysis was ordered but was not completed prior to the patient's discharge.