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Based on policy review, sepsis screening tool review, medical record review and physician interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 04/29/2019.

The findings included:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #11) who presented to the hospital's DED for evaluation of increased heart rate on 04/29/2019.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy review, sepsis screening tool review, medical record review, and physician interviews the hospital failed to ensure that an appropriate medical screening examination was provided for an individual within the capability of the hospital's emergency department for a patient presenting complaining of an increased heart rate, in 1 of 20 sampled patients (Patient #11).

Findings included:

Review of policy titled "EMTALA - Medical Screening Examination and Stabilization" last approved 02/2019 revealed, "...To establish guidelines for providing appropriate medical screening examination (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Labor Act (EMTALA) ... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ... and ... A request is made by the individual ... for an examination or treatment for a medical condition ... an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed ... If an EMC (emergency medical condition) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility or an appropriate transfer as required by EMTALA ..."

Facility Sepsis Screen Tool Review:
Review of Hospital A's Sepsis Screen Tool conducted on 10/30/2019 (no effective date) revealed, "SEPSIS SCREEN A. Infection suspected / documented No - screen negative Yes - (proceed) B. temp: > (greater than) 38.3 C (101F) < 36 C (96.8 F) HR: >90 RR: >20 acute mental status change if known: glucose: >140 (w/ [with] no diabetes hx) WBC: >12000 <4000 C. SBP: <90 decr'd (decreased) >40mmHg from baseline MAP: <65 ... sepsis screen: negative positive (A yes + two or more B) severe sepsis suspected (A yes + any C) ..." * Note to reader = this tool is quoted from a screen shot how it appears to facility staff upon utilization of the tool in the facility's electronic medical record system. * Interview was conducted with the Director of Quality on 10/30/2019 at 0923. Interview revealed every patient is screened for sepsis utilizing the scoring tool. Interview revealed utilization of the screening tool is an expectation, and not policy driven.

Closed medical record review conducted on 10/29/2019 revealed Patient #11 presented to Hospital A's DED (dedicated emergency department) on 04/29/2019 at 0057, with a complaint of increased heart rate. Review revealed triage (assessment by ED (emergency department) triage nurse to determine the priority in which patients will be seen based on their presenting chief complaint and signs and symptoms) was initiated on 04/29/2019, and Patient #11 was assigned an ESI (Emergency Severity Index-ED tool 5 level triage algorithm) acuity level of 3 (Urgent), and assigned a, "SEPSIS SCREEN (a tool used to guide to early recognition and treatment of sepsis and septic shock): NEGATIVE (no infection suspected/documented)." At 0110 vital signs were reported as blood pressure 123/73, pulse 148 (Normal pulse rate/heart rate 60-100), respirations 16, temperature 98.4, and pulse oximetry 97%, on room air. Review of an ED (Emergency Department) Provider Note written on 04/29/2019 at 1910 by MD #1 revealed, "...Time seen: 01:47 ... HISTORY OF PRESENT ILLNESS Chief Complaint: PALPITATIONS. FAST HEART RATE. It is described as a fast heartbeat. She did not lose consciousness. This started 3 days and is still present. No history of caffeine use prior to onset. It has been constant. No chest pain or discomfort, difficulty breathing, fainting episodes or tingling. Similar symptoms previously: Recent medical care: The patient was seen recently in a clinic. (Patient reports that she has been having a fast heartbeat for several days she was seen at [Named Urgent Care Clinic] twice had (sic) negative strep tests (test checks for streptococcus bacterial infection in the throat) both times she was seen at another walk-in clinic and wanes fill (sic) had a strep test that was negative and also had which she states was a faintly positive mono (Mononucleosis-an acute infection caused by a virus) test. REVIEW OF SYSTEMS No fever, chills, abnormal bleeding, nausea or black stools. No skin rash, depression or vomiting. She has had a sore throat but not had (sic) a poor appetite. All systems otherwise negative, except as recorded above. PAST HISTORY ... Recent diagnosis of mono. No history of heart rhythm problems or congestive heart failure. SOCIAL HISTORY Never smoker ... PHYSICAL EXAM Appearance: Alert. Oriented x3. No acute distress. Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. ENT: Ears normal. Nose normal. Pharyngeal (throat) erythema (redness). Pharynx normal. Neck: Normal inspection. CVS (Cardio Vascular System): Tachycardia (increased heart rate). Normal heart rate and rhythm. Heart sounds normal. Pulses normal. Respiratory: No respiratory distress. Breath sounds normal. Chest nontender. Abdomen: Soft and nontender. Bowel sounds normal. No organomegaly. Back: Normal external inspection. Skin: Skin warm. Normal skin color. No rash. Extremities: Extremities exhibit normal ROM (range of motion). No lower extremity edema (swelling). Neuro: Oriented X 3. No motor deficit ... EKG (Electrocardiogram-common test used to detect heart problems): Normal sinus rhythm. Rate: 140. Tachycardia. Normal ST and T waves (represents heart electrical activity) Laboratory Tests (Pertinent lab values as follows) ... WBC (White Blood Count) (Reference range 4.1 - 10.7) ... Result 15.6 ... NEU ABS [Neutrophils Absolute] (Reference Range 2.00 - 7.36) ... 14.12 ... NEU% [Neutrophils percent] (Reference Range 43.0 - 74.0) ... 90.3 ... POTASSIUM (Reference range 3.6 - 5.0) ... Result 3.0 ... Glucose (Reference Range 70 - 105) ... 125 ... PROGRESS AND PROCEDURES Course of Care: Heart rate improving in the110's now ... Patient is stable. Symptoms better Disposition (sic): Discharged. Condition: stable. CLINICAL IMPRESSION Sinus Tachycardia. Infectious mononucleosis. INSTRUCTIONS ... Return or contact your physician immediately if you condition worsens or changes unexpectedly, if not improving as expected, or if other problems arise. Follow-up: Follow up with your healthcare provider in two days ..." Total laboratory tests performed on Patient #11 included a CBC (Complete Blood Count) and a CMP (Comprehensive Metabolic Panel). Diagnostic studies included the EKG. Additional treatment provided during the DED admission included: 3 liters of Normal Saline infused intravenously and Potassium Chloride 40 MEQ by mouth. At 0345, Patient #11's vital signs were blood pressure 110/73, pulse 120, respirations 18, temperature 98.7, and pulse oximetry 99%, on room air. Patient #11 was discharged on 04/29/2019 at 0353. The facility staff to identify this patient was at risk for sepsis and failed to initiate their own sepsis protocol for patient #11 on 4/29/2019.

Closed medical record review conducted on 10/30/2019 revealed Patient #11 returned to UC (Urgent Care) A on 04/30/2019 at 1025. Review of a Provider Note written on 04/30/2019 (untimed) revealed, " ...HISTORY OF PRESENT ILLNESSS Chief Complaint: sore throat, L neck pain, R chest pain with deep breathing, short of breath and rapid HR.(heart rate).This started 9 days ago; Pt (patient) returns after being seen here 4/22 and 4/23 with pharyngitis (Sore throat) and neg (negative) strep, she was informed I'd like to check mono but it was premature, to wait a few more days. She went to UC (Another Clinic in the Area Named) and there was a 'faint line' on her mono test, dx'd (diagnosed) with mono and treated with Prednisone. She felt better in regards to sore throat but still felt poorly, went to ER (Harris Regional Hospital- Hospital A) last night with dyspnea (difficult or labored breathing) and palpitations, CBC, CMP (see results but in brief leukocytosis with a L (left) shift arguing towards bacterial etiology (bacterial cause) ... and hypokalemia for which she was given potassium) and was dx'd with mono and sinus tachycardia (EKG was done). She notes pleuritic chest pain R sided, dyspnea, elev (elevated) heart rate, low grade fever and when she takes a deep breath it is shallow and prompts a cough. She also admits to L sided neck pain, and is still present and worsening, at its maximum, severity described as severe. When seen in the E.D., severity described as severe. The patient has had loss of appetite, fatigue and weakness. She as had decreased urine output. (dark) ... REVIEW OF SYSTEMS: The patient has had difficulty breathing, fever and a sore throat, cough and headache. She has had chest pain. No abdominal pain, nausea, vomiting, diarrhea or black stools. No bloody stools, abnormal bleeding or skin rash ... PHYSICAL EXAM Appearance: Alert. Patient in mild distress. (toxic appearing)- (Severe illness) ...ENT (Ear Nose Throat) ... Moderate pharyngeal erythema with right tonsillar swelling and left tonsillar swelling and exudate ... Neck: Lymphadenopathy present ... (L neck is very tender slightly swollen, not erythematous. I cannot palpate an obvious abscess and there is not sufficient lymphadenopathy to support her tenderness. College age patient with pharyngitis, fever and neg strep would consider fusobacterium necrophorum-(bacteria responsible for Lemierre's syndrome and other medical conditions). CVS: Tachycardia. Rhythm normal. Respiratory: Mild respiratory distress with anxiety and tachypnea (pleuritic chest pain, inspiration is shallow and prompts cough). Moderately decreased air movement diffusely over both lungs (poor effort d/t [due to] discomfort), (+ splinting) ... Laboratory Tests ... MONO Negative ... CBC ... WBC 16.8 ... Chest 2V (Chest X-ray 2 View) ... IMPRESSION: Bilateral lower lobe pneumonia ... PROGRESS AND PROCEDURES Course of Care: concern for PE (Pulmonary Embolus- blood clots), PNA (Pneumonia), fusobacterium necrophorum could be a universal diagnosis. Cannot obtain blood culture here but would recommend obtaining in patient. CMV (Cytomegalovirus-viral infection) is in ddx (Differential Diagnosis) as well. Consider peritonsillar abscess (accumulation of pus due to an infection behind the tonsil). Pt is tachycardic, hypoxic (inadequate oxygenation of the blood), and meets SIRS (Systemic Inflammatory Response Syndrome) criteria ... Will transfer to ER ..." Patient #11 was transferred to Hospital A's DED and admitted to Hospital A.

Closed medical record review (from Hospital A) conducted on 10/30/2019 revealed a Discharge Summary written on 05/01/2019 at 1700 written by DO #2. Review revealed, " ...Admitting Diagnosis - Shortness of Breath. Discharge Diagnosis - Acute hypoxic respiratory failure, Bilateral pneumonia - presume bacterial, --S/p (status post) bronchoscopy 4/30, Sympathetic BL (bilateral) pleural effusions, Shock - multifactorial from distributive process with sedating meds as well as septic shock (Life threatening-serious infection causing extremely low blood pressure), Lactic acidosis, (excess lactic acid in the blood) POA (present on admission) - due to hypoxia +/- septic picture, Severe thrombocytopenia - most likely explanation is sepsis (potentially life threatening condition caused by the body's response to an infection) - Fibrinogen preserved; INR nml (normal); no visible signs of acute bleed. Acute anemia developed since admission - Obvious blood loss through some degree of pulmonary hemorrhage. -Profoundly low of iron and folate on testing. Unclear why this would be. ? (Questionable) eating disorder. Hypoalbuminemia (Low protein levels) - significant, Cholestasis, Vaginal candidiasis, Hypokalemia (low potassium level), Hypomagnesemia, (low magnesium level) Non-oliguric renal failure (Renal failure with urine output). Hospital Course Per H&P:' (Named Patient #11) ... presented to the (Named Hospital A) ED with complaint of 8 days of sore throat, shortness of breath, and fevers at home. She has presented to the Urgent Care several times over the past week with these complaints. Several strep screens have been negative. At one of these apts (appointments) she was told that she tested weakly positive for infectious mononucleosis. She was sent home once with a 5 day course of Prednisone, but otherwise she was not prescribed any antimicrobials. She again today presented to the Urgent Care stating that she was not feeling any better and her shortness of breath had worsened. She was sent to the (Named Hospital A) Ed where O2 sat at presentation was 88% on RA (room air). Vital signs otherwise were significant for T 102.9 (Normal Temp- 97 F -99F), HR 125-160, RR 20-26, BP 125/85. Over a couple hours her O2 sat ( oxygen Saturation level of oxygen carried by red blood cells through the arteries and delivered to internal organs) dropped to 73% (inadequate oxygenation of blood. Normal oxygen saturation is 95% to 100%) on 2L, then remained In the low 90's with increasing amounts of O2 up to HFNC (high flow nasal cannula) 100% / 40 lpm (Liters per minute). Lab work was significant for lactic acid (lactic Acid test measure the amount of lactic acid in the blood) up-trending from 2.2 > 6.3. WBC count 16,800. Mono and Strep screens negative. ABG on 65% / 40 lpm O2 was 7.37 / 25.6 / 64. She was given Rocephin / Azithromycin initially (Antibiotics) which was then broadened out to Vanc (Vancomycin) / Zosyn (Antibiotics) as well as 3L IV (intravenous) fluids. The hospitalist service was called for admission for further evaluation and management. Upon interview, she provides the above story ... No recent travel.' Intubated (process of insertion of a breathing tube into trachea for mechanical ventilation) shortly after admission by (Named Physician) with bronchoscopy performed following intubation. Findings of thick yellow secretions within the trachea and proximal mainstem bronchi. Difficult to sedate overnight; responded well to Morphine (pain Med) PCA (Patient controlled Analgesia-a method of pain control gives patients power to control their pain). Vent (Ventilator-mechanical ventilation) settings decreased from PEEP (positive end expiratory pressure) 12 / FiO2 0.9 to PEEP 14 / FiO2 0.50; breathing over vent with RR in mid-30's. T (temperature) Max 101.8, BP supported with Neosynephrine (medication used to treat low blood pressure). HR (Heart rate) and RR (Respiratory Rate) still elevated, but mildly improved since yesterday. Overnight it was noted that she was having bright red blood with ETT (endotracheal tube) suctioning. This became progressively worse throughout the day 5/1. Notably, her am (AM) platelet count and Hgb were 31,000 / 9.3 respectively with decrease to 29,000 / 8.2 at recheck at 14:00. With this new finding, the case was discussed with (Named Physician), intensivist, at (Named Hospital B) who accepted the patient in transfer ..." Patient #11 was transferred to Hospital B on 05/01/2019.

Review of a Discharge Summary from Hospital B written by MD #2 on 05/22/2019 at 1248 revealed, " ...Diagnosis: 1. Septic Shock with Fusobacterium infection 2. Acute Hypoxemic resp failure with ARDS (acute respiratory distress syndrome-respiratory failure acute onset accumulation of fluid in the lungs) s/p intubation and extubation 3. Iron deficiency anemia 4. Dysphagia and Pharyngeal abscess 5. septic thrombophlebitis. 6: Fusobacterium necrophorum BSI, Severe sepsis/Septic shock 7:Lemierre's Syndrome (refers to infectious thrombophlebitis of the internal jugular vein-.Lemierre syndrome most often results from complications of a bacterial throat infection), LIJ (Left Internal Jugular) Septic Thrombophlebitis, septic pulmonary emboli 8:Bilateral mastoid sinus opacification Procedures This Admission: intubation/extubation Discharge Condition: Good Discharge Destination: Home Hospital Course: Basic Information
23-year-old female with acute hypoxemic respiratory failure, ARDS, on vent for 2 weeks, extubated on 5/13, transition to nasal cannula O2 with good oxygenation, etiology of above is severe sepsis with septic shock, Lemierre's syndrome with septic Thrombophlebitis, with Fusobacterium bacteremia, On IV heparin, IV abx per ID, Septic Pulm Emboli (Patient #11 Named) is a 23 year old woman ... with no reported medical issues who presented to the ED 5/2 with one week of progressive dyspnea. She had reportedly already been to urgent care, where she had a negative rapid strep and received prednisone but not antibiotics. In the ED she was hypoxemic to 88% on room air, but rapidly worsened to SpO2 in the 70s while on nasal cannula O2, requiring intubation. Chest CT reportedly showed diffuse bilateral infiltrates. Bronchoscopy performed at the time of intubation showed friable airways with thick secretions ... Patient was in ICU on vent and extubated 5/13 and managing secretions well, she had Dobhoff tube till today for TFs (tube feedings) and meds Hospital course: pt is intubated and extubated for acute resp failure and ards (acute respiratory distress syndrome). she (sic) was also in septic shock and treated appropriately in the ICU. she (sic) is found to have Fusobacterium necrophorum BSI, Severe sepsis/Septic shock Lemierre's Syndrome, LIJ Septic Thrombophlebitis, septic pulmonary emboli she (sic) is later transferred to medical floor for continued care ID and pulmonary followed her she (sic) is treated with unasyn and later changed to flagyl and responded well. follow (sic) up blood cultures came back negative. she (sic) has also been on heparin drip for septic pul (pulmonary) embolic and later changed to Eliquis (blood Thinner) by the pulmonary team. it (sic) is recommended she should be on it at least for 3 months though adequate time rx (prescribed) for pul emboli is not definitely known. Today I evaluated her by the bedside. (sic) her father was with her. she (sic) is delighted to go home and follow up with both our ID (infectious disease doctor) and her pcp (primary care physician). She (sic) is aware she will continue the Eliquis for at least 3 months. she (sic) will continue po (by mouth) Flagyl (Antibiotic that fights bacterial infection) for about 4 weeks per id (infectious disease) recommendation. she (sic) has understood the gravity of her medical condition, plan of care and follow up ..."

Telephone physician interview was conducted with MD #1 (Patient #11's DED Medical Doctor on 04/29/2019.) Interview revealed, "I don't remember a lot about her, but some." Interview revealed the last time MD #1 assessed Patient #11 her heart rate was in "the 110s," and he remembered "thinking I wasn't exactly sure why she was tachy (tachycardic -fast heart rate). Clinically, the rest of the vital signs were fine, and she felt better, so she was stable for discharge." Interview revealed he did not explicitly recall her throat exam, but if anything was visualized out of the ordinary, it would have been documented in his assessment. Interview revealed MD #1 did not consider a chest x-ray clinically indicated as there was no history on 04/29/2019 of cough, shortness of breath, or respiratory complaints. Patient #11 did not present as possible pneumonia. Interview revealed the previous prescription of Prednisone could have accounted for the elevated white blood cell count, noting that a white blood cell count of 15.6 could have also been caused by a viral infection. Interview revealed MD #1 believe in avoiding inappropriate use of antibiotics. The reported diagnosis of Mono is a viral illness so there would be no clinical indication for antibiotics. "If there had been indications for chest x-ray and antibiotics, of course we would have used them."

Physician interview was conducted with the DED Medical Director (DEDMD) on 10/30/2019 at 1132. Interview revealed based on her later outcome, Patient #11's case was reviewed and opportunities for improvement were identified. Interview revealed if an infection is suspected to be caused by a bacterial agent, it would trigger antibiotic use. Appropriate antibiotic use is considered on a case by case basis. Regarding the decision to not perform a chest x-ray, "judging by the note and his exam alone," the DEDMD agreed a chest x-ray may not be required as there did not appear to be pulmonary involvement. Interview revealed the tachycardia and elevated white blood cell count could be part of Systemic Inflammatory Response Syndrome. Interview revealed the continued tachycardia and elevate white blood cell count may not require immediate intervention but noting those values may prompt "more in depth" search into their cause.

The facility failed to ensure that an appropriate medical screening examination was provided for patient #11 on 4/29/2019, which was within the capability of the hospital's emergency department as evidenced by failing to ensure the medical screening examination was completed at the time of discharge. Patient #11 was discharged with a heart rate of 120 beats per minute, and elevated WBC of 15.6 (high). The patient met the signs for sepsis according to ED screening and the facility's Sepsis Protocol. The facility's Sepsis protocol was not initiated. At discharge the patient's Clinical Impression was listed as "Sinus tachycardia and Infectious mononucleosis." Patient #11 returned to Hospital A's ED the next day in septic shock secondary to bilateral pneumonia. Patient #11 had to be intubated and placed on mechanical ventilation and ended up in the hospital's Intensive Care Unit.