HospitalInspections.org

Based on record review, policy and procedure review and interviews, the Critical Access Hospital (CAH) failed to follow their policy and procedure to provide stabilizing treatment for an individual with an emergency medical condition for one of 20 sampled patients (#1) prior to discharge home.

Findings include:

-The CAH ' s Emergency Department policy for EMTALA, last revised 03/13, reviewed on 10/14/13 at 12:45pm, directed " ...The basic Emergency Medical Treatment and Active Labor Act (EMTALA) requirements mandate that hospitals: 9. Discharge only stable patients ... "
-The CAH ' s policy Physician Assistant Protocol, last revised 06/13, reviewed on 10/14/13 at 12:30pm directed, " ...protocol for the Physician Assistant (PA) when designated medical condition and/or scenarios present, which require a telephone contact with the supervising physician ...Respiratory system ...suspicion of pulmonary embolism ... "
-Patient #1 's medical record review on 10/14/13 revealed they presented to the emergency department (ED) on 9/22/13 at 1:40am with a complaint of " can ' t breathe last couple of hours and feels like something sitting on [gender] chest ". Patient #1's vital signs were blood pressure 98/76, temperature 97.3 oral, pulse 125 (faster than normal), respirations 28 (faster than normal), and oxygen saturation 93% on room air. The patient rated their pain at a 1 on a 1-10 scale. Nursing assessment of the patient included moderate distress, alert, oriented, no respiratory distress with normal breath sounds, pulse strong and regular, all other systems normal. ED Physician Assistant(PA) staff A arrived in the ED at 2:00am, provided a medical screening examination (MSE), the patient received a Duo Neb breathing treatment and oxygen at 2 liters. ED PA staff A's assessment of patient #1 included heart rate 125 beats per minute(faster than normal), productive cough with yellow thick phlegm, tacky (fast) heart rate, fast breathing, decreased breath sounds, wheezing, abdomen distended, and lower extremity venous stasis 1+ edema(mild swelling caused by pooling of blood and fluid). Lab work revealed WBC (slightly elevated white blood count an indicator of infection) 10.5, glucose (blood sugar) 191(elevated), creatinine(a test for kidney function normal 0,43-1.13) 1.39, and BNP(a blood test indicating congestive heart failure a buildup of fluid in the lungs caused by heart failure normal range 1-100) 42.1. A chest x-ray revealed no acute process with flattening of the diaphragm compatible with some emphysema (lung disease). ED PA staff A documented diagnoses of dyspnea (difficulty breathing), tachypnea (fast breathing), hypoxia (deficiency in the amount of oxygen reaching the tissues), and early pneumonia. At 2:40am patient #1 received Rocephin (an antibiotic) 1 gram IM (intra-muscular) and Kenalog (a steroid) 80mgIM.

Discharge documentation at 3:15am indicated patient #1 went home with family. Discharge instructions included a prescription for Azithromycin (an antibiotic) 500mg by mouth for one day then 250mg for four days. Discharge documentation from the ED PA Staff A indicated patient #1 was stable with blood pressure 97/60, pulse 114, respirations 20, temperature 97.3, oxygen saturation 92%, and pain at a 1 on a 1-10 scale.

-Patient #1 returned to the ED approximately eight and one-half hours later on 9/23/13 at 1:55pm, arriving by ambulance, with a complaint of cough and shortness of breath for two days. Patient #1's nursing assessment indicated moderate distress, alert, oriented, tachycardia (fast heart rate), left lower extremity edema 4+(significant swelling of the left leg) and right lower leg edema 2+(moderate swelling of the right leg), vital signs included: blood pressure 90/56(low), pulse 127(faster than normal), respiratory rate 28(faster than normal), temperature 98.1 oral, oxygen saturation 95% on oxygen at 2 liters. The nursing assessment documented no respiratory distress (trouble breathing). ED PA staff A, arrived in the ED at 2:05pm and documented an MSE assessment that included sudden onset dyspnea (difficulty breathing), has been wearing oxygen, increased cough, pain with deeper breathing on left chest, hyperventilating (rapid breathing) on admission to the ED, heart rate 119 down to 90 with pursed lip breathing, oxygen saturations 93-97% on oxygen at 2 liters, tachycardia, alert oriented, and lungs fairly clear. The patient received fentanyl (a pain medication) 25mcg at 2:02pm and Duo Neb breathing treatment at 2:15pm. Lab work revealed WBC 14.0 (an indicator of infection normal range 5-10), protime 13.2, INR 1.3(mild thinning of the blood), D-Dimer 4709 (a blood test used when there is a suspicion of a pulmonary embolism normal range 0-400), glucose 302 (blood sugar normal range 70-100), BUN 32 (a test for kidney function normal 5-25), creatinine 2.18 (a test for kidney function normal 0,43-1.13), BNP 779 (a blood test indicating congestive heart failure a buildup of fluid in the lungs caused by heart failure normal range 1-100), and hemoglobin A1C 7.8(a blood test indicating an elevated blood sugar). The patient's chest x-ray and CT scan revealed some atelectasis (fluid) in the right lower lung field. The EKG indicated sinus tachycardia. Vital signs at 2:30pm were blood pressure 82/53, pulse 115, respirations, 28, temperature 98.1, and oxygen saturation 96%. The provider diagnosed the patient with hyperventilation (fast breathing), hyperglycemia (elevated blood sugar), insufficient anticoagulation (coagulation of the blood), and pulmonary embolism (a blood clot in the lung). ED PA Staff A instructed patient #1 to return every 24 hours for Lovenox (a blood thinning agent) 200mg SQ(subcutaneous) and lab work of protime/INR and BMP (blood chemistry test) and to follow-up with their primary care provider in two days. Patient #1 received Lovenox 150mg SQ at 2:55pm, Coumadin (a blood thinning agent) 10mg by mouth at 3:00pm and Lovenox 50mg SQ at 3:10pm. Nursing documented teaching on importance of taking medications as ordered. Patient #1's medical record documented they had not taken Coumadin or insulin by [gender] own omission at 3:10pm. Patient #1 was discharged home in stable condition with daughter at 3:20pm. Nursing documentation indicated when the patient got up to leave they became lightheaded and vomited water and orange juice approximately 500cc of the 720cc they drank in the ED. Documentation indicated the patient received discharge instructions with learning barriers addressed of Coumadin, insulin, and oxygen use. Vital signs at discharge included: blood pressure 96/54, pulse 112, respirations 24, temperature 98.1, oxygen saturation 93%, and no pain. Written discharge instruction included return to hospital tomorrow 9/24/13 for Lovenox 200mg, continue on antibiotic until it is finished, Coumadin 10mg on 9/24/13, must take your insulin and medications, and follow-up with the patient ' s primary care provider on 9/25/13 at 10:00am. The medical record lacked evidence of ED PA Staff A's required contact with their supervising physician about the pulmonary embolism.

-Patient #1 returned to the ED approximately twenty hours later on 9/24/13 at 11:14am by ambulance with CPR (cardiac pulmonary resuscitation) in progress. Patient #1's assessment by EMS included pulseless, placed a combitube (a tube to provide oxygen to the lungs) with oxygen at 1.5 liters, and started CPR. Patient #1 had an IV of normal saline infusing. Physician staff B present on admission. At 11:30am the code blue ceased and Patient #1 pronounced dead. Physician staff B, present on admission, documented the patient had been seen last two days-known diabetic with history of DVT/PE (venous blood clot/lung blood clot), Greenfield filter (device implanted to prevent fatal pulmonary embolism), has been noncompliant with Coumadin, obese, and diagnosed with acute myocardial infarction (heart attach) versus massive pulmonary embolism-deceased.
-ED PA Staff A, interviewed on 10/15/13 at 10:45am acknowledged they provided treatment for patient #1 in the ED on 9/22/13 and 9/23/13. ED PA Staff A stated they called the patient's regular provider on patient #1's second ED visit and discussed admission versus home discharge. ED PA staff A stated that on this last admission patient #1 could be admitted to the facility or discharged home and would receive Lovenox either way. ED PA Staff A stated they were not aware patient #1 was lightheaded and vomited at discharge on the 9/23/13 ED visit.
-RN Risk Manager staff D, interviewed on 10/15/13 stated a patient that presents to the ED must be seen by a qualified medical provider and have a complete medical screening examination. If an emergency medical condition exists the hospital must treat, stabilize and admit or transfer.
-Physician staff B, interviewed on 10/15/13 at 11:30am, stated that he did go to the ED during patient #1's ED admission 09/23/13 and discussed the patient's treatment with ED PA staff A. The medical record lacked documentation of the physician visit or contact by ED PA staff A.

Based on record review, interviews and peer review, the Critical Access Hospital (CAH) failed to provide treatment to stabilize an emergency medical condition within their capability for one of 20 sampled patients (#1) prior to discharging to home. Patient #1 expired within 24 hours.

Findings include:

-Emergency Medical Treatment and Labor Act (EMTALA) physician review received November 15, 2013 revealed patient #1 had an emergency medical condition that was not stabilized at the time of discharge from the ED and that the real time record and objective findings of patient #1 documented from the 9/23/13 ED admission suggest that material deterioration or a continual downhill progression of symptoms would occur within a reasonable degree of probability. The review documented that the real time record of patient # 1 does not identify and/or verify any shared decision making discussions with the patient and/or family in attendance.

-Patient #1's medical record review on 10/14/13 revealed they presented to the emergency department (ED) on 9/22/13 at 1:40am with a complaint of " can 't breathe last couple of hours and feels like something sitting on [gender] chest ". Patient #1's vital signs were blood pressure 98/76, temperature 97.3 oral, pulse 125 (faster than normal), respirations 28 (faster than normal), and oxygen saturation 93% on room air. The patient rated their pain at a 1 on a 1-10 scale. Nursing assessment of the patient included moderate distress, alert, oriented, no respiratory distress with normal breath sounds, pulse strong and regular, all other systems normal. ED Physician Assistant(PA) staff A arrived in the ED at 2:00am, provided a medical screening examination (MSE), the patient received a Duo Neb breathing treatment and oxygen at 2 liters. ED PA staff A ' s assessment of patient #1 included heart rate 125 beats per minute(faster than normal), productive cough with yellow thick phlegm, tacky (fast) heart rate, fast breathing, decreased breath sounds, wheezing, abdomen distended, and lower extremity venous stasis 1+ edema(mild swelling caused by pooling of blood and fluid). Lab work revealed WBC (white blood count an indicator of infection) 10.5, glucose (blood sugar) 191(elevated), creatinine(a test for kidney function normal 0,43-1.13) 1.39, and BNP(a blood test indicating congestive heart failure a buildup of fluid in the lungs caused by heart failure normal range 1-100) 42.1. A chest x-ray revealed no acute process with flattening of the diaphragms compatible with some emphysema. The patient received diagnoses of dyspnea (difficulty breathing), tachypnea (fast breathing), hypoxia (deficiency in the amount of oxygen reaching the tissues), and early pneumonia. At 2:40am received Rocephin (an antibiotic) 1 gram IM (intra-muscular) and Kenalog (a steroid) 80mgIM.

Discharge documentation at 3:15am indicated patient #1 went home with family. Discharge instructions included a prescription for Azithromycin (an antibiotic) 500mg by mouth for one day then 250mg for four days. Discharge documentation from the ED PA staff A indicated patient #1 was stable with vital signs blood pressure 97/60, pulse 114, respirations 20, temperature 97.3, oxygen saturation 92%, and pain at a 1 on a 1-10 scale.

-Patient #1 returned to the ED approximately eight and one-half hours later on 9/23/13 at 1:55pm, arriving by ambulance, with a complaint of cough and shortness of breath for two days. Patient #1's nursing assessment indicated moderate distress, alert, oriented, no respiratory distress, tachycardia (fast heart rate), left lower extremity edema 4+(significant swelling of the leg) and right lower edema 2+(moderate swelling of the leg), vital signs included: blood pressure 90/56(low), pulse 127(faster than normal), respiratory rate 28(faster than normal), temperature 98.1 oral, oxygen saturation 95% on oxygen at 2 liters. ED PA staff A, arrived in the ED at 2:05pm and provided an MSE. PA Staff A documented sudden onset dyspnea (difficulty breathing), has been wearing oxygen, increased cough, pain with deeper breathing on left chest, hyperventilating (rapid breathing) on admission to the ED, heart rate 119 down to 90 with pursed lip breathing, oxygen saturations 93-97% on oxygen at 2 liters, tachycardia, alert oriented, and lungs fairly clear. The patient received fentanyl (a pain medication) 25mcg at 2:02pm and Duo Neb breathing treatment at 2:15pm. Lab work revealed WBC 14.0 (an indicator of infection normal range 5-10), protime 13.2, INR 1.3(mild thinning of the blood), D-Dimer 4709 (a blood test used when there is a suspicion of a pulmonary embolism normal range 0-400), glucose 302 (blood sugar normal range 70-100), BUN 32 (a test for kidney function normal 5-25), creatinine 2.18 (a test for kidney function normal 0,43-1.13), BNP 779 (a blood test indicating congestive heart failure a buildup of fluid in the lungs caused by heart failure normal range 1-100), and hemoglobin A1C 7.8(a blood test indicating an elevated blood sugar). The patient ' s chest x-ray and a CT scan of the chest revealed some atelectasis (fluid) in the right lower lung field. The EKG indicated sinus tachycardia. Vital signs at 2:30pm were blood pressure 82/53, pulse 115, respirations, 28, temperature 98.1, and oxygen saturation 96%. The provider diagnosed the patient with hyperventilation (fast breathing), hyperglycemia (elevated blood sugar), insufficient anticoagulation (blood clots to quickly for medical condition), and pulmonary embolism (a blood clot in the lung). ED PA Staff A instructed patient #1 to return every 24 hours for Lovenox (a blood thinning agent) 200mg SQ(subcutaneous) and lab work of protime/INR and BMP (blood chemistry test) and to follow-up with their primary care provider in two days. Patient #1 received Lovenox 150mg SQ at 2:55pm, Coumadin (a blood thinning agent) 10mg by mouth at 3:00pm and Lovenox 50mg SQ at 3:10pm. Nursing documented teaching on importance of taking medications as ordered. Patient #1s medical record documented they had not taken Coumadin or insulin by his own omission. Patient #1 was discharged home in stable condition with daughter at 3:20pm. Nursing documentation indicated when the patient got up to leave they became lightheaded and vomited water and orange juice approximately 500cc of the 720cc they drank in the ED. Documentation indicated the patient received discharge instructions with learning barriers addressed of Coumadin, insulin, and oxygen use. Vital signs at discharge included: blood pressure 96/54, pulse 112, respirations 24, temperature 98.1, oxygen saturation 93%, and no pain. Written discharge instruction included return to hospital tomorrow 9/24/13 for Lovenox 200mg, continue on antibiotic until it is finished, Coumadin 10mg on 9/24/13, must take your insulin and medications, and follow-up with the patient's primary care provider on 9/25/13 at 10:00am. The medical record lacked evidence of ED PA staff A's required contact with their supervising physician for the pulmonary embolism.

-Patient #1 returned to the ED approximately twenty hours later on 9/24/13 at 11:14am by ambulance with CPR (cardiac pulmonary resuscitation) in progress. Patient #1's assessment by EMS (ambulance crew) included pulseless, placed a combitube (a tube to provide oxygen to the lungs) with oxygen at 1.5 liters, and started CPR. Patient #1 had an IV of normal saline infusing. At 11:30am the code blue ceased and Patient #1 was pronounced dead. Physician staff B, present on admission, documented the patient had been seen last two days-known diabetic with history of DVT/PE (venous blood clot/lung blood clot), Greenfield filter (device implanted to prevent fatal pulmonary embolism), has been noncompliant with Coumadin, obese, and diagnosed with acute myocardial infarction (heart attach) versus massive pulmonary embolism - deceased.
-ED PA Staff A, interviewed on 10/15/13 at 10:45am acknowledged they provided treatment for patient #1 in the ED on 9/22/13 and 9/23/13. ED PA Staff A indicated that they called the patient's regular provider and discussed admission versus home discharge and that they talked with Physician Staff B in the ED during patient #1's ED admission 9/23/13 as well. ED PA Staff A stated that on this last admission patient #1 could be admitted to the facility or discharged home and would receive Lovenox either way. ED PA Staff A stated they were not aware patient #1 was lightheaded and vomited at discharge on the 9/23/13 ED visit. Patient #1's medical record lacked documentation of consultation or assessment by a physician on the 9/22/13 and 9/23/13 ED visits.
-RN Risk Manager staff D, interviewed on 10/15/13 stated a patient that presents to the ED must be seen by a qualified medical provider and receive a medical screening examination. If an emergency medical condition exists the hospital must treat, stabilize and admit or transfer.
-Physician staff B, interviewed on 10/15/13 at 11:30am, stated that he did go to the ED during patient #1's ED admission 09/23/13 and discussed the patient's treatment with ED PA Staff A.