HospitalInspections.org

Based on review of medical records, Medical Staff Rules and Regulations, Emergency Services Agreement, policies and procedures, tour of the ED, observations, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE), stabilizing treatment, and an appropriate discharge, for one (1) of 20 sampled medical records when Patient #2 presented to the Emergency Department (ED) on 5/17/19 (first visit) and 5/18/19 (second visit) requesting treatment for a possible emergency medical condition.

Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination.

Cross refer to tag A-2407 as it relates to failure to provide stabilizing treatment.

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available in the ED to determine whether or not an emergency medical condition (EMC) exists for 1 (Patient #2) of 20 sampled patients who returned to the hospital's ED requesting treatment for complaint of continued fever.

Findings were:

MEDICAL RECORD REVIEWS:

Review of Patient #2's medical record for the first visit revealed the patient presented to the ED with complaints of "fever and dizziness" on 5/17/19 at 4:11 a.m. The Registration Questionnaire form noted that the patient had fever but no respiratory symptoms. At 4:12 a.m., documentation revealed Patient #2's primary care physician (PCP) was an out-of-town physician.

At 4:14 a.m., the triage (assessment to determine the priority in which patients will be seen based on their presenting chief complaint, signs, and symptoms) RN EE noted that Patient #2 was a level three (3) acuity (Urgent) patient. At 4:18 a.m., RN EE noted that Patient #2 reported having chills and low blood pressure since Tuesday 5/14/19. In addition, RN EE noted that Patient #2 reported that she woke up at 3:00 a.m. with nausea, vomiting, and diarrhea, became dizzy and fell hurting her right groin area. RN EE noted that Patient #2 denied having a fever, urinary symptoms, or any care prior to arrival in the ED. At 4:21 a.m., RN EE noted that Patient #2 ' s vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) were as follows:
--temperature 100.2 (normal 98.6),
--pulse 135 (normal 60-100),
--respirations 18 (normal 12-18),
--blood pressure 103/71 (normal 120/80), and
--oxygen saturation 95% (normal 94-100%).

At 4:25 a.m., ED Physician CC noted that Patient #2 complained of having chills for three (3) days without measurable fever and nausea, vomiting, and diarrhea that started earlier that morning, denies abdominal or chest pain, and has no shortness of breath. ED Physician CC performed a review of systems and physical examination which revealed the patient had chills, nausea, vomiting, and diarrhea, and that everything else was normal. At 4:27 a.m., ED Physician CC noted that the differential diagnosis (the process of differentiating between two [2] or more conditions which share similar signs or symptoms) was viral infection, bacterial infection, gastroenteritis (inflammation of the stomach, symptoms include abdominal pain, nausea, vomiting, and diarrhea).

At 4:31 a.m., RN EE noted that Patient #2 denied having any pain or any recent travel. In addition, RN EE noted that Patient #2 did not appear to be in any distress.
At 4:33 a.m., RN EE completed the Sepsis (blood stream infection) Protocol Screening assessment which included the following:
--Suspect infection
--Recent invasive procedure
--Indwelling catheter
--Temperature greater than 100.4 degrees
--Temperature less than 96.8 degrees
--Systolic blood pressure less than 90
--Respirations greater than 20
--Heart rate greater than 90
--Altered mental status
--Oxygen saturation less than 90% on room air
--Mean Arterial Pressure (MAP - The average pressure of the blood circulating through a person ' s arteries during the heart beat cycle. The value of the MAP is normally derived from the systolic blood pressure and diastolic blood pressure of the patient) less than 65.
RN EE noted that Patient #2 received one (1) point for suspicion of infection and one (1) point for heart rate greater than 90. RN EE noted that Patient #2's total score was three (3) [this was an incorrect score as the total should have been two (2)]. The Sepsis Protocol was not initiated as it required a score of more than two (2) to initiate the Sepsis Protocol. In addition, RN EE completed a Fall Risk Assessment and identified Patient #2 as a high fall risk, RN EE noted that a fall risk arm band was placed on Patient #2. RN EE also completed the Pneumonia Screening assessment which revealed Patient #2 ' s score was three (3), RN EE noted that she initiated the Pneumonia Protocol as required by a total score of three (3) or higher.

ED Physician CC ' s orders included the following:
--intravenous site, RN EE noted that a 20-gauge intravenous catheter (inserted into a vein to administer or draw blood, administer fluids and / or medications) was started in Patient #2 ' s right hand at 4:37 a.m. and Normal Saline (fluids) and Zofran (medication used to treat nausea and vomiting) 4 milligrams (mg) was administered;
--Orthostatic vital signs (lying/sitting/standing), this was performed at 4:37 a.m. by RN EE who noted that Patient #2 ' s lying pulse 118 and blood pressure 111/68, sitting pulse 124 and blood pressure 110/58, and standing pulse 132 and blood pressure 114/63;
--Complete Blood Count with automated differential (CBC - measures red blood cells [RBC], white blood cells [WBC], and platelets), the results revealed Patient #2 ' s WBC was 13.2 (normal 4.0-11.0) and RBC was 3.78 (normal 4.0-5.4, low signifies anemia);
--Basic Metabolic Panel (BMP - measures electrolytes, blood sugar, and kidney function), the results revealed Patient #2 ' s potassium level was 2.7 (normal 3.5-5.1) and creatinine level (kidney function) was 1.13 (normal 0.55-1.02 an elevation signifies the kidneys are not functioning properly);
--Lactic Acid with reflex (high levels can signify sepsis a blood stream infection and cause vomiting) results were within normal limits;
--Magnesium level was 1.4 (normal 1.8-2.4);
--Potassium Chloride 40 milliequivalents (meq) by mouth and 10 meq intravenously was administered by RN FF at 5:56 a.m.;
--Mag-Ox (used to treat low magnesium level) 400 mg by mouth was administered by RN FF at 6:00 a.m.

At 5:02 a.m., RN EE reassessed Patient #2 and noted that the patient ' s symptoms had not improved. RN EE noted Patient #2 ' s pulse as 111, respirations 23, blood pressure 111/57, and oxygen saturation as 93%. At 5:38 a.m. RN EE noted that she informed ED Physician CC of Patient #2 ' s abnormal lab results.

At 5:56 a.m., ED Physician CC noted that the Sepsis Protocol was not initiated because Patient #2 did not meet the criteria. At 5:57 a.m., ED Physician CC documented the ED course as follows:
--Physical examination is largely unremarkable, abdomen soft and nontender, bowel sounds normal, orthostatic blood pressures normal, CBC showed mildly elevated WBC and mild anemia, BMP showed low potassium and magnesium levels. Administered intravenous fluids, magnesium and potassium supplement, and will be discharged home with prescription for Zofran (used to treat nausea and vomiting), and instructions to follow-up with her PCP if her symptoms do not improve within 24-48 hours and to follow-up sooner if she develops a high fever or abdominal pain.

At 6:12 a.m. RN FF noted Patient #2 ' s pulse as 101, respirations 19, blood pressure 100/56, and oxygen saturation as 96% on room air. At 6:17 a.m. RN FF noted Patient #2 ' s pulse as 73, respirations 14, and oxygen saturation as 99% on 2 liters of oxygen by nasal cannula. At 7:17 a.m., RN DD noted that she discontinued Patient #2's intravenous line and that the patient's symptoms had improved. Patient #2's discharge vital signs were: pulse was 70, respirations were 18, and blood pressure was 108/64 sitting. ED Physician CC noted that the diagnosis was nausea with vomiting, unspecified and diarrhea unspecified and that Patient #2 was being discharged home with her spouse on 5/17/19 at 7:18 a.m. in stable condition.

Review of patient #2's medical record for the second visit revealed the patient presented to the ED (emergency department) with complaints of "fever" on 5/18/19 at 10:25 a.m. Patient #2's spouse signed the registration forms at 10:26 a.m. At 10:27 a.m., Triage RN GG noted that Patient #2 reported that Zofran had controlled her nausea and vomiting but that she continued to have fever and chills. RN GG further noted that Patient #2 was ambulatory, and that the patient denied any treatment prior to arrival in the ED. At 10:33 a.m., RN GG noted that Patient #2 was triaged as a level 3 (urgent). At 10:34 a.m., RN GG recorded Patient #2's vital signs as follows: temperature 99.8 (normal 98.6), pulse 109 (Normal 60-100), respirations 17, blood pressure 129/45, and oxygen saturation as 100% on room air;
-- A pain assessment which revealed Patient #2 was having body aches that the patient rated as 7/10 (0 is no pain and 10 is severe pain). RN GG noted that Patient #2 reported that the pain had started 2-3 days ago.
--Recent travel was negative.
--RN GG completed a brief physical assessment with no abnormal findings, RN GG noted that the patient did not appear to be in any distress ...
--Suicide Risk Screening, Abuse Assessment, Respiratory/TB Assessment, Sepsis Protocol Screening, Fall Risk Assessment, and Pneumonia Protocol Screening, all of which were negative and did not require any interventions.

At 11:23 a.m., ED Physician CC noted that Patient #2 presented with complaints of "chills" and that the patient had been seen in the ED approximately 36 hours earlier with complaints of fever, nausea, vomiting, and diarrhea ED Physician CC further noted that the patient had been discharged home earlier with a prescription for Zofran to control the nausea and vomiting and to take Tylenol (pain reliever and fever reducer) for the fever. ED Physician CC noted that Patient #2 reported that she had not had any further nausea, vomiting, diarrhea, or abdominal pain, but that she did have a fever last night. In addition, ED Physician CC noted that Patient #2 reported that she had chills and despite covering up with blankets she continued to feel cold, and that she took Tylenol several times during the night for fever but may not have been consistent with the timing. ED Physician CC completed a review of systems and a physical examination, which revealed Patient #2 was positive for body aches, fever, and chills. At 11:28 a.m., ED Physician CC noted that the differential diagnosis was viral infection / bacterial infection. ED Physician CC noted that he reviewed the following: all vital signs, nurses' notes, Sepsis Protocol which was not initiated because the patient did not meet the appropriate scoring criteria. ED Physician CC noted that Patient #2's physical exam was "unremarkable". In addition, ED Physician CC noted that Patient #2 was afebrile, had a mildly elevated heart rate, abdomen is soft and nontender, and is no longer having nausea, vomiting, or diarrhea. ED Physician CC noted that no additional testing would be performed, and no additional prescriptions would be performed given at "this time". ED Physician CC noted that Patient #2 was advised to continue to drink plenty of fluids, to take Tylenol every four (4) hours to prevent fever and to follow-up with her primary care physician on Monday (5/20/19) if not improved. ED Physician CC noted that Patient #2 verbalized understanding and agreed to comply with the follow-up.

At 11:29 a.m., ED Physician CC noted that Patient #2 was stable for discharge. ED Physician CC noted that Patient #2's symptoms had improved, that fever instructions and instructions to follow-up with her primary care physician were given.

At 11:41 a.m., RN HH noted that Patient #2's vital signs were pulse 94, respirations 16, blood pressure 110/65, oxygen saturation 94% on room air, and pain level 2/10. RN HH noted that the discharge assessment revealed Patient #2 was awake, alert and oriented to person, place, and time. RN HH noted that Patient #2 verbalized understanding of the discharge instructions which included:
--increasing fluids,
--fever instructions,
--follow-up with primary care physician,
--return to ED if symptoms continue or worsen.
In addition, RN HH noted that a copy of the discharge instructions was given to the patient, and that the patient agreed to having a follow-up ED call. RN HH noted that Patient #2 was discharged to home and that the patient was ambulatory when she left the ED at 11:42 a.m. Patient #2 signed receipt of the written discharge instructions which informed the patient that the examination and treatment she received in the ED had been rendered on an emergency basis only and was not intended to be a substitute for an effort to provide complete medical care. These instructions further informed Patient #2 to follow-up with her physician for any needed check-up and to report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit.

MEDICAL STAFF RULES AND REGULATIONS:

Review of the facility's Medical Staff Rules and Regulations, approved by the Chief of Staff 3/19/19, the Board of Trustees Chairman 4/25/19, the Chief Executive Officer 4/30/19, and the Corporate Legal Counsel 5/2/19, revealed the following:
"Article V
Emergency Medical Screening, Treatment & Transfer, and On-Call Roster Policy
5.1 SCREENING, TREATMENT & TRANSFER
5.1(a) Screening
(1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an " emergency medical condition " is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function...
(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department.

POLICY AND PROCEDURE:

Review of the facility policies included but was not limited to the following:
I. EMTALA MEDICAL SCREENING STABILIZATION POLICY, no policy number, last revision date 2/2017, revealed "All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ( " EMTALA " )...
POLICY: Each Hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.
DEFINITIONS:
MEDICAL SCREENING/STABILIZATION
General Requirements
In general, when an individual comes, by himself or herself, with another person, or by EMS (emergency medical services - ambulance) to the Dedicated Emergency Department of the Hospital and a request is made on the individual ' s behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, ... 4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition ...7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient ' s needs and must continue until he/she is stabilized, or an Appropriate Transfer occurs. There should be evidence of this evaluation prior to discharge or Transfer.


INTERVIEWS:

During a tour of the ED an interview was conducted on 7/29/19 at 2:00 p.m. with the ED Director AA. ED Director AA explained that he has been the ED Director for five (5) years and prior to that he was a Paramedic. The ED Director said that the ED is staffed 24 hours-a-day with a physician. The ED Director went on to explain that the MSE is performed by an ED physician. ED Director AA explained that EMTALA training is required annually as part of the facility's corporate compliance training. ED Director AA explained that RN EE (nurse that performed the triage assessment for Patient #2's 1st visit on 5/17/19 is out of town and not available for an interview). ED Director AA said that in May 2019 the ED had lots of patients present with gastroenteritis (stomach issues). ED Director AA explained that ED physicians usually order a urinalysis when patients present with abdominal pain, nausea, vomiting, diarrhea, and/or fever.

During an interview on 7/30/19 at 8:35 a.m. in the Conference Room, ED Medical Director BB confirmed that he reviewed Patient #2's medical records (first visit on 5/17/19 and second visit on 5/18/19). ED Medical Director BB explained that during the first visit, based on the patient's age and presentation Patient #2's complaints were more gastroenteritis in nature. ED Medical Director BB said that during the first visit, ED Physician CC documented that Patient #2's complaints included: chills for three (3) days with some fever, nausea, vomiting, and diarrhea that had started earlier that morning. ED Medical Director BB stated that during the first visit Patient #2 denied any abdominal pain, flank pain, or urinary problems, and that ED Physician CC's physical examination of Patient #2 was unremarkable. ED Medical Director BB said that all of Patient #2's symptoms seemed to point to gastroenteritis. ED Medical Director BB said that ED Physician CC's orders included: intravenous fluids, blood pressure to be taken lying / sitting / and standing, a CBC which revealed a mildly elevated WBC which is common with gastroenteritis. ED Medical Director BB went on to explain that mildly elevated WBCs can be due many things including: vomiting, bacterial or viral infections, and seizures. In addition, ED Medical Director BB said the CBC also showed a slightly low hemoglobin (RBC). ED Medical Director BB said ED Physician CC also ordered a BMP which revealed a low potassium level and high creatinine level both of which can be caused by vomiting, a Lactic Acid Level with Reflex which revealed the results were normal, and a Magnesium level which was low and could also be contributed to the vomiting. ED Medical Director BB said that Patient #2's first visit did not warrant a urinalysis due to the patient's signs and symptoms and the fact that the patient improved with the treatment administered at the time. ED Medical Director BB said Patient #2 was discharged home with a prescription for Zofran for the nausea and vomiting, instructions to follow-up with her primary care physician, and to return to the ED if her signs and symptoms worsened. ED Medical Director BB said that during the second visit, Patient #2's fever and chills continued but her nausea, vomiting, and diarrhea had improved. ED Medical Director BB said that ED Physician CC did evaluate Patient #2 but did not do any additional diagnostic testing. ED Medical Director BB confirmed that Patient #2 was discharged home after receiving discharge instructions. ED Medical Director BB said that he later received a call from Patient #2's spouse and was informed that the patient had gone to another hospital and was diagnosed with urosepsis (a severe urinary tract infection that can be life-threatening when left untreated). ED Medical Director BB explained that Patient #2's medical records for both visits had been sent for quality review. ED Medical Director BB said that he counseled ED Physician CC to keep in mind that a second visit is a chance to order additional testing and to evaluate the patient for any additional differential diagnosis. ED Medical Director BB said that the worst case scenario for Patient #2 considering the elevated heart rate and the patient's age group would have been urosepsis and that he might have ordered a urinalysis, he stated that if the urinalysis was contaminated due to the diarrhea, he would have ordered an in and out catherization (procedure to obtain a sterile urine specimen).

During an interview on 7/30/19 at 9:10 a.m. in the Conference Room, ED Physician CC stated he had three (3) years of Residency and then has worked in this facility's ED for one (1) year. ED Physician CC reviewed patient #2's medical record for the first visit and explained that upon examination the patient had no abdominal or urinary symptoms but did have a slightly elevated WBC. ED Physician CC explained that usually with bacteremia (presence of bacteria in the blood) the WBCs are a lot higher. He stated he was not alarmed because the patient's WBCs were slightly elevated, she was mildly anemic, but that he did treat her low potassium and magnesium levels. In addition, ED Physician CC said that he felt the mild elevated creatine level was due to the nausea, vomiting, and diarrhea. He explained that he treated the Patient #2 with intravenous fluids and Zofran for the nausea and vomiting and her symptoms improved prior to being discharged home with instructions to follow-up with her primary care physician or to return to the ED if her condition worsened. ED Physician CC said that less than 36 hours later Patient #2 returned to the ED (second visit) because it was the weekend and she had not had a chance to follow-up
with her doctor. ED Physician CC stated Patient #2 reported that her nausea, vomiting, and diarrhea had improved but that she still had fever and chills. He went on to explain that Patient #2 reported that she was bundling up with several blankets and had taken some Tylenol but was unclear as to whether she had taken it timely enough to control the fever. ED Physician CC said that he counseled the patient regarding taking the Tylenol every four (4) hours for fever. ED Physician CC said that he did not consider ordering a urinalysis and in hind sight he didn't know why he didn't order the urinalysis. He explained that he usually does order a urinalysis but that the patient did not have any urinary symptoms during either visit.
(The facility failed to ensure that an appropriate medical screening examination within the capability of hospital's ED was provided for patient #2 on her second visit on 5/18/2019 as evidenced by; failing to include ancillary services that were routinely available to the ED, for example chest x-ray and urinalysis, to determine the cause of the patient's continued complaint of fever. )

During an interview on 7/30/19 at 10:00 a.m. in the Conference Room, RN GG confirmed that she was the triage nurse on 5/18/19 during Patient #2's second visit. She stated she completed the Sepsis Protocol Screening and that Patient #2 did not meet the criteria for the Sepsis Protocol to be initiated. In addition, RN GG said Patient #2's heart rate was 109 and temperature was 99.8 degrees, both a little elevated but that the patient's respirations, blood pressure, and oxygen saturation were normal. RN GG said that Patient #2 reported that she continued to have fever and chills but that the Zofran had helped with the nausea and vomiting. RN GG said that patients with abdominal pain, nausea, or vomiting usually have a urinalysis ordered and that she wasn't sure whether a urinalysis had been ordered during Patient #2's first visit. RN GG stated that when she is the triage nurse, she observes patients entering the ED and that her documentation revealed that Patient #2 had ambulated into the ED, that the patient reported having body aches, and that the patient did not appear to be in any distress. RN GG said she completed the triage process and turned Patient #2 over to RN HH.

During an interview on 7/30/19 at 10:30 a.m. in the Conference Room, RN HH stated she vaguely remembers Patient #2. RN HH explained that she was the Charge Nurse on 5/17/19 during Patient #2's first visit and that she provided care for the patient during the second visit on 5/18/19. RN HH said that patients' criteria for the Sepsis Protocol Screening has to be a three (3) for it to be positive and to initiate the protocol. RN HH said that even if a patient doesn't meet the Sepsis Protocol the nurse can approach the ED physician if the nurse thinks the patient looks sick. RN HH said that usually one of the first things we (ED staff) do is get a urinalysis on most patients who complain of abdominal pain, nausea, vomiting, or fever, if they can void. RN HH confirmed that during Patient #2's second visit the patient's vital signs were stable with a mildly elevated heart rate, her nausea and vomiting had improved, but she continued to have mild fever and chills. RN HH said that upon discharge Patient #2's vital signs were normal. RN HH said Patient #2 verbalized understanding of the discharge instructions which included increasing fluids and taking an over-the-counter medication for the fever. RN HH said the ED did have a period of time when there were a lot of patients presenting with a stomach bug. RN HH confirmed that she receives EMTALA training annually as part of the corporate compliance training.

During a telephone interview on 7/30/19 at 4:30 p.m. in the Conference Room, RN DD stated she does not remembers Patient #2. RN DD went on to explain that recently the ED has had many patients come in with chills, fever, nausea, vomiting, and diarrhea. RN DD stated there seemed to have been a stomach bug going around. RN DD confirmed that the Sepsis Protocol Screening assessment requires a score of three (3) or more to initiate the Sepsis Protocol. RN DD said that typically physicians order a urinalysis when patients complain of abdominal pain, nausea, vomiting, and diarrhea, unless he or she feels the urinalysis is not required.

Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide stabilizing treatment within the capabilities of the hospital staff and facility available at the hospital for further medical examination and treatment as required to stabilize the medical condition for one (1) of 20 sampled medical records when Patient #2 presented to the Emergency Department (ED) on 5/17/19 (first visit) and returned on 5/18/19 (second visit) requesting treatment for complaints of continued chills and fever.

Findings were:

MEDICAL RECORD REVIEW:

Review of patient #2's medical record for the second visit revealed the patient presented to the ED with complaints of "fever" on 5/18/19 at 10:25 a.m. The registrar noted that Patient #2's primary care physician was an out-of-town physician. Patient #2's spouse signed the registration forms at 10:26 a.m. At 10:27 a.m., Triage RN GG noted that Patient #2 reported that Zofran had controlled her nausea and vomiting but that she continued to have fever and chills. RN GG further noted that Patient #2 was ambulatory, and that the patient denied any treatment prior to arrival in the ED. At 10:33 a.m., RN GG noted that Patient #2 was a level 3 acuity. At 10:34 a.m., RN GG recorded Patient #2's vital signs as follows: temperature 99.8, pulse 109, respirations 17, blood pressure 129/45, and oxygen saturation as 100% on room air. RN GG completed the triage assessment which included the following:
--List of allergies.
--List of all home medications.
--Past medical and social history.
-- A pain assessment which revealed Patient #2 was having body aches that the patient rated as 7/10 (0 is no pain and 10 is severe pain). RN GG noted that Patient #2 reported that the pain had started 2-3 days ago.
--Recent travel was negative.
--RN GG completed a brief physical assessment with no abnormal findings, RN GG noted that the patient did not appear to be in any distress.
--Suicide Risk Screening, Abuse Assessment, Respiratory/TB Assessment, Sepsis Protocol Screening, Fall Risk Assessment, and Pneumonia Protocol Screening, all of which were negative and did not require any interventions.

At 11:23 a.m., ED Physician CC noted that Patient #2 presented with complaints of "chills" and that the patient had been seen in the ED approximately 36 hours earlier with complaints of fever, nausea, vomiting, and diarrhea. ED Physician CC further noted that the patient had been discharged home earlier with a prescription for Zofran to control the nausea and vomiting and to take Tylenol for the fever. ED Physician CC noted that Patient #2 reported that she had not had any further nausea, vomiting, diarrhea, or abdominal pain, but that she did have a fever last night. In addition, ED Physician CC noted that Patient #2 reported that she had chills and despite covering up with blankets she continued to feel cold, and that she took Tylenol several times during the night for fever but may not have been consistent with the timing. ED Physician CC completed a review of systems and a physical examination, which revealed Patient #2 was positive for body aches, fever, and chills. At 11:28 a.m., ED Physician CC noted that the differential diagnosis was viral infection / bacterial infection. ED Physician CC noted that he reviewed the following: all vital signs, nurses' notes, Sepsis Protocol which was not initiated because the patient did not meet the appropriate scoring criteria. ED Physician CC noted that Patient #2's physical exam was "unremarkable". In addition, ED Physician CC noted that Patient #2 was afebrile, had a mildly elevated heart rate, abdomen is soft and nontender, and is no longer having nausea, vomiting, or diarrhea. ED Physician CC noted that no additional testing would be performed, and no additional prescriptions would be performed given at "this time". ED Physician CC noted that Patient #2 was advised to continue to drink plenty of fluids, to take Tylenol every four (4) hours to prevent fever and to follow-up with her primary care physician on Monday (5/20/19) if not improved. ED Physician CC noted that Patient #2 verbalized understanding and agreed to comply with the follow-up.

At 11:29 a.m., ED Physician CC noted that Patient #2 was stable for discharged. ED Physician CC noted that Patient #2's symptoms had improved, that fever instructions and instructions to follow-up with her primary care physician were given.

At 11:41 a.m., RN HH noted that Patient #2's vital signs were pulse 94, respirations 16, blood pressure 110/65, oxygen saturation 94% on room air, and pain level 2/10. RN HH noted that the discharge assessment revealed Patient #2 was awake, alert and oriented to person, place, and time. RN HH noted that Patient #2 verbalized understanding of the discharge instructions which included:
--increasing fluids,
--fever instructions,
--follow-up with primary care physician,
--return to ED if symptoms continue or worsen.
In addition, RN HH noted that a copy of the discharge instructions was given to the patient, and that the patient agreed to having a follow-up ED call. RN HH noted that Patient #2 was discharged to home and that the patient was ambulatory when she left the ED at 11:42 a.m. Patient #2 signed receipt of the written discharge instructions which informed the patient that the examination and treatment she received in the ED had been rendered on an emergency basis only and was not intended to be a substitute for an effort to provide complete medical care. These instructions further informed Patient #2 to follow-up with her physician for any needed check-up and to report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit.


POLICY AND PROCEDURE:

Review of the facility policies included but was not limited to the following:
I. EMTALA MEDICAL SCREENING STABILIZATION POLICY, no policy number, last revision date 2/2017, revealed "All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, ...requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ( " EMTALA " )...
POLICY: Each Hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.
DEFINITIONS:
MEDICAL SCREENING/STABILIZATION
General Requirements
In general, when an individual comes, by himself or herself, with another person, or by EMS (emergency medical services - ambulance) to the Dedicated Emergency Department of the Hospital and a request is made on the individual ' s behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in active labor; and, if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these policies. These same requirements apply if a prudent layperson would believe the individual is in need of an emergency examination or treatment... 5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment."



INTERVIEWS;

According to an interview conducted on 7/29/19 at 2:00 p.m. ED Director AA explained that ED physicians usually order a urinalysis when patients present with abdominal pain, nausea, vomiting, diarrhea, and/or fever.

During an interview on 7/30/19 at 8:35 a.m. in the Conference Room, ED Medical Director BB confirmed that he reviewed Patient #2's medical records (first visit on 5/17/19 and second visit on 5/18/19. ED Medical Director BB said that during the second visit, Patient #2's fever and chills continued but her nausea, vomiting, and diarrhea had improved. ED Medical Director BB said that ED Physician CC did evaluate Patient #2 but did not do any additional diagnostic testing. ED Medical Director BB confirmed that Patient #2 was discharged home after receiving discharge instructions. ED Medical Director BB said that he later received a call from Patient #2's spouse and was informed that the patient had gone to another hospital and was diagnosed with urosepsis (a severe urinary tract infection that can be life-threatening when left untreated). ED Medical Director BB explained that Patient #2's medical records for both visits had been sent for quality review. ED Medical Director BB said that he counseled ED Physician CC to keep in mind that a second visit is a chance to order additional testing and to evaluate the patient for any additional differential diagnosis. ED Medical Director BB said that the worst case scenario for Patient #2 considering the elevated heart rate and the patient's age group would have been urosepsis and that he might have ordered a urinalysis, he stated that if the urinalysis was contaminated due to the diarrhea, he would have ordered an in and out catherization (procedure to obtain a sterile urine specimen).

During an interview on 7/30/19 at 9:10 a.m. in the Conference Room with ED Physician CC. ED Physician CC reviewed patient #2's medical record for the first visit and explained that upon examination the patient had no abdominal or urinary symptoms but did have a slightly elevated WBC. ED Physician CC explained that usually with bacteremia (presence of bacteria in the blood) the WBCs are a lot higher. He stated he was not alarmed because the patient's WBCs were slightly elevated, she was mildly anemic, but that he did treat her low potassium and magnesium levels. In addition, ED Physician CC said that he felt the mild elevated creatine level was due to the nausea, vomiting, and diarrhea. He explained that he treated the Patient #2 with intravenous fluids and Zofran for the nausea and vomiting and her symptoms improved prior to being discharged home with instructions to follow-up with her primary care physician or to return to the ED if her condition worsened. ED Physician CC said that less than 36 hours later Patient #2 returned to the ED (second visit) because it was the weekend and she had not had a chance to follow-up with her doctor. ED Physician CC stated Patient #2 reported that her nausea, vomiting, and diarrhea had improved but that she still had fever and chills. He went on to explain that Patient #2 reported that she was bundling up with several blankets and had taken some Tylenol but was unclear as to whether she had taken it timely enough to control the fever. ED Physician CC said that he counseled the patient regarding taking the Tylenol every four (4) hours for fever. ED Physician CC said that he did not consider ordering a urinalysis and in hind sight he didn't know why he didn't order the urinalysis. He explained that he usually does order a urinalysis but that the patient did not have any urinary symptoms during either visit.

During an interview on 7/30/19 at 10:00 a.m. in the Conference Room, RN GG confirmed that she was the triage nurse on 5/18/19 during Patient #2's second visit. She stated she completed the Sepsis Protocol Screening and that Patient #2 did not meet the criteria for the Sepsis Protocol to be initiated. In addition, RN GG said Patient #2's heart rate was 109 and temperature was 99.8 degrees, both a little elevated but that the patient's respirations, blood pressure, and oxygen saturation were normal. RN GG said that Patient #2 reported that she continued to have fever and chills but that the Zofran had helped with the nausea and vomiting. RN GG said that patients with abdominal pain, nausea, or vomiting usually have a urinalysis ordered and that she wasn't sure whether a urinalysis had been ordered during Patient #2's first visit. RN GG stated that when she is the triage nurse, she observes patients entering the ED and that her documentation revealed that Patient #2 had ambulated into the ED, that the patient reported having body aches, and that the patient did not appear to be in any distress.

During an interview on 7/30/19 at 10:30 a.m. in the Conference Room, said that she vaguely remembers Patient #2. RN HH explained that she was the Charge Nurse on 5/17/19 during Patient #2's first visit and that she provided care for the patient during the second visit on 5/18/19. RN HH said that patients' criteria for the Sepsis Protocol Screening has to be a three (3) for it to be positive and to initiate the protocol. RN HH said that even if a patient doesn't meet the Sepsis Protocol the nurse can approach the ED physician if the nurse thinks the patient looks sick. RN HH said that usually one of the first things we (ED staff) do is get a urinalysis on most patients who complain of abdominal pain, nausea, vomiting, or fever, if they can void. RN HH confirmed that during Patient #2's second visit the patient's vital signs were stable with a mildly elevated heart rate, her nausea and vomiting had improved, but she continued to have mild fever and chills.


The facility failed to provide stabilizing treatment as required that was within the capabilities of the hospital ED staff and facilities for patient #2 on 5/18/2019 as evidenced by failing provide further work-up, no chest x-ray, and no urinalysis performed despite the patient's continued complaints of fever and chills on her second visit to the ED.