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Based on record review and interview, the hospital failed to comply with the provisions of 42 CFR 489.24 for one of 24 sampled patients (Patient 14) who presented to the hospital's ED seeking emergency medical treatment as evidenced by:

1. The hospital failed to ensure Patient 14, a nine week pregnant female, was provided ongoing monitoring of her EMC prior to discharge. There was no documentation in the patient's medical record to show ongoing assessments of the patient's complaints of abdominal pain were conducted as per the hospital's P&P. In addition, there was no documentation to show the physician was made aware the patient's consistently low BPs were not within normal parameters at the time the patient was discharged in order for the physician to determine if the patient's EMC was actually resolved. Cross reference to A2406.

2. The hospital failed to provide the necessary stabilizing treatment within their capability/capacity for Patient 14 prior to discharge from the ED. The ED nursing staff failed to update the physicians involved of the patient's continuing abdominal pain and consistent low BPs. Cross reference to A2407.

These failures resulted in Patient 14's return to the ED by paramedics in less than an hour after discharge, unresponsive and in critical condition from a ruptured ectoptic pregnancy (a complication of pregnancy in which the embryo is implanted outside the uterine cavity).

Based on observation and interview, the hospital failed to conspicuously post signs specifying the rights of individuals under under EMTALA law in places likely to be noticed by all individuals entering the ED. This failure could result in individuals not made aware of their rights to examination and treatment in the event of an emergency medical condition.

Findings:

On 2/23/15 at 0900 hours, a tour of the ED was conducted accompanied by the Director of Quality Services.

Signs specifying rights for examination and treatment for patients with emergency medical conditions and women in labor were posted on the wall in the waiting area and the hallway of the ambulance entrance; however, there was no signage posted in the triage, registration, and treatment areas for patients waiting for examination and treatment.

On 2/23/15 at 1030 hours, the CNO and Director of Quality Services acknowledged the above finding. The CEO and COO were also informed of the above finding during the exit conference on 2/24/15 at 1700 hours.

Based on record review and interview, the hospital failed to ensure one of 24 sampled patients (Patient 14) was provided ongoing monitoring of her EMC prior to discharge. There was no documentation in the patient's medical record to show ongoing assessments of the patient's complaints of abdominal pain were conducted as per the hospital's P&P. In addition, there was no documentation to show the physician was made aware Patient 14's consistently low BP was not within normal parameters at the time the patient was discharged in order for the physician to determine if the patient's EMC was actually resolved.

This failure resulted in the patient's return to the ED by paramedics in less than an hour after discharge, unresponsive and in critical condition from a ruptured ectoptic pregnancy.

Findings:

Review of the P&P titled Pain Management, original date 8/03, and last reviewed 1/15, showed a pain assessment scale would be utilized to determine the method for individualized pain screening, assessment, and management. Recognizing self-report is the most reliable indicator of pain presence and intensity.

RNs were responsible for assessment and reassessment of pain. A pain screening would be performed as determined by individual patient needs and at a minimum with the vital signs per unit specific standards of practice as indicated by changes in a patient's status and as their condition warranted.

The patient's pain would be reassessed to evaluate the effectiveness of pain interventions 30 minutes after receiving IV medications and 60 minutes after receiving oral medications.

Review of the P&P titled Triage, Medical Screening Examination and Nursing Assessment original date 3/98, and last reviewed 1/15, showed it is the responsibility of the ED nursing staff to assure triage and ongoing assessments are performed on all patients in the ED.

Content of the assessment includes (number 4) pain level. Assessment and reassessment are a continuing process during the patient's length of stay in the ED.

Patient 14's medical record was reviewed on 2/23/15. Documentation showed the patient was nine week pregnant and came to the hospital's ED on 2/14/15 at 0934 hours, complaining of severe abdominal pain rendering her being unable to walk and urinate. The triage nurse's initial assessment showed Patient 14's BP was 99/69 mmHg, HR was 82 bpm, and respiratory rate was 20 breaths per minute (normal vital sign ranges for the average healthy adult while resting are BP: 90/60-120/80 mmHg, HR: 60-100 bpm, and respirations: 12-18 breaths per minute). The patient rated her lower abdominal pain as 10/10 on a pain scale of 0 to 10 (with 0 = no pain and 10 = most pain).

At 1000 hours, RN 1 took over care of Patient 14 from the triage nurse. RN 1 noted the patient complained of "labor pains;" however, the RN did not document the patient's pain with a numerical pain scale level.

At 1245 hours, Patient 14 vomited. The patient stated the pain was worse with rib pain and shortness of breath. The patient was medicated with zofran 4 mg IV to alleviate vomiting and Tylenol 650 mg by mouth for pain. Again, RN 1 did not document the patient's pain with a numerical pain scale level before and after the pain medication was given.

At 1300 hours, RN 1 documented the patient's BP was 71/44 mmHg. At 1410 hours, when the BP was still low, RN 1 notified MD 1 who ordered an IV infusion of 1000 ml of normal saline and to admit the patient to the hospital for further evaluation by an OB/GYN consultant physician. At 1504 hours, the patient's BP was 82/56 mmHg and the HR was 89 bpm.

On 2/14/15 at 1430 hours, MD 2 (the OB/GYN consultant) saw Patient 14 in the ED and wrote orders to administer rocephin (antibiotic medication) 2 gm IV and give morphine sulfate (narcotic pain medication) 2 mg IV for pain. The order showed the nurse might release the patient home after the above orders were done.

RN 1 documented at 1501 hours, the rocephin was infused and morphine sulfate was administered for pain to Patient 14. There was no documentation of the patient's pain level before or after the pain medication administration. At 1620 hours, the patient's BP dropped to 62/33 mmHg. RN 1 notified MD 2 and received a verbal order to infuse one liter of IV fluids (lactated ringers) wide open. RN 1 documented on the nursing notes, per the OB/GYN consult, "may send patient home when systolic BP increased to 70's."

The last set of vital signs documented for Patient 14 in the medical record was taken at 1817 hours. The BP was 71/39 mmHg and HR was 120 bpm. No pain level assessment was documented and there was no documentation to show the RN notified MD 2 or the ED physician of Patient 14's current status.

At 1818 hours, RN 1 documented she attempted to discharge Patient 14, but the patient and her family member refused due to "too much pain." With Patient 14 being unable to walk, the family member stated he could not carry the patient to the car. Again, there was no documented pain level and notification of any of the physicians involved.

At 1830 hours, documentation by RN 2, the oncoming night shift charge nurse showed RN 1 reported to RN 2 that Patient 14 was discharged, but the family was being difficult; the patient just needed her IV out and was "okay to go home. Primary assessment not conducted." The documentation showed RN 2 explained the plan of care to the patient; MD had discharged her with prescriptions for an antibiotic and a narcotic pain medication.

Documentation by RN 2 showed the patient was "sitting up in bed, moaning," was awake, alert, and oriented, and agreed with the treatment plan. The patient was discharged via a wheelchair to the car.

There was no documented evidence the patient's pain level assessment at the time of discharge was found in the patient's medical record. In addition, the patient was discharged without signing the discharge instructions form. The form was witnessed by RN 2; however, the patient's signature line was blank.

On 2/14/15 at 1859 hours, Patient 14's family member called 911 as the patient was found unresponsive when the family member came back to the car after picking up the prescriptions. The patient was resuscitated and brought back to the same ED. Patient 14 was rushed to surgery when the ultrasound revealed bleeding in the abdomen. In the OR, 1300-1600 ml of blood was removed due to a ruptured ectopic pregnancy (cornual). The patient was transferred to the ICU on life support and was comatose with pupils fixed and dilated.

On 2/24/15 at 1200 hours, RN 1 (the primary ED nurse for Patient 14) was interviewed by telephone. The RN confirmed Patient 14 complained of an abdominal pain level of 10/10 on admission.

RN 1 stated she did not talk to MD 2 in the ED. The RN stated she only knew the OB consultant saw the patient because the ED physician handed her the orders written by the OB consultant.

RN 1 stated she did not think the OB consultant was aware the patient's BP was low (70/51 mmHg at 1410 hours). The OB consultant ordered to administer an IV antibiotic, give morphine sulfate 2 mg IV for pain, and wrote "may release patient home."

RN 1 stated after the morphine was given at around 1500 hours, the patient's BP was 62/33 mmHg at 1620 hours. The RN stated she informed the OB consultant who told her it was normal for pregnant women to have low BP, especially after receiving the morphine. The RN stated the OB consultant asked the RN how the systolic BP was for the last 2-3 hours and the RN responded 70-80's. The OB consultant then ordered to infuse a liter of IV lactated ringers and told the RN to release the patient once the systolic BP was in the 70's.

RN 1 stated after the IV of lactated ringers was infused, Patient 14's BP was 71/39 mmHg at 1817 hours. When she went to discharge the patient she stated the patient looked better and seemed in less pain; however, the patient refused to go home as she told the RN she was in too much pain. The RN stated the patient started to yell and was upset. The patient's HR increased to 120 bpm.

At 1830 hours, RN 1 stated she explained to RN 2 (the oncoming charge nurse) what was going on with Patient 14 regarding the labs, medications, vital signs, the patient, and her family member's refusal of discharge. RN 1 stated she told RN 2 the patient had not yet signed the discharge instructions. RN 1 stated RN 2 physically discharged the patient after RN 1 left.

When asked about the expected documentation of pain levels for ED patients, RN 1 stated she should reassess the patient 30 minutes after a pain medication was given. RN 1 stated, she "knew she didn't chart her best for how often she checked her. It was every 30 minutes." RN 1 also stated it was difficult to tell how much pain the patient was in as she "presented very flat." RN 1 was asked if she had asked the patient or documented a stated pain level for the patient at the time of discharge and she stated she did not.

RN 2 was interviewed by telephone on 2/14/15 at 1535 hours. The Charge RN stated he was approached by RN 1 and was told Patient 14 was okay for discharge, but the family had concerns that the patient was still in pain. RN 1 reported to him there were no further orders and he thought all was needed was the intervention from the Charge Nurse to facilitate the discharge.

RN 2 stated at 1820 hours, he walked to Patient 14's bedside and introduced himself. The family member looked upset and expressed concerns that the patient was still in pain. RN 2 stated he told them everything was ready for a discharge and the physician wrote prescriptions for an antibiotic and a pain medication to help relieve the pain at home. Assistance was given to the patient for discharge to the car by wheelchair at 1832 hours.

When asked, RN 2 stated he did not perform an assessment of Patient 14 as RN 1 painted a picture where he did not have to do anything but to be a liaison and physically discharged the patient. RN 2 stated he was not aware of the patient's last BP.

MD 2 was interviewed on 2/23/15 at 1305 hours. The MD stated he examined Patient 14 in the ED at approximately 1430 hours. He palpated the patient's abdomen and found it benign. The physician stated the patient did not appear in pain at that time.

MD 2 stated he explained to Patient 14 she might have a UTI. He felt the cramping might have been from the small subchorionic hemorrhage seen on the OB ultrasound, the UTI, or from the intercourse. MD 2 recommended the patient abstain from intercourse and follow up with her OB/GYN physician.

MD 2 stated he ordered morphine 2 mg IV for pain per the patient's request and a dose of IV rocephin for Patient 14 while in the ED as well as a prescription for Macrobid (oral antibiotic) and Percocet (pain medication) for the patient to fill on the way home. The physician stated he ordered to release the patient home after the above was accomplished. The physician stated when he left the ED Patient 14 seemed "fine, happy."

When asked if he was aware of the patient's vital signs after admission, he stated he did not recall. When asked if he spoke with the RN caring for Patient 14 while he was in the ED, the physician stated he did not recall if he had spoken with the RN caring for Patient 14 as he was at the ED "quite a few times that weekend."

MD 2 stated he was not called again after speaking with RN 1 at around 1600 hours, until around 1900 hours, when the ED called him to report Patient 14 was returned to the ED with paramedics, unresponsive after discharge.

MD 2 was asked if he would have authorized a discharge of Patient 14 with a BP of 70/40 mmHg and complaints of severe pain. The MD replied "no" and stated if the BP had not improved after the fluid challenge ordered, he would have to consider why not.

Based on interview and record review, the hospital failed to provide the necessary stabilizing treatment within their capability/capacity for one of 24 sampled patients (Patient 14) prior to discharge from the ED. The ED nursing staff failed to update the physicians involved that Patient 14's consistently low BP was not within normal parameters at the time the patient was discharged.

This failure resulted in the patient's return to the ED by paramedics in less than an hour after discharge, unresponsive and in critical condition from a ruptured ectoptic pregnancy.

Findings:

Review of the P&P titled Pain Management, original date 8/03, and last reviewed 1/15, showed a pain assessment scale would be utilized to determine the method for individualized pain screening, assessment, and management. Recognizing self-report is the most reliable indicator of pain presence and intensity.

RNs were responsible for assessment and reassessment of pain. A pain screening would be performed as determined by individual patient needs and at a minimum with the vital signs per unit specific standards of practice as indicated by changes in a patient's status and as their condition warranted.

The patient's pain would be reassessed to evaluate the effectiveness of pain interventions 30 minutes after receiving IV medications and 60 minutes after receiving oral medications.

Review of the P&P titled Triage, Medical Screening Examination and Nursing Assessment original date 3/98, and last reviewed 1/15, showed it is the responsibility of the ED nursing staff to assure triage and ongoing assessments are performed on all patients in the ED.

Content of the assessment includes (number 4) pain level. Assessment and reassessment are a continuing process during the patient's length of stay in the ED.

Patient 14's medical record was reviewed on 2/23/15. Documentation showed the patient was nine week pregnant and came to the hospital's ED on 2/14/15 at 0934 hours, complaining of severe abdominal pain rendering her being unable to walk and urinate. The triage nurse's initial assessment showed Patient 14's BP was 99/69 mmHg, HR was 82 bpm, and respiratory rate was 20 breaths per minute (normal vital sign ranges for the average healthy adult while resting are BP: 90/60-120/80 mmHg, HR: 60-100 bpm, and respirations: 12-18 breaths per minute). The patient rated her lower abdominal pain as 10/10 on a pain scale of 0 to 10 (with 0 = no pain and 10 = most pain).

The ED physician, MD 1 evaluated Patient 14 at 0959 hours. Blood tests, a urinalysis, and an ultrasound of the abdomen were ordered.

At 1000 hours, RN 1 took over care of Patient 14 from the triage nurse. RN 1 noted the patient complained of "labor pains;" however, the RN did not document the patient's pain with a numerical pain scale level.

At 1245 hours, Patient 14 vomited. The patient stated the pain was worse with rib pain and shortness of breath. The patient was medicated with zofran 4 mg IV to alleviate vomiting and Tylenol 650 mg by mouth for pain. Again, RN 1 did not document the patient's pain with a numerical pain scale level before and after the pain medication was given.

At 1300 hours, RN 1 documented the patient's BP was 71/44 mmHg. At 1410 hours, when the BP was still low, RN 1 notified MD 1 who ordered an IV infusion of 1000 ml of normal saline and to admit the patient to the hospital for further evaluation by an OB/GYN consultant physician. At 1504 hours, the patient's BP was 82/56 mmHg and the HR was 89 bpm.

On 2/14/15 at 1430 hours, MD 2 (the OB/GYN consultant) saw Patient 14 in the ED and wrote orders to administer rocephin (antibiotic medication) 2 gm IV and give morphine sulfate (narcotic pain medication) 2 mg IV for pain. The order showed the nurse might release the patient home after the above orders were done.

RN 1 documented at 1501 hours, the rocephin was infused and morphine sulfate was administered for pain to Patient 14. There was no documentation of the patient's pain level before or after the pain medication administration. At 1620 hours, the patient's BP dropped to 62/33 mmHg. RN 1 notified MD 2 and received a verbal order to infuse one liter of IV fluids (lactated ringers) wide open. RN 1 documented on the nursing notes, per the OB/GYN consult, "may send patient home when systolic BP increased to 70's."

The last set of vital signs documented for Patient 14 in the medical record was taken at 1817 hours. The BP was 71/39 mmHg and HR was 120 bpm. No pain level assessment was documented and there was no documentation to show the RN notified MD 2 or the ED physician of Patient 14's current status.

At 1818 hours, RN 1 documented she attempted to discharge Patient 14, but the patient and her family member refused due to "too much pain." With Patient 14 being unable to walk, the family member stated he could not carry the patient to the car. Again, there was no documented pain level and notification of any of the physicians involved.

At 1830 hours, documentation by RN 2, the oncoming night shift charge nurse showed RN 1 reported to RN 2 that Patient 14 was discharged, but the family was being difficult; the patient just needed her IV out and was "okay to go home. Primary assessment not conducted." The documentation showed RN 2 explained the plan of care to the patient; MD had discharged her with prescriptions for an antibiotic and a narcotic pain medication.

Documentation by RN 2 showed the patient was "sitting up in bed, moaning," was awake, alert, and oriented, and agreed with the treatment plan. The patient was discharged via a wheelchair to the car.

There was no documented evidence the patient's pain level assessment at the time of discharge was found in the patient's medical record. In addition, the patient was discharged without signing the discharge instructions form. The form was witnessed by RN 2; however, the patient's signature line was blank.

On 2/14/15 at 1859 hours, Patient 14's family member called 911 as the patient was found unresponsive when the family member came back to the car after picking up the prescriptions. The patient was resuscitated and brought back to the same ED. Patient 14 was rushed to surgery when the ultrasound revealed bleeding in the abdomen. In the OR, 1300-1600 ml of blood was removed due to a ruptured ectopic pregnancy (cornual). The patient was transferred to the ICU on life support and was comatose with pupils fixed and dilated.

On 2/24/15 at 1200 hours, RN 1 (the primary ED nurse for Patient 14) was interviewed by telephone. The RN confirmed Patient 14 complained of an abdominal pain level of 10/10 on admission.

The RN stated initially the patient was to be admitted per the treating ED physician as the patient refused to discharge due to her pain. The RN stated an OB/GYN consultant (MD 2) was then called to see the patient.

The RN stated she did not talk to MD 2 in the ED. RN 1 stated she did not think the OB consultant was aware the patient's BP was low (70/51 mmHg at 1410 hours). The OB consultant ordered to administer an IV antibiotic, give morphine sulfate 2 mg IV for pain, and wrote "may release patient home."

RN 1 stated after the morphine was given at around 1500 hours, the patient's BP was 62/33 mmHg at 1620 hours. The RN stated she informed the OB consultant who told her it was normal for pregnant women to have low BP, especially after receiving the morphine. The RN stated the OB consultant asked the RN how the systolic BP was for the last 2-3 hours and the RN responded 70-80's. The OB consultant then ordered to infuse a liter of IV lactated ringers and told the RN to release the patient once the systolic BP was in the 70's. RN 1 confirmed the MD's BP parameters were not written as an order in the record.

RN 1 stated after the IV of lactated ringers was infused, Patient 14's BP was 71/39 mmHg at 1817 hours. When she went to discharge the patient she stated the patient looked better and seemed in less pain; however, the patient refused to go home as she told the RN she was in too much pain. The RN stated the patient started to yell and was upset. The patient's HR increased to 120 bpm.

At 1830 hours, RN 1 stated she explained to RN 2 (the oncoming charge nurse) what was going on with Patient 14 regarding the labs, medications, vital signs, the patient, and her family member's refusal of discharge. RN 1 stated she told RN 2 the patient had not yet signed the discharge instructions. RN 1 stated RN 2 physically discharged the patient after RN 1 left.

When asked about the expected documentation of pain levels for ED patients, RN 1 stated she should reassess the patient 30 minutes after a pain medication was given. RN 1 stated, she "knew she didn't chart her best for how often she checked her. It was every 30 minutes." RN 1 also stated it was difficult to tell how much pain the patient was in as she "presented very flat." RN 1 was asked if she had asked the patient or documented a stated pain level for the patient at the time of discharge and she stated she did not.

RN 2 was interviewed by telephone on 2/14/15 at 1535 hours. The Charge RN stated he was approached by RN 1 and was told Patient 14 was okay for discharge, but the family had concerns that the patient was still in pain. RN 1 reported to him there were no further orders and he thought all was needed was the intervention from the Charge Nurse to facilitate the discharge.

RN 2 stated at 1820 hours, he walked to Patient 14's bedside and introduced himself. The family member looked upset and expressed concerns that the patient was still in pain. RN 2 stated he told them everything was ready for a discharge and the physician wrote prescriptions for an antibiotic and a pain medication to help relieve the pain at home. Assistance was given to the patient for discharge to the car by wheelchair at 1832 hours.

When asked, RN 2 stated he did not perform an assessment of Patient 14 as RN 1 painted a picture where he did not have to do anything but to be a liaison and physically discharged the patient. RN 2 stated he was not aware of the patient's last BP.

MD 2 was interviewed on 2/23/15 at 1305 hours. The MD stated he examined Patient 14 in the ED at approximately 1430 hours. He palpated the patient's abdomen and found it benign. The physician stated the patient did not appear in pain at that time as the patient was "laughing and giggling" with the family member, especially when discussing that the abdominal pain began soon after intercourse. The physician stated before he left the bedside, the patient asked for the IV pain medication. The physician stated the treating ED physician had shared she was not comfortable giving narcotic pain medication to a pregnant woman; however, he deemed it okay and ordered a dose of morphine IV.

MD 2 stated he explained to Patient 14 she might have a UTI. He felt the cramping might have been from the small subchorionic hemorrhage seen on the OB ultrasound, the UTI, or from the intercourse. MD 2 recommended the patient abstain from intercourse and follow up with her OB/GYN physician.

MD 2 stated he ordered morphine 2 mg IV for pain per the patient's request and a dose of IV rocephin for Patient 14 while in the ED as well as a prescription for Macrobid (oral antibiotic) and Percocet (pain medication) for the patient to fill on the way home. The physician stated he ordered to release the patient home after the above was accomplished. The physician stated when he left the ED Patient 14 seemed "fine, happy."

When asked if he was aware of the patient's vital signs after admission, he stated he did not recall. When asked if he spoke with the RN caring for Patient 14 while he was in the ED, the physician stated he did not recall if he had spoken with the RN caring for Patient 14 as he was at the ED "quite a few times that weekend."

MD 2 stated he was not called again after speaking with RN 1 at around 1600 hours, until around 1900 hours, when the ED called him to report Patient 14 was returned to the ED with paramedics, unresponsive after discharge.

MD 2 was asked if he would have authorized a discharge of Patient 14 with a BP of 70/40 mmHg and complaints of severe pain. The MD replied "no" and stated if the BP had not improved after the fluid challenge ordered, he would have to consider why not.