HospitalInspections.org

Based on interviews and record reviews, the Hospital #1 neglected to protect Patient #1 at discharge who was known to the emergency department staff to be altered from a traumatic brain injury and who had a history of recreational drug use. The facility failed to place the patient in a vehicle to make sure he made it back home some 80 miles away. The patient did not make it home and was readmitted to another hospital with complications from undiagnosed infections and dehydration from exposure. The findings are:

A. On 08/08/16 at 9:15 am during interview, the complainant outlined his concerns. He is now a 57-year-old male with a history of a traumatic brain injury. He was a poor historian with only a vague recollection of the sequence of events before and after his visit to Emergency Department (ED) #1 on 06/01/16. He believed that he was improperly treated in the ED and prematurely discharged. He was admitted to Hospital #2 the next day, 06/02/16. He arrived via ambulance unconscious and was admitted to the intensive care unit from the ED with a urinary tract infection, a lung infection and severe dehydration.

B. On 08/08/16 at 3:45 pm a representative from Patient #1's insurance provider was interviewed. She filed the Critical Incident Reports on 06/07/16 on behalf of Patient #1. He arrived at Hospital #1 via ambulance on 06/01/16. He was discharged to home around 6:20 pm. It is unclear if he was driven back to his home, some 80 miles or started to walk. Her critical incident report based on information from Patient #1 and his caregiver is uncertain on what Patient #1 did after leaving the Hospital #1. Patient #1's caregiver and Emergency Medical Technician or ambulance reports indicated that Patient #1 was picked up on the highway near [name of town] the next day around the same time 24 hours later, 18 miles from Hospital #1. He was transported to the Hospital #2, where he was admitted to the Intensive Care Unit directly from the ED. He was very ill with a urinary tract infection, a lung infection, and severe dehydration. He was discharged home 5 days later.

C. Review of the medical record for Patient #1 at Hospital #2 indicated the following:
"History and Physical - Admission...
History of Present Illness; The source was from [ED Physician #1], who spoke to an EMT [emergency medical technician]. It is not clear what his history of present illness is, but there is report that he was seen in the emergency room [#1] yesterday for inguinal pain. There is also a history that the patient walked from his home to [name of town] to get help and it was [there] from where he was picked up. I am not sure if any of this is accurate.
The patient was brought here to our emergency room and became what was low blood pressure, was given 5 L [liters] of fluid with improvement in his blood pressure. His oxygenation worsened and his respiratory effort decreased and he was intubated by ED Physician #1
for an acute hypoxic [low oxygen] respiratory failure. ...
Problems and Plan:
1. Pyuria [pus in the urine]/possible urinary tract infection, but no but no bacteriuria [sic] [bacteria in the urine]:
a Empiric cefepine [antimicrobial treatment just in case he has a urinary tract infection].
b. Culture urine, blood and sputum [tests for infection].
c. IV hydration [intravenous fluids].
2. Dehydration/mild rhabdomyolysis [muscle enzymes that indicate staying in one position until muscles break down].
a. Rehydrate and follow CKs [muscle enzymes that indicate heart muscle damage].
b. Monitor creatinine and BUN [blood tests indicating kidney function].
3. Possible right hilar infiltrate [fluid in lungs].
a. Induce a sputum [to test for infection].
b. Followup chest x-ray in the morning [to look for fluid or infection in lungs].
4. Respiratory failure, acute and hypoxic [low oxygen].
a. Mechanical ventilation [breathing].
b. Will wean as tolerated [off ventilator].
The patient will be admitted to the ICU [intensive care unit]...The patient is critically ill."

D. Record review of Patient #1 medical record at ED #1 indicated the following:

1. ED History and Physical dated 07/08/15: "HPI [history of present illness] Comments: [Patient #1] is a 56 y.o. [year old] male presenting with altered mental status. Pt was found this morning asleep in bed by his caregiver. EMS [emergency medical services] states he exhibited AMS [altered mental status] when evaluated by them this morning. Pt confirms that he consumed alcohol last night and is on several medications with sedative effects..."


2. ED History and Physical dated 08/22/15: "HPI [history of present illness] comments: [Patient #1] is a 56 year old male presenting with AMS [altered mental status]. Pt states he does not remember why or when he was transported to the hospital. EMS was called when his family noticed his AMS. Pt cannot state the day, month or year. Pt. states that he does not work due to disability, but cannot recall what his disability is. Pt. is aware he lives in [home town]. Pt. does not know why he was transported to the ED. Pt denies any cough, fever, SOB [shortness of breath], acute pain or recent illness."

3. ED History and Physical dated 06/01/16 at ED #1 indicated the following:
"HPI Comments: Pt. may have accidentally taken one extra gabapentin [slows nerve conduction to lessen pain], cymbalta [antidepressant] and klonopin [sedative]. Pt state he was tired earlier. Pt. now feels fine and AAOx4 [alert, appropriate and oriented to himself, time, place and situation]." "Diagnosis: possible overdose. Vital signs including temperature, oxygen saturation, blood pressure and heart rate were normal. A note by a ED nurse noted Patient #1 requested a urinary analysis. No results of a urinary analysis was found in the chart for the 06/01/16 ED visit."

E. Record review of the Hospital #1's Policy on discharge planning titled "Discharge Planning Services Required Under CMS Conditions of Participation," dated effective 04/01/2008, indicated the following:
Purpose: To describe procedures to ensure compliance with discharge planning services as required by the Centers of Medicare and Medicaid Services (CMS) Conditions of Participation and other applicable for Medicare- eligible recipients who are admitted to inpatient care.
Policy:
1. Hospital staff must identify, at an early stage of hospitalization, all patients that are likely to suffer adverse health consequences if there is no adequate discharge planning. Functional status, family support, and cognitive ability of the patients are all important factors when identifying individuals in need of discharge planning."