HospitalInspections.org

Based on document review and interview, it was determined that in 1 (Patient #2) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide stabilizing treatment.

Findings Include:

1. See findings cited at 42 CFR 489.24 (d) (1-3) Stabilizing Treatment (see tag 2407).

Based on document review and interview, the facility failed to ensure stabilizing treatment was provided for 1 of 20 patients (Patient #2).

Findings include:

1. Facility policy titled "Emergency Medical Treatment and Patient Transfer Policy" last reviewed/revised 9/1/2013 indicated the following: "...Definitions...1. Stable for Discharge: A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings. I. MEDICAL SCREENING EXAMINATION...A. Stabilizing Treatment for Emergency Medical Conditions...If it is determined through a Medical Screening Examination that an Emergency Medical Condition exists...emergency department personnel shall: (1) provide such further medical examination and treatment as may be required to stabilize the medical condition...within the Capabilities of the staff and facilities available at the Hospital..."

2. Facility policy titled "3.16.32 ED [Emergency Department] - Assessment and Reassessment in Emergency Services" last reviewed/revised 10/2018 indicated the following: "...I. PURPOSE: A. To identify patient care needs...III. ACTION DIRECTIVES: ...I. Emergency Department patients are monitored and reassessed at regular intervals as patient condition indicates based on response to care, significant change in condition, diagnosis test results, and information from various assessments of the patient. J. Patient reassessments will be done in a timeframe appropriate for the patient's condition...Minimally, nursing reassessment will be completed according to hospital policy: ...3) Category III - Every 30 minutes or less as appropriate...K. Both physicians and nurses should utilize continuing notes on the appropriate patients to assure aspects of assessment and care are adequately documented...N. ... vital signs (blood pressure, pulse, respirations, temperature) should be monitored as follows: ...2) Abnormal vital signs should be rechecked as indicated by patient's condition; 3) Vital signs should be taken at least 30 minutes after a patient has been administered medication that affects the hemodynamic status...or as indicated by the type of medication administered (excluding temperature, unless indicated by condition)...5. Vital signs should be taken at least every hour until discharge (excluding temperature unless indicated by condition)..."

3. Facility policy titled "3.11.03 Dismissing Patient from the Emergency Department" last reviewed/revised 5/2019 indicated the following: "...II. SPECIAL CONSIDERATIONS...C. All patients being discharged must have discharge vital signs if patient has been medicated or has been in the ED longer than 1 hour..."

4. Facility policy titled "1.03.18 Pain Assessment and Management" last reviewed/revised 1/2019 indicated the following: "...V. PROCEDURE: A. All patients have a right to have their pain managed. Patients are informed of their right to receive comfort through effective pain and symptom management. Patients and families are involved in making care decisions, including managing pain at a level that is acceptable to the patient. B. Patient will receive prompt assessment and management of pain..."

5. Review of Patient #2's medical record indicated the following:

The patient arrived to the Emergency Department on 12/13/19 at 0516 hours with complaint of chest pain, nausea/vomiting times one hour. The patient was triaged on 12/13/19 at 0520 hours with an acuity level of 3.

An ED provider note by MD1 (Doctor of Medicine/Emergency Medicine) dated 12/13/19 at 0600 hours indicated the following: "...Associated Diagnoses: Acute chest pain...Additional Information: Chief Complaint from Nursing Triage Note...12/13/2019 [at] 0520 [hours]...Chief Complaint CP [chest pain], N/V [nausea/vomiting] X [times] 1 HOUR, PT [Patient] HERE [OFTEN] FOR SAME...History of Present Illness...past medical history significant for end-stage renal disease on hemodialysis...Last dialyzed yesterday. History of chronic recurrent chest pain additionally without history of CAD [Coronary Artery Disease]. [He/She] presents [to the] emergency department for chest pain. Describes pain as aching and anterior in nature. Exact pain [he/she] has had before in the past...No associated abdominal pain, nausea. Had a normal run of dialysis yesterday. Episode started 1 hour prior to arrival...Problem list: Medical...[included but were not limited to]...Essential hypertension...Diabetic gastroparesis...Resistant hypertension...Insulin pump titration...Uncontrolled type 2 diabetes mellitus with complication, with long-term current use of insulin...Medical Decision Making...Patient is pending x-ray of the chest and lab work at this time. Case signed out to [MD2, Doctor of Medicine/Emergency Medicine] who agrees to follow up and disposition patient. Impression and Plan...Diagnosis: Acute chest pain...Plan: Condition: Stable. Disposition: Patient care transitioned to: Time: 12/13/2019 [at 0604 hours], [MD2]..."

A review of Patient #2's vitals flowsheet indicated the following:

a) On 12/13/19 at 0520 hours, Patient #2 had a blood pressure of 211/117, respiratory rate of 20, pulse of 101, oxygen saturation of 98%, left side chest pain/discomfort with a pain level of 8/10.

b) On 12/13/19 at 0553 hours, Patient #2 had a blood pressure of 194/103, respiratory rate of 20, pulse of 106 and oxygen saturation of 99%. The medical record lacked documentation and/or refusal of a pain level assessment at this time.

c) On 12/13/19 at 0555 hours, Patient #2 had a heart rate of 106 and pain level of 10/10. The medical record lacked documentation and/or refusal of a blood pressure and respiratory rate assessment at this time.

d) On 12/13/19 at 0600 hours, Patient #2 had a heart rate of 108 and pain level of 10/10. The medical record lacked documentation and/or refusal of a blood pressure and respiratory rate assessment at this time.

e) On 12/13/19 at 0645 hours, Patient #2 had a pain level of 8/10. The medical record lacked documentation and/or refusal of a blood pressure, heart rate and respiratory rate assessment at this time.

f) On 12/13/19 at 0749 hours, Patient #2 had a blood pressure of 210/101, heart rate of 103, oxygen saturation of 97% on room air, left side chest pain/discomfort constant with a pain level of 10/10. The medical record lacked documentation and/or refusal of a respiratory rate assessment at this time.

g) On 12/13/19 at 0800 hours, Patient #2 had a heart of 102. The medical record lacked documentation and/or refusal of a blood pressure and respiratory rate assessment at this time.

A review of Patient #2's physician orders by MD1 and "Medication Administration Record" indicated the following:

Clonidine 0.1 mg (milligrams) 1 tablet by mouth STAT (immediately), first dose on 12/13/19 at 0534 hours ordered on 12/13/19 at 0534 hours. The medical record lacked documentation that the blood pressure medication was administered and/or refused by the patient.

Nitroglycerin 0.4 mg, 1 tablet, sublingual, every 5 minutes as needed for chest pain, STAT, first dose on 12/13/19 at 0532 hours. The medication was administered on 12/13/19 at 0550, 0555 and 0600 hours. The medical record lacked documentation and/or refusal of a blood pressure assessment at 0555 and 0600 hours. The next blood pressure documented was at 0749 hours.

The medical record lacked documentation of treatment and reassessment of Patient #2's blood pressure.

Zofran 4 mg, solution for injection, intravenous push, once, STAT, first dose 12/13/19 at 0532 hours ordered on 12/13/19 at 0532 hours. The medication was administered on 12/13/19 at 0733 hours due to no intravenous access.

Pepcid 20 mg, solution for injection, intravenous push, once, STAT, first dose 12/13/19 at 0532 hours ordered on 12/13/19 at 0532 hours to be infused over 2 minutes. The medication was administered on 12/13/19 at 0734 hours due to no intravenous access.

The medical record lacked documentation of a reassessment of Patient #2's nausea after the medications of Zofran and Pepcid were administered and/or prior to the patient discharge from the emergency department.

Aspirin 324 mg, 1 tablet, chewed, once, STAT, first dose 12/13/19 at 0531 hours ordered on 12/13/19 at 0531 hours. The medication was administered on 12/13/19 at 0545 hours.

A review of Patient #2's labs indicated the following: "...[A] Basic Metabolic Profile with Total Calcium...[was] collected on 12/13/2019 [at 0634 hours]...Glucose...Result...649...Units...mg [milligrams]/dl [deciliter]...Reference Range...[70-99]...Verified Date/Time...12/13/2019 [at 0719 hours]...Result Comments...Glucose: The critical value was called...[to a Registered Nurse]...at 12/13/2019 [at 0719 hours]...and read back and verified appropriately..."

The medical record lacked documentation of treatment and reassessment of Patient #2's blood glucose of 649 mg/dl.

Patient #2's medical record indicated the medications that were ordered by a physician included Pepcid, Zofran, Nitroglycerin, aspirin and clonidine, no additional medications and/or interventions were noted to be ordered to treat Patient #2's blood glucose of 649 or chest pain level of 10/10.

A nurse's note dated 12/13/19 at 0749 hours indicated the patient was requesting to speak with the doctor for pain medications.

A nurse's note dated 12/13/19 at 0802 hours indicated the following: "...Discharge papers given, questions answered, pt verbalized understanding and attempted to call pain management..."

Patient #2 was discharged from the ED to home on 12/13/19 at 0810 hours.

The medical record lacked documentation that stabilizing treatment was provided for Patient #2 prior to discharge from the emergency department and written documentation from MD2 on his/her findings and rationale for the patient's discharge.

Review of medical record for Patient #2 at Facility #2 indicated the patient arrived to the facility by ambulance on 12/13/19 at 1012 hours. The patient arrived with a chief complaint of severe abdominal pain, nausea, shortness of breath, low oxygen saturation. Patient #2's ED provider note dated 12/13/19 at 1027 hours, from Facility #2, indicated the following: "...Patient presents to the emergency department via ambulance from a pain management office where [he/she] apparently got a celiac block. [He/She] has 2 injections which are covered by Band-Aids to [his/her] lower thoracic region posteriorly. Reports that [he/she] is having 10/10 severe epigastric pain. [He/She] has a [history] of chronic pancreatitis and gastroparesis. Started getting short of breath about 2-3 hours ago. [He/She] denies anything really bringing it on. [He/She] was at [Facility #1] from reports from the medics, we are trying to confirm this with the patient. Patient is in severe pain, [he/she] refuses to really talk or give history because of the pain, and immediately begins demanding pain medication without answering questions effectively...Physical Exam Visit Vitals BP [blood pressure]...182/112...Heart Rate: 109...Respiratory Rate: 13, SpO2: 96%...LABS...Glucose 652...[Physician order dated 12/13/19 at 1127 hours]...Patient presents in critical, worsening condition with severe hypoxemia and respiratory distress. [He/She] was immediately placed on a non-rebreather, [he/she] did not tolerate this, we tried BiPAP [Bilevel Positive Airway Pressure], titrating the settings, [he/she] did marginally better with this. We were able to sit the patient up, get [him/her] onto a nitroglycerin infusion to help with [his/her] hypertensive emergency and the patient is doing better ...will arrange for emergent dialysis to help reduce [his/her] volume overload which is causing severe shortness of breath and hypoxic respiratory failure. At present time, we have been able to avoid intubation secondary to the use of BiPAP. Patient is maintaining [his/her] own airway at present time but is critically ill. [His/Her] gastroparesis appears to be acting up as well...ED Admit to Inpatient...The primary encounter diagnosis was Hypertensive emergency. Diagnosis of Acute respiratory failure with hypoxia...Other hypervolemia, End stage renal disease on dialysis, Gastroparesis, and Hyperglycemia were also pertinent to this visit..."

6. An interview on 2/3/20 at approximately 4:50 p.m. with A6 (Emergency Department Nurse Manager at Facility #1), he/she verified that the complete emergency department medical record was provided for Patient #2.

7. An interview on 2/4/20 at 10:19 a.m. with A6, he/she verified that Patient #2 had an acuity level of 3 at point of triage in the emergency department.

8. An interview on 2/4/20 at 11:07 a.m. with A7 (Interim Emergency Department Director), he/she verified that Patient #2 had a physician order for Clonidine 0.1 milligrams tablet by mouth STAT ordered on 12/13/19 at 0534 hours, but the medication was not administered as ordered.
A7 verified that Patient #2's had a blood glucose of 649, the medical record lacked documentation of physician order to treat the elevated blood glucose and/or a reassessment of the blood glucose. A7 verified that Patient #2's vital signs were not documented as reassessed per policy every 30 minutes. A7 verified that if a patient is on pain management the patient will not be given narcotics unless there is an acute finding of pain and/or trauma.

9. An interview on 2/4/20 at 11:18 a.m. with A3 (Chief Quality Officer), he/she verified that it seems like part of the medical record for Patient #2 was missing by reviewing the medical record and observing the lack of documentation.

10. An interview on 2/4/20 at 11:22 a.m. with A6, he/she verified the medical record information for Patient #2.

11. An interview on 2/4/20 at 11:25 a.m. with A7, he/she verified that MD2 (Doctor of Medicine/Emergency Medicine) lacked documentation in Patient #2's medical record of his/her rationale for discharging Patient #2 to home with the lack of treatment to his/her blood glucose of 649 and elevated blood pressures.

12. An interview on 2/4/20 at 11:37 a.m. with A6 and A7, they verified that Patient #2's medical record lacked documentation of a reassessment of nausea after Zofran and Pepcid was administered and/or prior to Patient #2's discharge.

13. An interview on 2/4/20 at 3:12 p.m. with A8 (Chief Medical Officer), he/she verified that clonidine was ordered but not administered to Patient #2. A8 verified that the documentation in Patient #2's medical record was unclear, it looked like some communication occurred, but was not documented in the medical record.

14. An interview on 2/4/20 at 3:19 p.m. with A8 and A10 (Utilization Review Physician/Physician Advisor), they verified that by review of Patient #2's medical record they cannot tell if appropriate treatment was completed for Patient #2 due to lack of documentation by MD2. They verified that MD1 (Doctor of Medicine/Emergency Medicine) cared for Patient #2 on 12/13/19 until 0600 hours and then care was transferred to MD2.. A8 and A10 verified that after 0600 hours on 12/13/19, it is like part of the medical record for Patient #2 is not there. They also verified the lack of documentation of reasoning for discharging Patient #2 and the lack of treatment in the medical record.

15. An interview on 2/4/20 at 5:15 p.m. with A10, he/she verified that Patient #2 had a blood glucose of 649 and he/she would have admitted the patient based on his/her lab blood glucose of 649 alone and treated the elevated blood glucose. A10 verified that Patient #2 had gastroparesis which causes his/her nausea/vomiting. A10 verified that the last two hours that Patient #2 was in the emergency department there was lack of documentation from MD2. A10 also verified that the patient was administered nitroglycerin and that there should have been documentation of the patient's blood pressure prior to and after each administration of the nitroglycerin. A10 verified that there was a lack of documentation of Patient #2's vitals and that there should be more frequent documentation of vitals in the medical record for the patient.