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Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital's emergency department to determine whether an emergency medical condition existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1's hypotension (low blood pressure) and hypoxia (low blood oxygen level) was not fully addressed during their ED visit.


The findings were:

The complete medical record of Patient #1's ED visit at Hospital A on 12/29/22 was reviewed. It was noted:

Patient #1 was brought to the ED by ambulance after a witnessed seizure-like activity at the group home. The patient is non-verbal with cognitive impartment but presented with "abnormally grimacing and clenching fists." During the patient's ED visit, it was noted that the patient had abnormal vital signs as evidenced by low blood pressure, as low as 55/29; low blood oxygen levels, as low as 89%; and the chest x-ray results revealed possible pneumonia. The patient's blood labs (completed blood count, comprehensive metabolic panel, influenza, and COVID test) were all negative. The patient was not provided with further evaluation and treatment of their hypoxia, hypotension, and pneumonia; but was instead discharged to home. The patient and caregiver were given written discharge instruction on seizure care but no written discharge instruction for hypoxia care, hypotension care, or pneumonia care. The patient was seen at a different ED approximately 10 hours later due to worsening symptoms and was admitted for altered mental status and sepsis.

1. ED Provider Note: Chief Complaint: Seizures. Patient "is a 55 y.o. [year old] female who presents to the ED via EMS with c/o Seizures onset x PTA [post-traumatic amnesia?]. Pt is accompanied by sister/guardian who states the pt collapsed and 'shaking' on the floor of the shower at her group home for 15 mins and could not get up, then care giver contacted 911. EMS upon arrival states she has exhibited seizure-like sxs [symptoms]. Pt is nonverbal baseline and is abnormally grimacing and clenching fists ..."

2. Vital Signs (Patient Care Timeline)
1640: Temperature 96.5F; Pulse 100; Resp 20, BP 104/62; SpO2 94%
1730: Pulse 94; Resp 14; BP 92/55
1900: Pulse 81; Resp 16; SpO2 92%
1907: Pulse 86; Resp 17; SpO2 89%; BP 55/29
1920: Pulse 92; Resp 16; SpO2 92%; BP 110/91
1925: Pulse 91; Resp 16; SpO2 91%; BP 107/87

3. Chest X-ray radiologist report
"Impression: ...Hyperexpanded lungs. Moderate bilateral perihilar and bibasilar opacification which probably represents pneumonia or aspiration..."

4. Written discharge instruction handout had information on seizure care but did not contain any information on pneumonia care.


The surveyor interviewed Staff #6 (the ER physician that took care of Patient #1 on 12/29/22 at Hospital A) via email on 12/18/23. Staff #6 stated that there was no need for transfer or that the patient required a higher level of care that was provided in the ED.


The complete medical record of Patient #1's ED visit at Hospital B on 12/30/22 was reviewed, it was noted:
Patient #1 was brought to the ED of Hospital B by EMS [Emergency Medical Services] due to " ... HR [heart rate] was in the 90s and SpO2 was 92% but went into 80s.." The patient's initial triage vital signs showed a high blood pressure of 151/121 and a respiratory rate of 40. The patient's white blood cell count was slightly elevated and blood gases were abnormal. The patient's CT scan of their chest revealed "Diffuse consolidation in the left lower lobe and posterior lingula with additional areas of infiltrate throughout the left upper lobe and right lower lobe suspicious for multifocal pneumonia. Trace left pleural effusion." Patient #1 was admitted to Hospital B for pneumonia and remain at the hospital for 27 days.