HospitalInspections.org

Based on interview, record review, review of video footage, and review of the facility's policies, the facility failed to stabilize one (1) of 23 sampled patients, Patient (P) 13. P13 presented to the ED for stabilizing treatment on 08/29/2025 and was discharged to home approximately 5 hours later. P13 was seen and admitted to Facility #2 the next morning for stabilizing treatment..

The findings include :


Cross Refer to A2407.

Based on interview, review of video footage, record review, review of the website mapquest.com, and review of the facility's policies, the facility failed to stabilize one (1) of 23 sampled patients, Patient (P) 13 prior to discharge.

The findings include:

Review of Facility #1's policy EMTALA-Stabilization, approved 08/19/2005 and reviewed 10/14/2008, revealed it was the policy of Facility #1 that patients being transferred or discharged must be first stabilized as required by Federal and state law. Further review of this policy revealed an individual was considered stable for discharge when within reasonable clinical confidence, it was determined the individual has reached the point where his or her continued care, including diagnostic work up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual was given a plan for appropriate follow-up care with the discharge instructions.

Review of the Facility #1's policy entitled Triage Assessment and Reassessment, adopted 10/2024, revealed this policy applied to all clinical staff in the Emergency Department and the purpose was to ensure timely and accurate triage, assessment, and reassessment of patients to prioritize care and manage resources effectively based on the Emergency Severity Index (ESI).

Review of camera footage from 08/29/2025 from 4:53 PM revealed P13 was brought into Facility #1's ED on a stretcher by ambulance and transferred to an ED bed.

Review of P13's medical record revealed P13 arrived at Facility #1 by Ambulance on 08/29/2025 at 4:53 PM, presenting with a headache. It was found upon triage that P13's oxygen saturation level was low. P13 had a triage assessment performed by the nurse on 08/29/2025 at 5:09 PM. This assessment revealed that P13 had a pulse oximetry level of 72% on room air and had a respiratory rate of 26 breaths per minute with shallow, spontaneous, non-labored breathing. Labs including the ABG revealed the patient had an elevated pCO2 [59 - range 35 to 45 mm Hg], low pO2 [38 - range 83 to 108 mm Hg], high HCO3 [32.6 - range 21 to 28 mm Hg], high total CO2 [34.40 - range 21 to 32 mmol/L], High base excess [5 - range -2 to -3 mmol/L], and low oxygen saturations [69 - range 95 to 98%]. MD2 was notified of these abnormal lab results on 08/29/2025 at 5:58 PM. P13 was assessed by MD3 at 7:32 PM. The results from the EKG interpreted at 7:37 PM on 08/29/2025 revealed that P13 was in sinus tachycardia with a rate of 106 beats per minute with no ST or T-wave abnormalities.

On 08/29/2025 at 8:31 PM the chest x-ray revealed that the radiologist's impression was that P13 had bronchitis and low lung volumes with streaky bibasilar atelectasis. The radiology report revealed the patient's lungs were mildly hypo inflated with associated crowding of the central broncho vascular structures and streaky scattered atelectasis at the lung bases. The report concluded there may be some degree of peri bronchial cuffing which could reflect bronchitis. At 8:51 PM on 08/29/2025 a DuoNeb® was administered to the patient and P13 was discharged home on 08/29/2025 at 10:20 PM. The discharge assessment revealed that P13's pulse oximetry was 82% on room air with a respiratory rate of 18 breaths per minute. Review of P13's medical record revealed only two sets of vital signs were recorded for the patient: those upon admission and discharge.

In an interview on 09/29/2025 at 5:13 PM Registered Nurse (RN)1 stated she did remember P13. RN1 stated P13 was overweight and came to the ED for a headache and the patient's oxygen saturation kept dropping despite being on oxygen. RN1 stated MD3 came in and turned off P13's oxygen. RN1 stated she remembered asking MD3 if he wanted a repeat ABG when MD3 stated that P13 was ready for discharge. RN1 stated the physician did not want the ABG repeated and RN1 voiced concern to the doctor about him wanting to discharge P13 with the oxygen saturations being so low. MD3 told RN1 that P13 was obese, had sleep apnea and needed a sleep study. RN1 stated she was unsure how much longer P13 remained in the ED after MD3 turned off the patient's oxygen but stated P13 was there long enough that the patient's oxygen saturation dropped low again. RN1 stated she contacted MD3 to ask if he wanted the oxygen turned back on and MD3 stated no. MD3 stated once again that P13 had sleep apnea and needed a sleep study. RN1 said that P13 was discharged. RN1 stated the physicians decided when patients were stable enough to discharge. RN1 stated that she did not feel that P13 was stabilized prior to discharge, and she felt P13 would have benefited from being admitted to Facility #1.

In an interview on 09/29/2025 at 5:32 PM with Respiratory Therapist (RT)1 she stated she remembered P13 and stated the patient did not complain of SOA [shortness of air], but the patient's oxygen saturation was 71% and the pO2 was critically low. RT1 stated oxygen was administered to P13 via nasal cannula. RT1 stated that P13 appeared hypoxic and short of air but did not seem confused due to the lowered oxygen saturations.

In an interview on 09/29/2025 at 5:42 AM RN3 stated she was there for the initial triage and treatment of P13. RN3 stated she remembered P13 came to the ED with a headache and ED staff got the patient's vital signs and noted that P13's oxygen saturation was low on room air. RN3 stated she moved P13 to a room so she could hook P13 up to the telemetry monitor to continuously monitor the oxygen saturation and other vital signs. RN3 stated due to the low oxygen saturation P13 was placed on oxygen which brought the saturation up to an acceptable oxygen saturation level (greater or equal to 90%). RN3 stated P13 did not come in complaining of SOA and stated there were no visual clues that P13 was in respiratory distress. RN3 stated P13 did not appear confused or cyanotic. RN3 went on to say when she took P13's vital signs the first time, P13's oxygen saturation was so low that she thought the machine was not working and even tried a second machine before placing P13 on the telemetry monitor.

In an interview on 09/30/2025 at 9:42 AM RN2 stated he was the nurse that discharged P13 and was there when two other nurses and a RT told the doctor that P13 desaturated on room air. RN2 stated the physician blew them off and stated that P13 had sleep apnea and that was causing the patient's oxygen saturations to drop. The nurses and RT told MD3 that P13 was awake and playing on a phone when the oxygen saturations dropped. One nurse, RN2 stated, advocated for P13 to go home with supplemental oxygen and MD3 did not want to do that either. RN2 stated he spoke with P13 when the patient was signing the discharge paperwork. According to RN2, the patient did not appear hypoxic or dyspneic and P13's oxygen saturation was 86-88% on room air.

In an interview on 09/30/2025 at 10:07 AM, P13 stated she went to Facility #1 on 08/29/2025 with a migraine that had lasted two days and because she "felt out of character and weird". P13 stated she called an ambulance to come and take her to the hospital and the ambulance took her to the closest hospital, Facility #1. P13 stated her oxygen was low in the ambulance and the ED nurse confirmed this once she was at Facility #1. P13 stated her pulse oxygen level was 74% and the nurse placed her on oxygen. P13 stated hospital staff drew labs including an ABG. P13 stated MD3 came into her room and took the oxygen off and told P13 that he was going to run a few more tests because the ABG results were bad. According to P13, hospital staff tried multiple times to get a second ABG but could not because she was dehydrated and MD3 canceled the order for the second ABG. P13 stated she was given a breathing treatment and wondered why she was not admitted to the hospital. P13 stated the alarms on the telemetry monitor kept alarming because of the oxygen desaturation. P13 stated she had to "really work on her breathing" to keep the alarms from sounding. P13 stated the MD discharged her home on antibiotics. P13 stated she went home and tried to sleep but at 7:00 AM she asked her husband to take her to Facility #2. P13 stated at Facility #2 she was immediately taken back to a room in the ED where it was found that her oxygen was still extremely low, they did tests and admitted her to Facility #2 within the hour with diagnoses of pneumonia in both lungs and acute respiratory failure. P13 stated after discharge she felt that she was discriminated against at Facility #1 for being obese and filed a grievance with Facility #1. P13 stated that when she first arrived at Facility #1 her husband was not with her, but he was in the room when the MD turned off the oxygen and wanted to discharge her.

In an interview on 09/30/2025 at 11:10 AM the Hospital Medical Director (HMD) stated it was her expectation that a patient's oxygen saturation should be stabilized prior to a patient being discharged home. The HMD stated P13 should have never been discharged home with a low oxygen saturation level of 82% if the patient had a chronic issue. The HMD stated that if the nurses taking care of P13 were concerned that P13 was being unsafely discharged or treated they could have called the ED Medical Director or herself. According to the HMD, anyone that observed an issue with a patient's treatment and had voiced this to the provider without being acknowledged could ask others to intervene.

In an interview on 09/30/2025 at 11:25 AM MD2 stated that he did not remember seeing P13 despite his name being in the patient's medical chart. MD2 stated that he would not discharge a patient with an oxygen saturation of 82%.

In an interview on 09/30/2025 at 11:45 AM, MD3 stated P13 was morbidly obese, had a previous diagnosis of sleep apnea and already had an appointment for a sleep study. MD3 stated P13 was not compliant with wearing a CPAP at home and that was why the patient's oxygen was low. MD3 said he monitored P13 multiple times during the ED visit and P13 did not appear in any distress other than her headache. MD3 stated he did not want to start P13 on oxygen because he was concerned the increased oxygen would cause the patient to retain CO2, become hyper carbic and die. MD3 stated he elected not to admit and monitor P13 to Facility #1 because she was completely stable. MD3 stated the patient's chest x-ray showed no issues, and exams/lungs were normal. MD3 stated the patient's bronchitis was the cause of P13's headache and stated the headache was caused from sleep apnea and not from low oxygenation saturation.

In an interview on 10/30/2025 at 11:55 AM the Regional ED Medical Director (REDMD) stated she had received a peer-to-peer review for MD3 regarding this complaint after P13 called in a grievance. The REDMD stated after reviewing P13's medical chart she had issues with staff only charting vital signs twice (admission and discharge) but stated there were no notes in the chart stating that there were any issues with the patient's care voiced by nursing. REDMD stated when P13 called Risk Management the patient reported she was diagnosed with pneumonia at Facility #2, but REDMD stated there was not any evidence of this in P13's chest x-ray at Facility #1. The REDMD stated when she spoke with MD3 he stated the results of the ABG were skewed, mixed arterial and venous blood and that P13 had oxygen saturation fluctuations due to hypoventilation. REDMD stated the investigation of this grievance was still in process. The REDMD stated she would want a patient to have an oxygen saturation of 90% or greater prior to discharge and P13's documented pulse oxygenation value upon discharge was documented at 82%.

In an interview on 09/30/2025 at 1:54 PM the Medical Surgical Director (MSD) stated she oversaw the medical surgical floor at Facility #1. The MSD stated that she would not have felt comfortable sending a patient home with an oxygen saturation of 82% and would have kept this patient.

In a phone interview on 09/30/2025 at 5:57 PM, F1 stated he was the husband of P13 and stated that he came to Facility #1 after getting off work. F1 stated at the time he arrived P13 was in a room on a stretcher hooked up to a monitor and wearing oxygen. F1 stated a doctor came into the room turned off the oxygen and said P13 had a slight case of bronchitis and gave her a prescription for antibiotics. F1 stated the doctor (MD3) told P13 that she was fat, had sleep apnea, needed to lose weight and needed to have a sleep study. F1 stated when the doctor turned off the oxygen P13's oxygen dropped in the 70s and 80s and the patient would have to continually take deep breaths to get the oxygen saturation to a normal level. F1 stated the nurses questioned the doctor about sending P13 home, but the doctor repeated that P13 was overweight and had sleep apnea. F1 stated it was around 10:30 PM when P13 was discharged home. F1 said around 7:00 AM the next morning, he took P13 to Facility #2 where she was immediately taken to a room in the ED, and it was found that P13's oxygen saturation was 74%. F1 stated P13 was admitted to the Facility #2 before noon on 08/30/2025 with pneumonia in both lungs and acute respiratory failure.

Review of mapquest.com indicates the approximate distance between Facility #1 and Facility #2 is 71 miles (a 1 hour and 30-minute drive).

In an interview on 10/01/2025 at 1:36 PM the Director of Quality and Infection Prevention (DQIP) stated P13's grievance came to her from Risk Management Compliance. The DQIP stated she began the investigation by initiating a peer-to-peer review of MD3, the treating physician. The DQIP stated this review was being done by the HMD. The DQIP stated the investigation was still ongoing but there had not been any changes to existing ED policies and no new policies had resulted from this incident and investigation. The DQIP stated P13 filed a complaint stating she felt like the doctor that treated her did not listen to her concerns and discriminated against her because she was obese. The DQIP stated she would have expected that nursing staff should have documented any concerns they had about discharging P13 and who they spoke to about those concerns in P13's medical chart.

In an interview on 10/01/2025 at 5:13 PM MD4, who was the physician that treated P13 at Facility #2, stated that P13 was placed on a CPAP and had a CT of her lungs done to make sure that she did not have a pulmonary embolism (PE). MD4 stated that P13 did not have a PE but the chest x-ray showed mild opacities that were indicative of pneumonia. MD4 stated P13 was on 5 liters of oxygen via nasal cannula when MD4 saw the patient. MD4 stated P13's BMP was normal, and the patient was not tachycardic (heart rate of 97 and respiratory rate 16). MD4 stated P13 did not appear to be in respiratory distress despite having an ABG result of PPO2 of 42. MD4 stated P13's oxygen saturation was 82% on room air in the ED upon arrival. MD4 stated this was not a normal oxygen saturation and MD4 would not have discharged a patient with an oxygen saturation this low even if the patient had sleep apnea. MD4 stated that P13 was placed on antibiotics, and it was determined that P13's SOA was from pneumonia and atelectasis. According to MD4, P13's SOA was not a result of sleep apnea, and this was not the cause of the patient's low oxygen saturation.

In an interview on 10/02/2025 at 8:37 AM with the Director of Risk Compliance (DRC) stated she was made aware of the care P13 received and the patient's feelings that MD3 had discriminated against her for being an obese patient when P13 reported a grievance on 09/15/2025. The DRC said that P13 stated she did not feel ready to go home when MD3 discharged her. P13 told the DRC she went home and was unable to sleep so her husband took her to Facility #2 the following morning. The DRC stated when a grievance was made against Facility #1 their process was to investigate who was involved in the complaint and in this case, it was a provider-based complaint, so they looked at the provider involved. The DRC stated she did know that P13 had low oxygen saturation in the ambulance ride to the hospital. The DRC stated because the complaint was directed at the provider, she passed the grievance to the Director of Quality and Infection Prevention (DQIP) who initiated a peer review process for MD3 which was conducted by the Regional ED Director who was also a physician. The DRC stated she also talked with the ED Nursing Director and stated the ED Nursing Director was working in the ED on the day the incident occurred but did not remember any nursing staff saying anything about P13 having low oxygen saturations or not being stable enough to go home. The DRC explained the facility had a "Stop the Line" policy that instructed nursing staff how to go up the chain of command if they felt the care being provided was in question. The DRC stated as an outcome of this incident she felt staff should be re-educated on the "Stop the Line" policy.

The CNO/CEO stated in interview on 10/02/2025 at 8:50 AM she was not familiar with the incident and only knew what she had gleaned from this investigation. The CNO/CEO stated she would not feel comfortable discharging a patient home with an oxygen saturation of 82% on room air. The CNO/CEO stated it was her expectation that nursing staff chart vital signs throughout the patient's stay in the ED and it was unacceptable that there were only two sets of vital signs charted for P13 despite her being there approximately 5.5 hours. (There were only admission and discharge vital signs charted for P13). The CNO/CEO stated that based on the ESI level there was a frequency for the patient's vital signs and staff should follow those recommendations and chart them accordingly. The CNO/CEO stated as part of the investigation for the grievance there would be a peer-to-peer review of MD3, and that process involved another physician asking questions about why they did what they did. The CNO/CEO stated after the review if the provider was found negligent, they could be placed on a performance improvement plan or in severe cases lose their privileges to practice at the facility. The CNO/CEO stated the investigation was still in progress and no rulings had come from the peer-to-peer review.