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Based on a review of policy/procedures, review of medical record documentation, and staff interviews, the hospital failed to enforce policies/procedures requiring staff to provide a proper medical screening exam for 1 of 28 patients who presented to the hospital's Emergency Department (ED) requesting emergency care for 1 of 28 sampled patient records reviewed between 5/1/14 through 10/20/14(Patient #5) . Patient #5 presented to the hospital on 9/7/14 seeking medical care for complaints of back pain staring on 9/1/14 with the first visit to the ED. The patient's came to the ED for the 5th time since 9/1/14.

Failure to provide a complete medical screening exam in the ED for patients requesting emergency care resulted in staff providing inadequate or ineffective care and support to treat the EMC and resulted in the patient's condition worsening.

Findings include:

1. Review of the hospital policy/procedure titled "Transfer and Emergency Examination Policy," reviewed 8/2011, revealed in part... "2. Definition of Emergency Medical Condition (EMC). a. Medical/Psychiatric is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: ii. Serious impairment to bodily functions.

Definition of a MSE. 6. An MSE is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an EMC exists. The MSE must be provided by Qualified Medical Personnel, as defined by Administrative Policy and Procedure No. 141, entitled "Medical Screening Exam Providers"."

2. Review of Patient #5's ED medical record dated 9/7/14 at 4:53 PM revealed the following documentation.

History of Present Illness:

Patient #5 presented to the ED on 9/7/14 at 4:53 PM complaining of back pain/ sciatica starting 2 weeks ago. The pain was abrupt during onset and has been constant. The pain is relieved by taking prescription medications. Nothing causes it to get worse. It is described as being severe and radiating to the right hip and thigh. The quality is noted to be sharp. No bladder or bowel dysfunction. No sensory or motor loss. Similar symptoms with previous ED visits.

Physical Exam:

Back has moderate vertebral point tenderness over the mid and lower lumbar spine. Moderate soft tissue tenderness in the right and lower lumbar area. No limitation in range of motion. Patient has mildly altered mental status, is confused and forgetful. Patient is slow to respond.

Lab results:

Patient's potassium level 3.3 MEQ/L (3.5 to 5.1 normal), white blood cells (WBC) 30.7 (4.9 to 10.0 normal) and platelets 599 (145 to 375 normal).

Progress and Procedures:

Practitioner A, Physician's Assistant (PA) documented at 6:45 PM; Discussed apparent altered mental status with patient. Patient denies using any illegal drugs or any narcotics other than her Fentanyl patch (pain medication) which is currently applied. The patient denies being diaphoretic (sweating) although it is obvious when doing the physical exam, Patient is told she will not be given any narcotics during this visit because she has had numerous orders for them and not filled the orders. Discussed the high WBC's with the patient and instructed her this is likely due to the recent prednisone she is taking. Discussed importance of following up with her primary care provider tomorrow as scheduled to resolve the sciatica pain and not just cover up the pain with medications. At this time the patient is stable and wishes to go home.

Disposition:

Discharge home in unchanged condition. Condition stable.

Medical record co-signed by Practitioner B, Medical Doctor (MD) at 7:51 PM agreeing with Practitioner A's findings and plan.

During an interview on 10/20/14 at 3:00 PM, Practitioner A, PA, stated Patient #5 presented the ED on 9/7/2014 complaining of back pain and sciatica. A physical exam showed bilateral lower extremity pain that was worse with straight leg raises. The patient groaned in pain during the assessment. The patient was not able to focus during the evaluation and did not make sense at times. The patient was not able to remember if she obtained the medication ordered from the previous visit. I thought the patient might be drug seeking and called the physician monitoring program (PMP) to see if she had obtained previous narcotic prescriptions, which she had not.

Practitioner A said the patient's WBC's were 30.7, really high. Practitioner A consulted with Practitioner B about the WBC's being so high. Practitioner B said the patient had just started prednisone a couple days earlier and this would cause the elevation in the WBC's. Practitioner A also discussed a possible infection causing the WBC elevation with Practitioner B. Practitioner A ordered and obtained a urine sample for testing of a possible urinary tract infection. Practitioner A said a couple days later she questioned herself if she should have completed further testing for infection. The urine test was ordered for a culture, so the results were not available for 2 days.

During an interview on 10/20/14 at 3:20 PM, Practitioner B stated he consulted with Practitioner A about Patient #5's ED visit on 9/7/14. Practitioner B said he did not complete a physical exam for the patient. Practitioner B said he did not recall Practitioner A commenting on the patient's mentation. Practitioner B said they discussed the elevated WBC's and platelets. He did not know what caused the platelet elevation, but the elevation WBC's was because of the recent use of prednisone.

3. Review of Patient #5' ED record from 9/8/14 showed she presented to the ED at 6:35 PM with a complaint of flank pain. Practitioner C, PA noted the patient had presented to the ED on 9/1, 9/2, 9/4 and 9/7 for the same complaint. On 9/7 the lab test showed WBC's elevated at 30.7. Practitioner C ordered a Computed Tomography (CT), form of x-ray to identify any structural problems. Practitioner C also repeated lab tests that showed WBC's 39.5 and platelets 748. Practitioner C consulted with Practitioner D, MD and determined further testing was needed to determine the cause of the elevated WBC's. Practitioner C documented she went to the patient's room to discuss the further testing and the patient had signed out against medical advice (AMA). Practitioner C went to the parking lot and did not see the patient. Practitioner C called the patient but the patient did not answer. The patient's mailbox was full, so Practitioner C could not leave a message. Practitioner C faxed the information to the patient's primary care provider so they could follow up if seeing the patient the next day.

During an interview on 10/20/14 at 4:35 PM, Practitioner C stated she was going to order more testing for Patient #5 after the WBC test result showed an elevation at 39.5. The day before on 9/7 the patient's WBC's were 30.7. Practitioner C said she wanted to test the patient further for possible sepsis (infection).

During an interview on 10/21/14 at 7:15 AM, Practitioner D, MD stated he consulted with Practitioner C on the patient's ED visit 9/8. The patient's WBC's were elevated and he wanted a CT with contrast (dye) to identify any problems. When patients are on prednisone, this anti-inflammatory medication usually does not cause such a severe elevation of WBC's. Practitioner D said he would probably have admitted the patient for further testing with the WBC's being elevated both on 9/7 and 9/8, but the patient signed out AMA before this could occur.

The hospital staff failed to follow their policies during the 9/7/14 ED visit by providing a complete medical screen exam for Patient #5. When identifying the patient's WBC's were elevated so high and the patient had a change in mentation, staff should have provided further testing to determine the cause of high elevation of the patient's WBC's.

Refer to A 2406 for additional information.

Based on a review of policy/procedures, review of medical record documentation, and interview with staff, the hospital failed to provide an appropriate medical screening exam for 1 of 28 sampled patients who presented to the hospital's Emergency Department (ED) requesting emergency care between 5/1/14 through 10/20/14 (Patient #5).

Patient #5 presented to the hospital's ED 7 times between 9/1/14 and 9/9/14. The patient came to the ED on 9/1/14, 9/2/14, 9/4/14, and 9/5/14 prior to presenting to the hospital's ED, for the 5th time since 9/1/14, on 9/7/14 and for the 7th time on 9/9/14 seeking medical care for complaints of back pain starting on 9/1/14 with the patient's first visit to the ED. Patient #5 presented to the hospital's ED for the 6th time on 9/8/14 but left Against Medical Advice (AMA) prior to the completion of testing.

Failure to provide a complete medical screening exam in the ED for patients requesting emergency care resulted in staff providing inadequate or ineffective care and support to treat Patient #5's Emergency Medical Condition (EMC) and resulted in the patient's condition worsening.

Findings include:

1. Review of the hospital policy/procedure titled "Transfer and Emergency Examination Policy," reviewed 8/2011, revealed in part... "2. Definition of Emergency Medical Condition (EMC). a. Medical/Psychiatric is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: ii. Serious impairment to bodily functions.

Definition of a MSE. "6. An MSE is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an EMC exists. The MSE must be provided by Qualified Medical Personnel, as defined by Administrative Policy and Procedure No. 141, entitled "Medical Screening Exam Providers"."

2. Review of Patient #5's ED medical record dated 9/7/14 at 4:53 PM revealed the following documentation.

History of Present Illness:

Patient #5 presented to the ED on 9/7/14 at 4:53 PM complaining of back pain and sciatica starting 2 weeks ago. The pain was abrupt during onset and has been constant. The pain is relieved by taking prescription medications. Nothing causes it to get worse. It is described as being severe and radiating to the right hip and thigh. The quality is noted to be sharp. No bladder or bowel dysfunction. No sensory or motor loss. The patient had similar symptoms with previous ED visits on 9/1/14, 9/2/14, and 9/4/14.

Physical Exam:

Back has moderate vertebral point tenderness over the mid and lower lumbar spine. Moderate soft tissue tenderness in the right and lower lumbar area. No limitation in range of motion. Patient has mildly altered mental status, is confused and forgetful. Patient is slow to respond.

Lab results:

Patient's potassium level 3.3 MEQ/L (3.5 to 5.1 normal), white blood cells (WBC) 30.7 (4.9 to 10.0 normal) and platelets 599 (145 to 375 normal).

Progress and Procedures:

Practitioner A, Physician Assistant (PA), documented the following at 6:45 PM. Discussed apparent altered mental status with patient. Patient denies using any illegal drugs or any narcotics other than her Fentanyl patch (pain medication) which is currently applied. The patient denies being diaphoretic (sweating) although it is obvious when doing the physical exam, Patient is told she will not be given any narcotics during this visit because she has had numerous orders for them and not filled the orders. Discussed the high WBC's with the patient and instructed her this is likely due to the recent prednisone she is taking. Discussed importance of following up with her primary care provider tomorrow as scheduled to resolve the sciatica pain and not just cover up the pain with medications. At this time the patient is stable and wishes to go home.

Disposition:

Discharge home in unchanged condition. Condition stable.

The patient's medical record was co-signed by Practitioner B, a Medical Doctor (MD) at 7:51 PM agreeing with Practitioner A's findings and plan.

During an interview on 10/20/14 at 3:00 PM, Practitioner A, PA, stated Patient #5 presented the ED on 9/7/2014 complaining of back pain and sciatica. A physical exam showed bilateral lower extremity pain that was worse with straight leg raises. The patient groaned in pain during the assessment. The patient was not able to focus during the evaluation and did not make sense at times. The patient was not able to remember if she obtained the medication ordered from the previous visit. I thought the patient might be drug seeking and called the physician monitoring program (PMP) to see if she had obtained previous narcotic prescriptions, which she had not.

Practitioner A said the patient's WBC's were 30.7, really high. Practitioner A consulted with Practitioner B about the WBC's being so high. Practitioner B said the patient had just started prednisone a couple days earlier and this would cause the elevation in the WBC's. Practitioner A also discussed a possible infection causing the WBC elevation with Practitioner B. Practitioner A ordered and obtained a urine sample for testing of a possible urinary tract infection (UTI). Practitioner A said a couple days later she questioned herself if she should have completed further testing for infection. The urine test was ordered for a culture, so the results were not available for 2 days.

During an interview on 10/20/14 at 3:20 PM, Practitioner B stated he consulted with Practitioner A about Patient #5's ED visit on 9/7/14. Practitioner B said he did not complete a physical exam for the patient. Practitioner B said he did not recall Practitioner A commenting on the patient's mentation. Practitioner B said they discussed the elevated WBC's and platelets. He did not know what caused the platelet elevation, but the elevation WBC's was because of the recent use of prednisone.

3. Review of Patient #5's ED record from 9/8/14 showed she presented to the ED at 6:35 PM with a complaint of flank pain. Practitioner C, PA noted the patient had presented to the ED on 9/1, 9/2, 9/4 and 9/7 for the same reason. On 9/7 the lab test showed WBC's elevated at 30.7. Practitioner C ordered a Computed Tomography (CT), a form of x-ray to identify any structural problems. Practitioner C also repeated lab tests that showed WBC's were 39.5 and platelets were 748. Practitioner C consulted with Practitioner D, MD and determined further testing was needed to determine the cause of the elevated WBC's. Practitioner C documented she went to the patient's room to discuss the further testing and the patient had signed out against medical advice (AMA). Practitioner C went to the parking lot and did not see the patient. Practitioner C called the patient but the patient did not answer. The patient's mailbox was full, so Practitioner C could not leave a message. Practitioner C faxed the information to the patient's primary care provider so they could follow up if seeing the patient the next day.

During an interview on 10/20/14 at 4:35 PM, Practitioner C stated she was going to order more testing for Patient #5 after the WBC test result showed an elevation at 39.5. The day before on 9/7 the patient's WBC's were 30.7. Practitioner C said she wanted to test the patient further for possible sepsis (infection).

During an interview on 10/21/14 at 7:15 AM, Practitioner D, MD, stated he consulted with Practitioner C on the patient's ED visit 9/8. The patient's WBC's were elevated and he wanted a CT with contrast (dye) to identify any problems. When patients are on prednisone, this anti-inflammatory medication usually does not cause such a severe elevation of WBC's. Practitioner D said he would probably have admitted the patient for further testing with the WBC's being elevated both on 9/7 and 9/8, but the patient signed out AMA before this could occur.

4. Review of Patient #5's ED record from 9/9/14 revealed the patient presented with a complaint of back and right leg pain. Practitioner B evaluated the patient and prescribed an antibiotic for a UTI. Practitioner B discharged the patient in stable condition. The discharge decision was based on the following: the patient's condition is stable, patient is ambulatory, drinking fluids and pain is controlled. Diagnoses were UTI and right lumbar radiculopathy clinically improved and almost normal.

During an interview on 10/21/14 at 8:10 AM, Practitioner B stated if he reviewed Patient #5's ED record from 9/8/14, he would have just looked at the CT scan results. The patient presented with musculoskeletal pain and he would have had no reason to look at the blood work labs. Practitioner B also stated he did not review the 9/8 practitioner's discharge note to identify the treatment they were providing the patient. Practitioner B said if he would have reviewed the labs, he would have completed further testing to determine what caused the elevation in WBC's. Practitioner B said this patient's treatment might have slipped through the cracks.

5. Review of Patient #5's clinic record from 9/9/14 revealed a nursing note dated 9/11/14 stating phone call received from a physician requesting clinic records because the patient expired overnight and the body is being transported for autopsy and toxicology.

The hospital staff failed to provide a complete MSE during the 9/7 and 9/9/14 ED visits by not providing further testing when identifying the patient's WBC's and platelets were elevated so high.