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Based on staff interview and review of clinical records, policy, procedures, facility documentation and Emergency Department (ED) logs it was determined the facility failed to comply with 42 CFR 489.24 related to failure to ensure a patient was stabilized prior to discharge for one (#5) of 20 sampled patients.


Patient #5's clinical record dated 10/1/2011 revealed the patient was admitted to the ED via ambulance with a chief complaint of having had a seizure. The patient was seen and examined by the ED physician. Orders included Ativan, a loading dose of Cerebyx (anti seizure medication) and a intravenous fluid (IV) of 1000 milliliters of normal saline with vitamins (used to treat alcohol intoxication) at 125 milliliters (ml) per hour. At 3:42 a.m. the physician ordered that the patient may be discharged at 7:00 a.m. or earlier if a sober ride was available.

Review of facility documentation (investigation of the incident on 10/1/2011 related to patient #5) dated 10/1/11 at 7:10 a.m. and interview with the Risk Manager on 11/15/11 at approximately 4:50 p.m. revealed the patient was given a bus pass on discharge. He left the ED and went to the bus stop located on the campus but on city property. The patient reportedly fell from the curb and fell in front of a city bus and expired at the scene. Documentation (facility investigation of the incident related to patient #5) revealed the patient had hit the glass sliding doors on the way out of the ED and was wobbly.

Review of nursing documentation did not reveal evidence of the patient being assessed prior to discharge for the oxygen saturation on room air after the oxygen was discontinued (no time), the ability to eat or drink, the ability to ambulate or his mental and neurological status after being intoxicated and receiving Ativan and a loading dose of Cerebyx. There was no evidence the physician was notified that the patient refused discharged vital signs or the IV infusion was not infused as ordered. There was no documentation of how the patient left the ED or if a sober ride was available.

Policy and procedure "Patient Care Process" #100.185.74 effective 8/11 and "Emergency Department: Discharge" #09-03-004 effective 9/09 were not implemented by the nurse. There nurse did not follow policy and procedure for reassessment and discharge to determine if the patient remained stabilized and to alert the physician if not prior to discharge.

Refer to findings in Tag A2407.

Based on staff interview and review of policy, procedure, clinical records, and facility documentation(facility investigation) it was determined the facility failed to ensure a patient was stable prior to leaving the Emergency Department for 1 (#5) of 20 sampled patients. This practice does not ensure a patient is evaluated to ensure the patient is stable prior to discharge from the emergency department.

Findings include:

1. Patient #5 presented to the Emergency Department (ED) via ambulance on 10/1/11 at 12:35 a.m. with a chief complaint of a reported seizure and had not taken his seizures medications for seven months. The triage documentation noted a blood pressure of 99/61 and the patient was on 2 liters of oxygen via nasal cannula with a oxygenation level of 100%. The patient's identified problem included at risk for falls.

Review of the ambulance run sheet revealed a witnessed seizure. The patient was post postictal (it is during this period that the brain recovers from the trauma of a seizure) on arrival, confused, and verbally combative. The patient had been drinking.

Review of ED physician documentation dated 10/1/11 at 2:30 a.m. revealed the patient admitted to drinking and had stopped taking his seizure medications. The exam noted the patient had alcohol on his breath and the neurological exam was normal. Review of the ED physician reassessment dated 10/1/11 at 3:42 a.m. revealed the patient was resting comfortably and would be given a loading dose of IV Cerebyx.

Review of physician orders dated 10/1/11 at 2:50 a.m. instructed for seizure precautions, intravenous (IV) fluids of Normal Saline 1000 milliliters (ml) with multivitamins, thiamine, folic acid, and magnesium sulfate at 125 ml per hours for eight hours. The orders include Ativan (medication used to treat insomnia, acute seizures and for sedation)1 milligram (mg) times one, a blood alcohol level, other laboratory studies, a CT of the head with transportation as a stretcher, a Dilantin (anti-seizure medication)level, and a urine drug screen. Physician orders dated 10/1/11 at 3:39 a.m. instructed for Cerebyx (anti seizure medication)1000 milligrams (mg) one time. Physician order dated 10/1/11 at 3:41 a.m. instructed to discharge the patient home at 7:00 a.m.. The patient may be discharged home earlier if a sober ride is available.

Review of the initial nursing assessment dated 10/1/11 at 12:46 a.m. revealed the patient was alert and oriented to person, place, and time, cooperative, and appropriate. The patient was on a cardiac monitor
The patient stated a history of seizures, chest pain, and angina. Review of nursing documentation revealed the vital signs were stable at at 3:32 a.m. with 2 liters oxygen via nasal cannula with 100 % saturation. There was no evidence of any other assessment. The documentation at 5:44 a.m. noted no blood pressure was obtained, oxygen was administered at 2 liters via nasal cannula with a saturation level of 96%. There was no evidence of any other assessment.

Review of laboratory results showed a sub therapeutic dilantin level and a blood alcohol of 287 (normal blood alcohol level is 0-5). The urine drug screen was positive for opiates and benzodiazepines.

Review of the Medication Administration Record (MAR) indicated the Cerebyx was completed at 4:18 a.m. and the Ativan at 3:31 a.m. The IV infusion was documented as started at 3:32 a.m. and discontinued at 9:10 a.m. over two hours after the patient had left the facility. The documentation noted 1000 mls had infused. Based on the time the infusion was started and the patient discharged, the patient should have received approximately 300 mls.

Review of discharge instruction revealed they were signed by the patient and nurse. The nurse indicated the date and time was 10/1/11 at 6:42 p.m. The instruction included for alcohol intoxication to drink plenty of non alcoholic fluids and eat regular meals.

Review of nursing documentation did not reveal evidence of the patient being assessed prior to discharge for the oxygen saturation on room air after the oxygen was discontinued, the patient's ability to eat or drink, the ability to ambulate or his mental and neurological status after being intoxicated and receiving Ativan and a loading dose of Cerebyx. There was no evidence the physician was notified that the patient refused discharged vital signs or the IV infusion was not infused as ordered. There was no documentation of how the patient left the ED or if a sober ride was available as ordered.

Review of documentation (facility's investigation of incident on 10/1/2011 related to patient #5) dated 10/1/11 at 7:10 a.m. and interview with the Risk Manager on 11/15/11 at approximately 4:50 p.m. revealed the patient was given a bus pass on discharge. He left the ED and went to the bus stop located on the campus but on city property. The patient reportedly fell from the curb and fell in front of the city bus and expired at the scene.

Interview with the Risk Manager and Director of Patient Services on 11/16/11 at approximately 2:20 p.m. and review of documentation(facility's investigation of incident on 10/1/2011 related to patient #5) revealed the following: A staff member reported the patient walked into the ED walk in/exit door then was leaning against the wall and was mumbling. The incident caused the doors to come off their tracks. Another staff member reported the patient seemed wobbly. The interview and review of the clinical record failed to reveal that the patient who had just been discharged was assessed for injury or the need to return to the ED.

Review of policy and procedure "Patient Care Process" #100.185.74 effective 8/11 indicated Emergency Department patients are to be reassessed every two hours. Review of policy and procedure "Emergency Department: Discharge" #09-03-004 effective 9/09 indicated patients may be discharged when the vital signs are stable, neurological status is at baseline and the patient is able to care for self.. The discharge documentation is to include the date and time of discharge and type.

The nurse did not follow policy and procedure for reassessment and discharge to determine if the patient remained stabilized or to alert the physician if not stable prior to discharge.