HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 24 medical records reviewed, it was determined the facility failed to implement policies to perform an appropriate medical screening examination and provide stabilizing treatment to a patient.

Findings include:

Review of medical record #1 revealed a 73-year-old patient presented to the Emergency Department on 2/26/23 with complaint of cough and weight loss. Significant findings revealed the chest x-ray showed "mild to moderate perihilar interstitial infiltrates bilaterally. Patchy consolidation/atelectasis/effusion at the right base." The patient was discharged home with prescriptions for Pneumonia.
The patient returned to Emergency Department on 10/21/23 with complaints of hemoptysis and weight loss. A CT-scan showed the patient has extensive consolidative changes and numerous cavitating nodules some of which communicate with the adjacent bronchus. The patient was discharged from the Emergency Department with a prescription for an antibiotic.

The facility failed to conduct an appropriate medical screening evaluation to determine whether an emergency medical condition existed before discharging the patient from the emergency department.

See findings at A 2406.

Review of medical record #1 identified, the patient returned to Emergency Department on 10/21/23, with complaint of hemoptysis. A CT-Scan showed extensive consolidative changes in the right lower lobe with multifocal areas of cavitating nodularity some of which communicates with the adjacent bronchus as well as innumerable nodular densities throughout the lung fields. The patient was given two (2) antibiotics then discharged from the Emergency Department approximately six (6) hours after arrival, with a prescription for an antibiotic.

The facility failed to identify and provide appropriate stabilizing treatment for a patient who presented to the emergency department.

See findings at A 2407.

Based on medical record review, document review and interview, in one (1) of 24 medical records reviewed, it was determined the facility failed to provide an appropriate and complete medical screening examination for a patient. This was evident for medical record (MR) #1.

Findings include:

The policy titled "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA (Emergency Medical Treatment and Active Labor Act)," reviewed 3/2020 states, "Every person who comes to a Northwell Health Emergency Department for examination or who presents elsewhere on the premises as defined above and states that he/she has an Emergency will be given an appropriate medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists."

Review of MR #1 identified this 73-year-old patient arrived at the Emergency Department (ED) on 2/26/23 at 2:13 PM with a complaint of cough x 2 months, not eating, no appetite and weight loss. The patient had a previous medical history of Hypertension and Diabetes Mellitus and the patient had seen a doctor who prescribed cough medication, but the cough had not improved. The patient's triage revealed the height was 5' 4" and the patient's weight was 115 lbs. The patient was alert and oriented to person, place and time and his vital signs upon arrival were temperature 99.1F (normal 97F - 99F), pulse 103 (normal 60-100), respiration 18 (normal 12-20), B/P 165/78 (normal 90-120/50-90) and oxygen saturation was 96% (normal 96%-100%) on room air. The physical examination including lab tests were done, and swabs for viral infections were also negative. A chest x-ray read at 3:39 PM showed "mild to moderate perihilar infiltrates and patchy consolidation/atelectasis/effusion at the right base evident. Impression: mild to moderate perihilar interstitial infiltrates bilaterally. Patchy consolidation/atelectasis/effusion at the right base."

The patient was given Ceftin 500mg and Azithromycin 500 mgs (antibiotics) at 5:15 PM, orally, then discharged from the Emergency Department at 5:48 PM with a diagnosis of Acute Cough and Pneumonia; prescriptions for Ceftin 500mg twice per day x 7 days and Azithromycin 250mg daily x 4 days and instructions to follow-up with his primary doctor in one (1) week.

There was no complete assessment of the weight loss and x-ray findings of the patchy consolidation at the right base of the lung.

The patient returned to the Emergency Department on 10/21/23 at 3:47 PM, with complaint of hemoptysis (coughing up blood) x 2 days. The patient's weight had decreased to 107 lbs. Diagnostic workup included a CT-Scan. The radiologist documentation at 8:03 PM, indicated the CT-Scan of the chest showed "diffuse bronchiectasis. Extensive consolidative changes in the right lower lobe with multifocal areas of cavitating nodularity some of which communicates with the adjacent bronchus as well as innumerable nodular densities throughout the lung fields, right lung greater than the left, may represent extensive infectious or inflammatory etiology however neoplastic etiology cannot be ruled out."

The Emergency Department's doctor documented at 8:15 PM that a CT-Scan of the chest showed "the patient has extensive consolidative changes and numerous cavitating nodules some of which communicate with the adjacent bronchus which likely explains hemoptysis." The doctor also documented a message was sent to the radiologist to ask if the imaging is consistent with pulmonary tuberculosis (TB).
The radiologist documented an addendum at 8:20 PM indicating the "Differential diagnosis includes fungal infection and Tuberculosis cannot be excluded."
The Emergency Department doctor documented "Sputum tests to include culture, fungal infection, and AFB (acid fast bacilli to detect TB infection) culture were ordered; however, patient is having difficulty producing sputum for the test. Will allow an additional 20 minutes or so for patient to attempt to produce some sputum, otherwise these tests will need to be performed in the outpatient setting."

The patient was discharged from the Emergency Department at 9:27 PM with a prescription for Doxycycline (antibiotic) and a diagnosis of possible bacterial infection. "The primary diagnosis was hemoptysis with additional impression of pulmonary cavitary lesion, multiple pulmonary nodules, you may have a bacterial infection, fungal infection, Tuberculosis, inflammatory disease or lung cancer."

There was no documentation in the medical record that a complete and appropriate screening was provided for the symptoms presented.

During interview of Staff F (Chief Medical Officer) conducted on 11/30/2023 at 10:11 AM, Staff F stated that Staff G, Program Director Infection Prevention Committee escalated this case to me about two weeks ago and the response from the emergency department was not appropriate. All the questions that should have been asked during the visit were not asked. The patient's chart was empty. Furthermore, the patient was not isolated, not placed on airborne precautions and was then released back into the community when he should have been admitted.


During an interview conducted on 11/30/23 at 10:40 AM with Staff A, the first Emergency Department doctor that saw the patient on 10/21/23, Staff A stated, "the patient did potentially have an emergency medical condition."


During an interview with Staff B, Section Chief, Pulmonary Program Director conducted on 11/30/23 at 11:50 AM, Staff B stated given the patient's presentation with hemoptysis, the patient should have "been admitted, placed on airborne isolation, treated with oral antibiotics, and the staff should have collected AFB x 3 before discharging the patient from the hospital. We should have established how much blood and with the extent of the cavitation. If the patient had cancer the patient should also be admitted because of the bleeding, this is a priority."

These findings were shared with Staff C, Director of Regulatory Affairs on 12/1/23 at approximately 3:15 PM.

Based on medical record review, document review and interview, in one (1) of 24 medical records reviewed, it was determined the facility failed to (a) complete an appropriate medical screening exam and (b) initiate appropriate treatment determination before the patient was discharged from the Emergency Department. This finding was evident in medical record (MR) #1.

Findings include:

The policy titled "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA (Emergency Medical Treatment and Active Labor Act)," reviewed 3/2020 states, "... A medical condition is stabilized when the hospital has provided sufficient treatment to assure, within reasonable medical probability that no clinical deterioration of the condition is likely to result from or occur during transfer or with respect to discharge, the treating physician has determined, with reasonable clinical confidence, that the emergency medical condition has resolved, and that continued care can be reasonably performed on an outpatient basis."

Review of Medical Record #1 identified this 73-year-old patient presented to the Emergency Department on 2/21/23 at 2:13 PM with complaints of cough x 2 months, no appetite and weight loss. Significant physical assessment finding was the patient's weight of 115 lbs. Diagnostic workup showed the radiologist identified on a chest x-ray there was "mild to moderate perihilar infiltrates and patchy consolidation/atelectasis/effusion at the right base. Impression: mild to moderate perihilar interstitial infiltrates bilaterally. Patchy consolidation/atelectasis/effusion at the right base." The patient was discharged from the Emergency Department at 5:48 PM that day after receiving stat doses of antibiotics and prescriptions for antibiotics to treat Pneumonia.

The patient returned to the Emergency Department on 10/21/23 at 3:47 PM with a complaint of hemoptysis (coughing up blood) x 2 days. The patient's weight had decreased to 107 lbs. The significant finding was the radiologist documentation at 8:03 PM that the CT-Scan of the chest showed "diffuse bronchiectasis. Extensive consolidative changes in the right lower lobe with multifocal areas of cavitating nodularity some of which communicates with the adjacent bronchus as well as innumerable nodular densities throughout the lung fields, right lung greater than the left, may represent extensive infectious or inflammatory etiology however neoplastic etiology cannot be ruled out." The radiologist documented an addendum at 8:20 PM indicating the "Differential diagnoses includes fungal infection and Tuberculosis cannot be excluded."

The patient was discharged from the Emergency Department at 9:27 PM that night with a prescription for Doxycycline (antibiotic) and a diagnosis of "possible bacterial infection. The primary diagnosis was hemoptysis with additional impression of pulmonary cavitary lesion, multiple pulmonary nodules, you may have a bacterial infection, fungal infection, Tuberculosis, inflammatory disease, or Lung Cancer."

The facility failed to identify the extent of the patient's medical symptoms and condition and make a determination for appropriate treatment.

During an interview with Staff B, Section Chief Pulmonary Program Director conducted on 11/30/23 at 11:50 AM, Staff B stated given the patient's presentation with hemoptysis, the patient should have "been admitted, placed on airborne isolation, treated with oral antibiotics, and the staff should have collected AFB x 3 before discharging the patient from the hospital. We should have established how much bleeding and with the extent of the cavitation the patient must be admitted."


These findings were shared with Staff C, Director of Regulatory Affairs on 12/1/23 at approximately 3:30 PM.