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Based on document review, record review, policy review and interview the Hospital failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to perform an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking emergency medical care. Failure to perform an appropriate MSE and provided stabilizing treatment places all patients presenting at this hospital at risk for harm and injury up to an including death.


Findings Include:


The hospital failed to perform an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed for 3 of 28 patients (P1, P2 and P14) who presented to the emergency department (ED) seeking medical care. (Refer to A2406)

The hospital failed to provide stabilizing treatment for 2 of 28 patients (P2 and P14) who presented to the emergency department seeking medical care. (Refer to A2407)

Based on record review, interview, and policy review, the hospital failed to perform an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed for 3 of 28 patients (P1, P2 and P14) who presented to the emergency department (ED) seeking medical care. Failure to perform an appropriate MSE has the potential to place patients at risk for harm or injury up to and including death.

Findings Include:


Review of a document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" revised on 04/17/23 showed, "The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ...

Standards for Medical Screening Examinations

1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional].
2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred.
3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition [EMC].
4. If the Medical Screening Examination [MSE] does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital's facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures ....

...DEFINITIONS

" ...Capacity" means the ability of the hospital to accommodate the individual requesting examination, or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, equipment, and the hospital's past practices of accommodating additional patients.

"Comes to the Emergency Department" means an individual:

1. Has presented at a Hospital's Dedicated Emergency Department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition ...
2. Has presented on Hospital property, other than the Dedicated Emergency Department, and requests examination or treatment for what may be an Emergency Medical Condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment.

"Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy.
Serious impairment to any bodily functions.
Serious dysfunction of any bodily organ or part ...

Some intoxicated individuals may meet the definition of "emergency medical condition" because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ.

Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or to others, would be considered to have an emergency medical condition ..."

"Medical screening examination" is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves ancillary studies and/or diagnostic tests and procedures. A medical screening examination is not an isolated event, but an ongoing process. The medical record shall include continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be documentation in the medical record of an evaluation prior to discharge or transfer.

Review of the hospital's "Guided Criteria for Obstetric Patients" indicated ". . . Hypertensive, pregnant patients less than 20 weeks will need evaluation in the ED first. If treatment requires Magnesium, then they will transfer to LDR [labor department room]. Hypertensive pregnant patients that are greater than 20 weeks will transfer to LDR. . ."



Patient 1 (P1)


Review of the "Arrival Section" in P1's Electronic Medical Record (EMR) revealed P1 presented to the ED on 07/23/24 at 9:35 PM with a chief complaint of headache.

Review of the "ED Note- Physician" dated 12/24/24 at 12:23 AM and electronically signed by Staff K, Physician, located in P1's EMR revealed, "[Patient name] ...presents to the ED for evaluation for multiple issues as well as a headache. Patient was unable to keep calm in the waiting room and was escorted out by security before I had the opportunity to gather more history or exam. I did not have an opportunity to assess capacity. No phone number other than [P1's] son's number was listed for contact. Patient-provider relationship was not established. No PCP listed ... Psychiatric: agitated, yelling.

Medical Decision Making ...Documents reviewed: Emergency department nurses' notes, emergency department records, prior records. Impression and Plan: Patient left before evaluation by physician. ..."

Review of the "Disposition Documentation" by Staff I, Registered Nurse (RN), dated 07/23/24 at 10:07 PM located in P1's EMR revealed, " ...Discharge Comments: Patient was escorted out before being seen by provider. Patient screaming at this RN [Registered Nurse]and [Staff H2] was threatening to "kick your asses, [profanity] America, I'll [profanity] all you Americans up" Security called."

The hospital failed to perform an MSE to determine if P1 had an EMC. The medical record failed to show an MSE had been performed.

During an interview on 10/22/24 at 10:17 AM, Staff F, Risk Management, stated that he/she became aware of an incident that occurred with P1 on 07/23/24 in the ED when Staff G2, RN and Staff H2, emergency medical technician (EMT) submitted a report to the hospital event reporting. Staff F stated an investigation was initiated and several interviews were conducted with staff and a review of the patient's medical record was conducted. When asked what the conclusion of the investigation was, Staff F stated, "It was brought to the SA [State Agency] because the group agreed an EMTALA violation occurred."

During an interview on 10/22/24 at 1:50 PM, Staff H, Security Manager, stated that an officer was called to assist with a patient who was yelling profanities in the ED. When Staff V walked into the triage area and tried to use the de-escalation techniques learned in training, the triage nurse (Staff G2) kept interrupting and interjecting with his/her efforts. Staff H stated, "the nurse [Staff G2] said, "get [P1] the [profanity] out of here." Staff H stated [Staff V name], "deferred to the triage nurse - trusted the process and that care was received. The security officer did not verify whether the patient was screened."

During an interview on 10/22/24 at 3:30 PM, Staff K, Physician stated, "What I recall is what is documented in the medical record. I was told by the triage nurse [name] that the patient was unable to keep calm and was escorted out of the hospital by security before an MSE was done. I did not have any contact with the patient and did not conduct an MSE. The patient left before the MSE could be done. What I documented [in the medical record] is what was told to me and information populated from the patients visit."

During an interview on 10/22/24 at 4:15 PM, Staff G2, RN stated, "I went into the waiting area to get the patient and bring [him/her] back to triage. The patient was mumbling something, but I didn't know what it was. I told [him/her] to get on the scale so I could weigh [him/her], and [he/she] started yelling at me. I tried to tell [him/her] to stop, 'that we would not be doing this,' but [he/she] kept on 'yelling [profanity] Americans and [profanity] America.' An EMT [emergency medical technician] came in the area and the patient continued yelling. [The EMT] said to just call security, so we did." Staff G2 stated there were no other providers in the triage area during the incident. Staff G2 stated, "When security arrived, I asked [him/her] to escort the patient out. You can't have a patient in here [ER] acting like that. I did not mean out of the hospital, but security escorted the patient out of the hospital. There was nothing else I could do."

Staff G2 stated he/she has certification in managing assaultive behaviors, but he/she did not make any attempt to de-escalate the situation. Staff G2 stated, "It would not have worked. The patient was not going to listen. I told security several times that the patient would not listen to anything [he/she] was trying to say or do." Staff G2 stated he/she did not report to the security officer that P1 did not have an MSE completed.

During an interview on 10/23/24 at 8:30 AM, Staff V, Security Officer stated, "I was called to the ED around 9:50 PM [on 07/23/24]. A patient was being verbally aggressive, and I was called to assist. When I arrived in triage the patient was arguing with the nurse. I tried twice to talk to the patient, but the triage nurse kept interrupting and saying take [him/her] off the property. There was an escalation between the nurse and the patient, so I decided to remove the patient from the ED to defuse everything. I was never given the chance to use any de-escalation techniques because the nurse [Staff G2] kept interrupting and telling me to 'get [him/her] out' 'get [him/her] out.' I should have verified the patient received an MSE, but I did not."

Patient 2 (P2)

Review of P2's medical recorded showed P2 was a 7 day old female brought to the ED by her parents on 07/02/24 at 12:35 AM with chief complaint of not eating.

P2's medical record showed a document titled, "ED Note-Physician" by Staff R, Physician, dated 07/02/24 at 1:19 AM, " ...The patient presents with Not eating/vomiting (eject matter from the stomach thru the mouth) ...Additional history: Patient is a 7 day/old female that was brought in by parents for concern of jaundice (yellow color of the skin)/decreased p.o. [oral] intake and lethargy (feeling of being tired). Denies any fever/and was seen in the clinic recently and had a bilirubin (the breakdown of red blood cells in the blood) of 13. Patient is bottle-fed and parents have been unable to get her to eat. She did have 1 episode of emesis (matter ejected from the stomach when vomiting) that was noted to be yellow ...Reexamination/Reevaluation Will repeat bilirubin level/pediatric team consulted/ labs currently pending at time of admit Will admit for observation/ discussed with admitting team. HPI (History of Present Illness) assisted via translation service from iPad. Impression and Plan Neonatal jaundice... Vomiting ... Plan Condition Stable Disposition: Admit to Observation Unit ..."


Review of Staff G, Physician, Pediatric Hospitalist's order dated 07/02/24 at 2:31 AM for P2, showed "Order: Place in Observation."

Review of P2's Gastrointestinal Assessments dated 07/02/24 at 1:30 AM to 07/03/24 at 12:00 AM showed P2 vomited 10 times.


Review of a documents titled, "Provider Notification," dated 07/02/24 at 6:05 PM, showed Staff I2 documented, "pt has vomited x 3 since started formula."


Review of P2's "Nutrition Progress Note," dated 07/03/24 at 9:51 AM, showed Staff L2, Registered Dietician (RD) documented, " ...Nutrition Related History Current Presentation Nutrition: Pt admitted [sic] for vomiting and inability to tolerate feeds. Had UGI (upper gastrointestinal test)- no obstruction, indicated reflux and gastroenteritis (inflammation and infection of the stomach). Feeding tube placed to duodenum with Pedialyte (sic) (oral electrolytes) running, continuing to vomit @6 milliliters/hour (ml/hr) ... Weight History Nutrition: 9% below birth wt (sic) on admit, significant ... Enteral Nutrition Recommendation (use of a tube to deliver nutrition to people who are unable to eat or swallow safely): trial Similac Alimentum @ 5ml/hr, if tolerated advance slowly towards 23 milliliters/hour (ml/hr) to provide 150 ml/kg; reflux (spitting up gastric contents) precautions. Meal and Snack Delivery Recommendation: NPO (nothing by mouth), when starting feeds will need to titrate up slowly, start with 20ml q2-3 hrs TPN [total parenteral nutrition -feeding that provides nutrients through a vein] - IV [intravenous] Fluids Recommendation: if unable to tolerate EN (enteral nutrition), will need to consider PN (parenteral nutrition) in 2-3days TPN - IV Fluids Recommendation-cont: continue IV fluids with dextrose (sugar water) until tolerating feeds ..."


Review of P2's Gastrointestinal Assessments dated 07/03/24 at 12:00 AM to 07/04/24 at 12:00 AM showed P2 vomited 8 times.


Review of a "Provider Notification" dated 07/03/24 at 7:53 PM, showed Staff J2, Bachelor of Science in Nursing (BSN) documented, "notified provider episode of emesis. "Provider Requested Interventions ...Other: continue tube feeding at 20ml/hr.'"


Review of P2's Gastrointestinal Assessments dated 07/04/24 at 12:00 AM to 07/05/24 at 12:00 AM showed P2 vomited 6 times.


Review of P2's "Progress Note- Generic" dated 07/04/24 at 4:16 PM, showed Staff K, Physician documented, "Called by RN that patient has not taken bottle all day successfully w/o [sic] [without] vomiting all formula up. Discussed case with [Physician], will switch to Alimentum formula via NJ tube (nasojejunal- a tube that goes in the nose and passes thru the stomach to a portion of the intestine) starting at rate of 15 ml/hr for first 1-2 hours. Then increase to 20 ml/hr for 4 hours, increase to goal rate of 25 ml/hr. Discussed instructions with nursing team. Orders placed and verified by nursing team."


Review of a "Provider Notification," dated 07/04/24 at 8:00 PM, showed Staff M2, RN documented "patient vomited large amount about 30 minutes after increase tubefeed (sic)."


Review of a "Provider Notification" dated 07/05/24 at 2:50 AM, showed Staff M2, RN documented, " ...Patient continues to vomit overnight. Will vomit about every 2 hours, and then will have episodes of vomiting every 30 minutes. vomit does not look normal-almost looks like stool. Has had one stool smear that is orange/clay looking."


Review of a "Progress Note" dated 07/05/24 at 3:05 AM, showed Staff N2, Physician documented, "As emesis has significantly increased in frequency and volume after increasing to 25 ml/hr, will decrease formula TF [tube feeding] to 20 ml/hr for the next 2 hours. Following may trial increase back to 25 ml/hr."


Review of a "Provider Notification," dated 07/05/24 at 7:50 AM, showed, Staff M2, RN documented, " ...resident finished rounds, and this RN let the resident know that there was great concern about the patient. This RN really believes that the patient is throwing up stool, not just bile like it was believed. Patient vomited at least 10 times over night."


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 8:32 AM, showed Staff S, RN documented, P2's abdomen was soft and appeared appropriate for age and size, round and symmetric and continued to vomit.


Review of P2's "Nutrition Progress Note," dated 07/05/24 at 10:24 AM, showed Staff L2, RD documented, " ...Assessment Nutrition Related History Current Presentation Nutrition: Pt is fussy this morning, vomited all night. Attempted oral feeds yesterday, pt did not cue and was uninterested. Pt is elevated in crib this morning, mother at bedside. Diet History Nutrition: per mom, pt has not taken a full bottle since birth. First feeds after birth were not tolerated well, produced odd noise then would stop eating ...Nutrition Dx/Intervention/Goals TPN - IV Fluids Recommendation: continue to recommend TPN with poor nutrition since birth (10 days minimal nutrition) ..."

Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 12:00 PM, showed Staff S, RN documented, P2's abdomen was distended and continued to vomit.


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 5:20 PM, showed Staff S, RN documented P2's abdomen was distended, firm and had bile/mucous emesis.


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 12:00 AM to 07/06/24 at 3:44 AM showed P2 vomited 8 times.

Review of the medical record showed that P2 vomited 32 times between 07/02/24 and 07/06/24. Further review of the medical record showed staff failed to notify or document the physician/provider was notified 28 of 32 times on 07/02/24, 07/03/24, and 07/05/24.


Review of the medical record showed P2 weighed 3.7 kilograms (kg), (8 pounds 3 ounces) at birth; on admission to observation on 07/02/24 P2 weighed 3.47 kg (7 pounds 10 ounces) and on 07/05/24, P2 weighed 3.12 kg (6 pounds 8 ounces).


Review of a document titled, "Neurological Assessment," dated 07/05/24 at 8:32 AM, showed Staff S, RN documented P2's anterior and posterior fontanels (soft spots in front and back on a newborns head where the suture lines meet) were flat and soft (a normal assessment for a newborn). Further review of the medical record on 07/05/24 at 8:00 PM showed Staff Y documented that P2's anterior and posterior fontanels were sunken and depressed (an abnormal sign that could indicate the patient is not getting enough fluids).


Review of a "Progress Note-Addendum" dated 07/05/24 at 12:49 PM, Staff G, Physician, documented that a conversation with P2's parents discussed the deep concern that patient was down 15% total from birth weight. The documentation showed that if no improvement was seen in the next 24-48 hours the patient would be sent to a Kansas City hospital for a comprehensive, multidisciplinary assessment and treatment.


Review of a Progress Note Addendum dated 07/05/24 at 1:06 PM by Staff G, Physician showed, "Upgrade to inpatient status as pt has failed oral challenge several times and remains NJ dependent with ongoing weight loss. I do not anticipate a d/c [discharge] in the next 48hr."


Even though H1 has a Pediatric General Medical floor and a Pediatric Intensive Care Unit (PICU) available for ill and critically ill pediatric patients and H2 has a level 3 (ability to care for critically ill neonates) Neonatal Intensive Care unit (NICU), P2 was placed on observation status on 07/02/24 at 2:03 AM and moved to the Pediatric Unit on 07/02/24 at 2:22 AM for continued observation. During observation status from 07/02/24 to 07/05/24, documentation showed P2 was noted to have a significant loss in body weight of 15 %; inability to adequately tolerate or consume oral intake or nasogastric (NG- a tube is passed in the nose to a portion of the stomach to deliver feedings) feedings; loss of a functioning IV on 07/03/24; excessive sleepiness and drowsiness; poor cueing ability; lack of desire for oral feedings; poor sucking; minimal rooting reflex; vomiting with all feedings; and reported vomiting of stool.


The hospital failed to perform an appropriate MSE for P2 to determine if an EMC existed including, but not limited to, the fact that labs were not obtained or completed between the dates of 07/02/24 and 07/05/24 even though P2 continued to have poor nutritional and fluid intake, loss of a functioning IV, vomiting and weight loss.


Patient 2 died on 07/06/24 at 3:44 AM.


During an interview on 10/22/24 at 3:49 PM, Staff R, Physician, stated that, P2 was a 6- or 7-day old infant. The mother carried the patient to full term. The patient had an elevated bilirubin level at birth. The patient presented with difficulty feeding and vomiting and slightly jaundiced but was below bilirubin light level. P2 would cry and was making tears. The mother was notified that we would do an IV and check blood levels. Wanted to get her admitted to the pediatric floor. No abdominal distension noted. ED doctors do not have admitting privileges, pediatrics was consulted. There was no trouble with bed availability. Pediatric patients get beds quickly usually. Staff R stated that the actual provider decides the admission status. The hospitalist makes the admitting determination and decides on observation or actual admission. The pediatricians take over and write admitting orders. The expectation is the consulting physician will follow up with care needed after leaving the ED. Staff R stated that admitting observation status verse inpatient status is a billing issue, the patient must stay two midnights for inpatient status. Staff R stated that if they go inpatient first, then it causes billing issues. Usually, they start with observation then change to inpatient if needed. Staffing plays a big part of bed availability.


During an interview on 10/22/24 at 4:07 PM, Staff Q, RN stated that the infant had bilious emesis (vomit that contains bile); the parents spoke very broken English, pediatrics was instantly contacted. The pediatric resident came down and IV access was not able to be established. IV team was called for assistance. The mother tried to feed and P2 still couldn't hold anything down. PICU nursing staff were informed the patient did not have an IV site and needed one. The patient was sick with a weak little cry. Vital signs were stable when transferred to the pediatric floor. P2 was only in the ED about 1 or 2 hours total. Pediatric beds are usually available quickly.


During an interview on 10/22/24 at 2:45 PM, Staff L, RN, stated that their job consists of going thru the medical records and identifying a change in patient status by reviewing clinical VS, lab work, etc. An algorithm is used based on the payor or insurance type and it identifies if the patient would benefit from being made inpatient status. The physician will be called and transfer orders to change the patient to inpatient status are entered. Staff L went on to state that if the patient is self-pay the same algorithm that is used for Medicare and Medicaid is used so it makes the transition smoother if they apply for the insurance later.


During an interview on 10/22/24 at 4:25 PM, Staff S, RN, stated that on 07/05/24, day shift (7 AM to 7 PM) the [Physician] was called while still on the Pediatric floor. The [Physician] was notified that the infant was breathing funny with subcostal (a breathing condition when the abdomen pulls into the ribcage) retractions and desaturating (low oxygen level). P2 was suctioning and placed on an oxygen mask and then a cannula (device used to administer oxygen). P2 responded a little with oral suctioning and with decompressing (removing air from stomach) her stomach. Oxygen saturations' (level of oxygen in the blood) were in the 90's (normal range for patient age is > or = to 93%). The [Physician] called the pediatric intensivist (critical care physician). The PICU charge nurse was notified that P2 needed sent right away to a higher level of care. Staff S stated that she thought P2 was stable that day until she wasn't.


During an interview on 10/22/24 at 3:00 PM, Staff N, Physician, stated that she was the on call as the Pediatric Intensivist the night P2 was transferred to the PICU. She stated that she was involved in the care the end on 07/05/24 at around 7:00 PM. She stated the infant was not doing well when arriving in the PICU due to breathing difficulties and still vomiting.


During an interview on 10/23/24 at 10:20 AM, Staff Y, RN, stated that when arriving on shift P2 had just vomited. A NG was placed and copious amount of stool as return. P2's tongue was brown and sandpaper from stool emesis. The NG returned about 500 ml of brown, thick liquid and it appeared to be stool. While attempting to intubate (place a breathing tube in the airway) the patient projectile vomited more brown fluid. It appeared she aspirated (inhaled into the lungs) the contents. There was concern P2 had been vomiting stool prior to arriving in the PICU. Staff Y stated that the patient's eyes were sunken in and eyes rolled back in the head. A urinary catheter (a tube inserted in to the bladder to drain urine) was placed and no urine output was present. When P2 was intubated, she was somewhat stabilized however unable to keep the blood pressures up in an acceptable range, so we started an epinephrine (medication to increase heartrate) drip. She had a single lumen Peripherally Inserted Central Catheter (PICC) in the right lower leg. The decision was made to transfer her to [H3]. The H3 transport team arrived about midnight. The transport team immediately took over and assumed the care of the patient. While attempting to transfer P2 to transport incubator, P2 had no heartbeat. CPR (cardiopulmonary resuscitation) was started. Staff Y stated that the fact P2 was vomiting stool at least 20 times during that day was concerning. Communication with the parents was difficult, we did have someone who could translate working on the unit and then we used the iPad translator too.



Patient 14 (P14)

Review of P14's electronic medical record (EMR), with Staff C and Staff E assisting with navigation of the EMR, indicated P14 was triaged on 09/24/23 at 9:24 AM by Staff NN, Physician Assistant, with the chief complaint of "lower abd [abdominal] pain that started when she woke up this morning, took 2 [two] tylenol this morning, vomiting x [times] 3 times, last bm [bowel movement] 9/23 [09/23/23] reports normal, LMP [last menstrual period] 2 days ago."

Review of P14's history of present illness indicated "The patient presents with Abdominal pain. The onset was 2 hours ago. The course/duration of symptoms is constant. Location: Generalized abdomen. The character of symptoms is pain. Risk factors consist of hypertension. Therapy today: see nurses notes. Associated symptoms: nausea, vomiting, Constipation, Blood when wiping, Denies dysuria and denies fever. 38-year-old female patient with a history of HTN [hypertension] on Ozempic presenting to the ED for evaluation of generalized abdominal pain. Patient reports 2 hours ago constant generalized abdominal pain began with associated vomiting x 3, nausea, constipation, and blood when wiping today but denies any associated fevers, back pain, or dysuria. Patient states that she took 2 Tylenol 1.5 [one and a half] hours ago with no relief. Patient reports her last normal bowel movement was yesterday and she normally has bowel movements every other day but this episode is different because of associated pain. She endorses a history of hidradenitis [sic] [painful, long-term skin condition that causes skin abscesses and scarring on the skin] surgery around the abdominal area but denies any abdomen surgery. . ."

Review of P14's review of systems indicated ". . . Gastrointestinal symptoms: Abdominal pain, diffuse, pain, nausea, vomiting, constipation. . ."

Review of P14's vital signs indicated blood pressure 116/80, heart rate 107, respiratory rate 18, and oxygen saturation 100%.

Review of Staff K's (ED Physician/Director) ED note dated 09/24/23 at 10:32 AM indicated "The patient presents with abdominal pain. The onset was 3 hours ago. The course/duration of symptoms is constant. . . A 38-year-old female patient with a PMHx [prior medical history] of PCOS [polycystic ovary syndrome] with baseline irregular periods, prior miscarriages, hidradenitis suppurativa with bilateral axillary and pelvic excisions, and DM [diabetes mellitus] on Ozempic arrives to the ED for evaluation of a constant suprapubic abdominal pain beginning 3 hours ago 0700 [7:00 AM]. She states that when she woke up this morning, she felt a cramping sensation in her abdomen, which felt as if her bladder was full. She reports dysuria with associated hematuria. She states that when she wiped she had some vaginal bleeding. She states that while in the bathroom, she developed nausea with 1 [one] episode of vomiting and diaphoresis. Here in the ED she reports chills. Patient states that her LMP ended 2 days ago. She is sexually active. She states her and her husband are trying for a baby. Patient states that she still has her gallbladder, appendix, uterus, and ovaries. She reports that she felt normal and at her baseline yesterday. VS [vital signs] upon evaluation include HR [heart rate] 100, O2 sat [oxygen saturation] 100% on RA [room air], BP [blood pressure] 113/73. Additional Hx [history] was provided by the patient's friend. . . No OB/GYN.. ."

Review of P14's lab results on 09/23/23 at 12:15 PM indicated Beta hCG POC [quantitative human chorionic gonadotropin (HCG or hCG) blood test measures the specific level of HCG in the blood during pregnancy] was greater than 2000.0 Intl [international] Units/mL [per milliliter] ABN [abnormal]; Pregnancy screen, Urine positive; UA [urinalysis] blood positive 3+; UA WBC [white blood cells] 6-10 /HPF [high power field] ABN; UA RBC [red blood cells] greater than 50 /HPF ABN; epithelial cells 11-20 /HPF ABN; UA Hyal [hyaline] Cast 3-5 [LPF] [low power field] ABN.

Review of the ultrasound obstetric less than 14 (fourteen) weeks performed transvaginally performed on 09/23/23 at 11:22 AM indicated "PROCEDURE: US [ultrasound] Pregnancy 1st [first]Trimester.

FINDINGS: Uterus measures 9.7 x 5.1 x 4.6 cm [centimeters]. Endometrial thickness is 1.2 cm.
There are Nabothian [a tiny bump that forms when skin cells trap mucus inside the glands in the cervix] cysts in the cervix. There is a questionable fibroid in the anterior lower uterine segment measuring 1.9 x 2.1 x 1.8 cm. There is no evidence of an intrauterine or extrauterine pregnancy. The left ovary normal in size and morphology. Right ovary is not visualized.

IMPRESSION: No evidence of intrauterine or extrauterine pregnancy. Recommend continued correlation with serial beta-hCGs and followup [sic] ultrasound as warranted. Small fibroid uterus as well as some nabothian cyst."

Review of P14's EMR indicated lab staff reported ". . . the patient's exact hCG is 20,891." Average hCG levels in blood during pregnancy of 200 - 32,000 µ/L indicates a 6 week pregnancy and an hCG level of 3,000 - 160,000 µ/L indicates a 7 week pregnancy.

Review of Staff K's medical decision making indicated "patient presents with lower abdominal pain. The patient turned out to have a positive pregnancy test. Beta hCG is over 20,000. The patient had a sonogram which was unremarkable. Patient advised to get a repeat beta-hCG in 48 hours. Patient advised to get a repeat sonogram in 7 [seven] days. Patient advised to call for an appointment with OB/GYN tomorrow. [Staff K documented in ED physician note that P14 did not have an obstetrician/gynecologist] Patient agrees to do so. I have answered all of the patient's questions. I have given the patient's strict return precautions. Patient is aware that this could be an abnormal pregnancy."

Staff K's documentation indicated the treatment and disposition was P14 "will be discharged home. The patient is comfortable and agrees with the disposition plan. All questions have been answered and strict return precautions have been given."

Staff K's documentation on 09/24/23 at 12:37 PM indicated "Discussion of pertinent results, Dx [diagnosis], and plan of discharge with patient. I state that she will need to be started on prenatal vitamins, acquire an OB/GYN, and cease all smoking or drinking. Patient verbalizes agreement with this plan. Patient is cl

Based on record review, document review, policy review and interview the Hospital (H1) failed to provide stabilizing treatment for 2 of 28 patients (P2 and P14) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.


Findings Include:


Review of a document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" revised on 04/17/23 showed, "The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ...

...Stabilizing Treatment Where the MSE reveals that the person has an EMC, the Hospital will provide Stabilizing Treatment as required to stabilize the medical condition or will transfer the patient in accordance with the Transfer provisions below. Stabilizing treatment is ongoing and must be continued until the patient is Stabilized or appropriately Transferred ... "Qualified Medical Person or Personnel" (QMP) refers to physician and non-physician individuals defined by the medical staff's bylaws, rules, and regulations or other document approved by the Hospital's governing body to perform the medical screening examinations for those individuals that present to a Dedicated Emergency Department and request examination and treatment ..."



Review of a policy titled, "Level of Service," revised 07/20/22, showed, "Policy: All [H1 and H2] facilities have established processes to ensure that patients are admitted and maintained at the appropriate patient status and clinical level of care ...The patient status and level of care is reflected in the medical record and on all billing documentation to ensure proper billing to all payers ...b. Observation Level of Care: Hospital outpatient services furnished by a hospital on the hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing staff that are reasonable and necessary to evaluate an outpatient's condition or determine the need for a possible admission to the hospital as an inpatient if medically necessary ...C. Inpatient Level of Care: 1. Hospital inpatients are admitted to the hospital for purposes of receiving acute inpatient hospital services."


Patient 2 (P2)

Review of P2's medical recorded showed P2 was a 7 day old female brought to the ED by her parents on 07/02/24 at 12:35 AM with chief complaint of not eating.

Review of P2's medical record showed a document titled, "ED Note-Physician" by Staff R, Physician, dated 07/02/24 at 1:19 AM, " ...The patient presents with Not eating/vomiting (eject matter from the stomach thru the mouth) ...Additional history: Patient is a 7 day/old female that was brought in by parents for concern of jaundice (yellow color of the skin)/decreased p.o. [oral] intake and lethargy (feeling of being tired). Denies any fever/and was seen in the clinic recently and had a bilirubin (the breakdown of red blood cells in the blood) of 13. Patient is bottle-fed and parents have been unable to get her to eat. She did have 1 episode of emesis (matter ejected from the stomach when vomiting) that was noted to be yellow ...Reexamination/Reevaluation Will repeat bilirubin level/pediatric team consulted/ labs currently pending at time of admit Will admit for observation/ discussed with admitting team. HPI (History of Present Illness) assisted via translation service from iPad ..."

Review of Staff G, Physician, Pediatric Hospitalist's order dated 07/02/24 at 2:31 AM for P2, showed "Order: Place in Observation."


Review of P2's Gastrointestinal Assessments dated 07/02/24 at 1:30 AM to 07/03/24 at 12:00 AM showed P2 vomited 10 times.


Review of a "Provider Notification," dated 07/02/24 at 6:05 PM, showed Staff I2 documented, "pt has vomited x 3 since started formula."


Review of P2's "Nutrition Progress Note," dated 07/03/24 at 9:51 AM, showed Staff L2, Registered Dietician (RD) documented, " ...Nutrition Related History Current Presentation Nutrition: Pt admitted [sic] for vomiting and inability to tolerate feeds. Had UGI (upper gastrointestinal test)- no obstruction, indicated reflux and gastroenteritis (inflammation and infection of the stomach). Feeding tube placed to duodenum with Pedialyte (sic) (oral electrolytes) running, continuing to vomit @6 milliliters/hour (ml/hr) ... Weight History Nutrition: 9% below birth wt (sic) on admit, significant ... Enteral Nutrition Recommendation (use of a tube to deliver nutrition to people who are unable to eat or swallow safely): trial Similac Alimentum @ 5ml/hr, if tolerated advance slowly towards 23 milliliters/hour (ml/hr) to provide 150 ml/kg; reflux (spitting up gastric contents) precautions. Meal and Snack Delivery Recommendation: NPO (nothing by mouth), when starting feeds will need to titrate up slowly, start with 20ml q2-3 hrs TPN [total parenteral nutrition -feeding that provides nutrients through a vein] - IV Fluids Recommendation: if unable to tolerate EN (enteral nutrition), will need to consider PN (parenteral nutrition) in 2-3days TPN - IV Fluids Recommendation-cont: continue IV fluids with dextrose (sugar water) until tolerating feeds ..."


Review of P2's Gastrointestinal Assessments dated 07/03/24 at 12:00 AM to 07/04/24 at 12:00 AM showed P2 vomited 8 times.


Review of a "Provider Notification" dated 07/03/24 at 7:53 PM, showed Staff J2, Bachelor of Science in Nursing (BSN) documented, "notified provider episode of emesis. "Provider Requested Interventions ...Other: continue tube feeding at 20ml/hr.'"


Review of a document titled, "Gastrointestinal Assessment," dated 07/04/24 at 12:00 AM to 07/05/24 at 12:00 AM showed P2 vomited 6 times.

Review of P2's "Progress Note- Generic" dated 07/04/24 at 4:16 PM, showed Staff K, Physician documented, "Called by RN that patient has not taken bottle all day successfully w/o [sic] [without] vomiting all formula up. Discussed case with [Physician], will switch to Alimentum formula via NJ tube (nasojejunal- a tube that goes in the nose and passes thru the stomach to a portion of the intestine) starting at rate of 15 ml/hr for first 1-2 hours. Then increase to 20 ml/hr for 4 hours, increase to goal rate of 25 ml/hr. Discussed instructions with nursing team. Orders placed and verified by nursing team."


Review of a "Provider Notification," dated 07/04/24 at 8:00 PM, showed Staff M2, RN documented "patient vomited large amount about 30 minutes after increase tubefeed (sic)."


Review of a "Provider Notification" dated 07/05/24 at 2:50 AM, showed Staff M2, RN documented, " ...Patient continues to vomit overnight. Will vomit about every 2 hours, and then will have episodes of vomiting every 30 minutes. vomit does not look normal-almost looks like stool. Has had one stool smear that is orange/clay looking."


Review of a "Progress Note" dated 07/05/24 at 3:05 AM, showed Staff N2, Physician documented, "As emesis has significantly increased in frequency and volume after increasing to 25 ml/hr, will decrease formula TF [tube feeding] to 20 ml/hr for the next 2 hours. Following may trial increase back to 25 ml/hr."

Review of a "Provider Notification," dated 07/05/24 6:34 AM, showed Staff M2, RN documented, "Physician notified that the patient was weighed this morning and weighed 3.12 kg."

Review of a "Provider Notification," dated 07/05/24 at 7:50 AM, showed, Staff M2, RN documented, " ...resident finished rounds, and this RN let the resident know that there was great concern about the patient. This RN really believes that the patient is throwing up stool, not just bile like it was believed. Patient vomited at least 10 times over night."


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 8:32 AM, showed Staff S, RN documented, P2's abdomen was soft and appeared appropriate for age and size, round and symmetric and continued to vomit.


Review of P2's "Nutrition Progress Note," dated 07/05/24 at 10:24 AM, showed Staff L2, RD documented, " ...Assessment Nutrition Related History Current Presentation Nutrition: Pt is fussy this morning, vomited all night. Attempted oral feeds yesterday, pt did not cue and was uninterested. Pt is elevated in crib this morning, mother at bedside. Diet History Nutrition: per mom, pt has not taken a full bottle since birth. First feeds after birth were not tolerated well, produced odd noise then would stop eating ...Nutrition Dx/Intervention/Goals TPN - IV Fluids Recommendation: continue to recommend TPN with poor nutrition since birth (10 days minimal nutrition) ..."

Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 12:00 PM, showed Staff S, RN documented, P2's abdomen was distended and continued to vomit.


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 5:20 PM, showed Staff S, RN documented P2's abdomen was distended, firm and had bile/mucous emesis.


Review of P2's "Gastrointestinal Assessment," dated 07/05/24 at 12:00 AM to 07/06/24 at 3:44 AM showed P2 vomited 8 times.


Review of the medical record showed P2 weighed 3.7 kilograms (kg), (8 pounds 3 ounces) at birth; on admission to observation on 07/02/24 P2 weighed 3.47 kg (7 pounds 10 ounces) and on 07/05/24, P2 weighed 3.12 kg (6 pounds 8 ounces).


Review of the medical record showed that P2 vomited 32 times between 07/02/24 and 07/06/24. Further review of the medical record showed staff failed to notify or document the physician/provider was notified 28 of 32 times on 07/02/24, 07/03/24, and 07/05/24.


Review of P2's "Intake and Output" showed the following:

07/01/24 at 7:00 PM to 07/02/24 at 7:00 AM - Intake by IV fluid 95.4167 ml Output 31, with 1 emesis.
07/02/24 at 7:00 AM to 07/03/24 at 7:00 AM - Intake by IV fluid 200.75, Tube feed 163, Output 124 with 10 emesis.
07/03/24 at 7:00 AM to 07/04/24 at 7:00 AM - Intake by IV fluid 48 ml, Tube feed 387, Output 90 with 9 emesis.
07/04/24 at 7:00 AM to 07/05/24 at 7:00 AM - Intake by IV none, Tube feed 432.5, Output 93 with 15 emesis.

Review of Vascular Access notes dated 07/05/24 at 4:08 PM showed Staff RN documented, Peripheral IV Number of Attempts: "1, won't thread, site dc'd [discontinued]"

Review of a physician's order dated 07/05/24 at 4:16 PM entered by Staff G, Physician, showed, "Order: Consult to Pharmacy (TPN Pharmacy Consult) ...Order Details: ...Routine, TPN Pharmacy Dosing and Level, Daily ..."

Review of P2's Vascular Access notes dated 07/05/24 at 5:00 PM showed Staff O2, RN documented, Central IV Activity: "Insert new site", Central IV Procedure Type: "Non-emergent"


Review of a document titled, "Neurological Assessment," dated 07/05/24 at 8:32 AM, showed P2's anterior and posterior fontanels (soft spots in front and back on a newborns head where the suture lines meet) were flat and soft (a normal assessment for a newborn). Further review of the medical record on 07/05/24 at 8:00 PM showed that P2's anterior and posterior fontanels were sunken and depressed (an abnormal sign that could indicate the patient is not getting enough fluids).


Review of a "Progress Note-Addendum" dated 07/05/24 at 12:49 PM, Staff G, Physician, documented that a conversation with 2's parents discussed the deep concern that patient was down 15% total from birth weight. The documentation showed that if no improvement was seen in the next 24-48 hours the patient would be sent to a Kansas City hospital for a comprehensive, multidisciplinary assessment and treatment.


Review of a Progress Note Addendum dated 07/05/24 at 1:06 PM by Staff G, Physician showed, "Upgrade to inpatient status as pt has failed oral challenge several times and remains NJ dependent with ongoing weight loss. I do not anticipate a d/c [discharge] in the next 48hr."


The hospital failed to provide stabilizing treatment to P2 who continued to have poor nutritional and fluid intake. Tube feedings continued although the infant continued to vomit. The record showed P2 received 48 ml of IV fluids on 07/03/24 and then did not receive any IV fluids until after 7:00 PM on 07/05/24 as indicated in the Intake and Output documentation. TPN was recommended on 07/03/24 and 07/05/24 by Staff L2, RD and an order was not placed until 07/05/24 at 4:16 PM.


Patient 2 died on 07/06/24 at 3:44 AM.


During an interview on 10/22/24 at 3:49 PM, Staff R, MD, stated that, P2 was a 6- or 7-day old infant. The mother carried the patient to full term. The patient had an elevated bilirubin level at birth. The patient presented with difficulty feeding and vomiting and slightly jaundiced but was below bilirubin light level. P2 would cry and was making tears. The mother was notified that we would do an IV (when a tube is inserted into a vein to deliver fluids) and check blood levels.

During an interview on 10/22/24 at 4:07 PM, Staff Q, RN stated that the infant had bilious emesis (vomit that contains bile); the parents spoke very broken English, pediatrics was instantly contacted. The pediatric resident came down and IV access was not able to be established. IV team was called for assistance. The mother tried to feed and P2 still couldn't hold anything down. PICU (pediatric intensive care unit) nursing staff were informed the patient did not have an IV site and needed one. The patient was sick with a weak little cry. Vital signs were stable when transferred to the pediatric floor. P2 was only in the ED about 1 or 2 hours total. Pediatric beds are usually available quickly.


During an interview on 10/22/24 at 4:25 PM, Staff S, RN, stated that on 07/05/24, dayshift (7 AM to 7 PM) the [Physician] was called while still on the Pediatric floor. The [Physician] was notified that the infant was breathing funny with subcostal (a breathing condition when the abdomen pulls into the ribcage) retractions and desaturating (low oxygen level). P2 was suctioning and placed on an oxygen mask and then a cannula (device used to administer oxygen). P2 responded a little with oral suctioning and with decompressing (removing air from stomach) her stomach. Oxygen saturations' (level of oxygen in the blood) were in the 90's (normal range for patient age is > or = to 93%). The [Physician] called the pediatric intensivist (critical care physician). The PICU charge nurse was notified that P2 needed sent right away to a higher level of care. Staff S stated that she thought P2 was stable that day until she wasn't.

During an interview on 10/22/24 at 3:00 PM, Staff N, MD, stated that she was the on call as the Pediatric Intensivist the night P2 was transferred to the PICU. She stated that she was involved in the care the end on 07/05/24 at around 7:00 PM. She stated the infant was not doing well when arriving in the PICU due to breathing difficulties and still vomiting.

During an interview on 10/23/24 at 10:20 AM, Staff Y, RN, stated that when arriving on shift P2 had just vomited. A NG was placed and copious amount of stool as return. P2's tongue was brown and sandpaper from stool emesis. The NG returned about 500 ml of brown, thick liquid and it appeared to be stool. While attempting to intubate (place a breathing tube in the airway) the patient projectile vomited more brown fluid. It appeared she aspirated (inhaled into the lungs) the contents. There was concern P2 had been vomiting stool prior to arriving in the PICU. Staff Y stated that the patient's eyes were sunken in and eyes rolled back in the head. A urinary catheter (a tube inserted in to the bladder to drain urine) was placed and no urine output was present. When P2 was intubated, she was somewhat stabilized however unable to keep the blood pressures up in an acceptable range, so we started an epinephrine (medication to increase heartrate) drip. She had a single lumen Peripherally Inserted Central Catheter (PICC) in the right lower leg. The decision was made to transfer her to [H3]. The H3 transport team arrived about midnight. The transport team immediately took over and assumed the care of the patient. While attempting to transfer P2 to transport incubator, P2 had no heartbeat. CPR (cardiopulmonary resuscitation) was started. Staff Y stated that the fact P2 was vomiting stool at least 20 times during that day was concerning. Communication with the parents was difficult, we did have someone who could translate working on the unit and then we used the iPad translator too.


Patient 14 (P14)

Review of P14's electronic medical record (EMR), with Staff C and Staff E assisting with navigation of the EMR, indicated P14 was triaged on 09/24/23 at 9:24 AM by Staff NN, Physician Assistant, with the chief complaint of "lower abd [abdominal] pain that started when she woke up this morning, took 2 [two] tylenol this morning, vomiting x [times] 3 times, last bm [bowel movement] 9/23 [09/23/23] reports normal, LMP [last menstrual period] 2 days ago."

Review of P14's history of present illness indicated "The patient presents with Abdominal pain. The onset was 2 hours ago. The course/duration of symptoms is constant. Location: Generalized abdomen. The character of symptoms is pain. Risk factors consist of hypertension. Therapy today: see nurses notes. Associated symptoms: nausea, vomiting, Constipation, Blood when wiping, Denies dysuria and denies fever. 38-year-old female patient with a history of HTN [hypertension] on Ozempic presenting to the ED for evaluation of generalized abdominal pain. Patient reports 2 hours ago constant generalized abdominal pain began with associated vomiting x 3, nausea, constipation, and blood when wiping today but denies any associated fevers, back pain, or dysuria. Patient states that she took 2 Tylenol 1.5 [one and a half] hours ago with no relief. Patient reports her last normal bowel movement was yesterday and she normally has bowel movements every other day but this episode is different because of associated pain. She endorses a history of hidradenitis [sic] [painful, long-term skin condition that causes skin abscesses and scarring on the skin] surgery around the abdominal area but denies any abdomen surgery. . ."

Review of P14's review of systems indicated ". . . Gastrointestinal symptoms: Abdominal pain, diffuse, pain, nausea, vomiting, constipation. . ."

Review of P14's vital signs indicated blood pressure 116/80, heart rate 107, respiratory rate 18, and oxygen saturation 100%.

Review of Staff K's (ED Physician/Director) ED note dated 09/24/23 at 10:32 AM indicated "The patient presents with abdominal pain. The onset was 3 hours ago. The course/duration of symptoms is constant. . . A 38-year-old female patient with a PMHx [prior medical history] of PCOS [polycystic ovary syndrome] with baseline irregular periods, prior miscarriages, hidradenitis suppurativa with bilateral axillary and pelvic excisions, and DM [diabetes mellitus] on Ozempic arrives to the ED for evaluation of a constant suprapubic abdominal pain beginning 3 hours ago 0700 [7:00 AM]. She states that when she woke up this morning, she felt a cramping sensation in her abdomen, which felt as if her bladder was full. She reports dysuria with associated hematuria. She states that when she wiped she had some vaginal bleeding. She states that while in the bathroom, she developed nausea with 1 [one] episode of vomiting and diaphoresis. Here in the ED she reports chills. Patient states that her LMP ended 2 days ago. She is sexually active. She states her and her husband are trying for a baby. Patient states that she still has her gallbladder, appendix, uterus, and ovaries. She reports that she felt normal and at her baseline yesterday. VS [vital signs] upon evaluation include HR [heart rate] 100, O2 sat [oxygen saturation] 100% on RA [room air], BP [blood pressure] 113/73. Additional Hx [history] was provided by the patient's friend. . . No OB/GYN.. ."

Review of P14's lab results on 09/23/23 at 12:15 PM indicated Beta hCG POC [quantitative human chorionic gonadotropin (HCG or hCG) blood test measures the specific level of HCG in the blood. HCG is a hormone produced in the body during pregnancy] was greater than 2000.0 Intl [international] Units/mL [per milliliter] ABN [abnormal]; Pregnancy screen, Urine positive; UA [urinalysis] blood positive 3+; UA WBC [white blood cells] 6-10 /HPF [high power field] ABN; UA RBC [red blood cells] greater than 50 /HPF ABN; epithelial cells 11-20 /HPF ABN; UA Hyal [hyaline] Cast 3-5 [LPF] [low power field] ABN.

Review of the ultrasound obstetric less than 14 (fourteen) weeks performed transvaginally performed on 09/23/23 at 11:22 AM indicated "PROCEDURE: US [ultrasound] Pregnancy 1st [first]Trimester.

FINDINGS: Uterus measures 9.7 x 5.1 x 4.6 cm [centimeters]. Endometrial thickness is 1.2 cm.
There are Nabothian [a tiny bump that forms when skin cells trap mucus inside the glands in the cervix] cysts in the cervix. There is a questionable fibroid in the anterior lower uterine segment measuring 1.9 x 2.1 x 1.8 cm. There is no evidence of an intrauterine or extrauterine pregnancy. The left ovary normal in size and morphology. Right ovary is not visualized.

IMPRESSION: No evidence of intrauterine or extrauterine pregnancy. Recommend continued correlation with serial beta-hCGs and followup [sic] ultrasound as warranted. Small fibroid uterus as well as some nabothian cyst."

Review of P14's EMR indicated lab staff reported ". . . the patient's exact hCG is 20,891."

Review of Staff K's medical decision making indicated "patient presents with lower abdominal pain. The patient turned out to have a positive pregnancy test. Beta hCG is over 20,000. The patient had a sonogram which was unremarkable. Patient advised to get a repeat beta-hCG in 48 hours. Patient advised to get a repeat sonogram in 7 [seven] days. Patient advised to call for an appointment with OB/GYN tomorrow. [Staff K documented in ED physician note that P14 did not have an obstetrician/gynecologist] Patient agrees to do so. I have answered all of the patient's questions. I have given the patient's strict return precautions. Patient is aware that this could be an abnormal pregnancy."

Staff K's documentation indicated the treatment and disposition was P14 "will be discharged home. The patient is comfortable and agrees with the disposition plan. All questions have been answered and strict return precautions have been given."

Staff K's documentation on 09/24/23 at 12:37 PM indicated "Discussion of pertinent results, Dx [diagnosis], and plan of discharge with patient. I state that she will need to be started on prenatal vitamins, acquire an OB/GYN, and cease all smoking or drinking. Patient verbalizes agreement with this plan. Patient is clinically stable for discharge. All questions and concerns have been addressed. Patient is comfortable with discharge. They have been given strict return precautions. Notes: On serial evaluation in the emergency department, the patient has remained stable and well appearing. The patient has been in no acute distress."

During a telephone interview on 10/22/24 at 2:07 PM, Staff K stated Staff NN, Physician Assistant, was no longer employed at the hospital and was not available to be interviewed. Staff K stated he/she reviewed the medical record and stated he/she typically orders a transvaginal ultrasound, because one can visualize the intrauterine pregnancy and ovaries the best. He/She stated for 12 to 20 weeks gestation, he/she would do a transabdominal ultrasound. Staff K stated the recommendation at discharge was appropriate. Staff K stated if the repeat hCG rises, he/she would expect an ectopic pregnancy, and the patient may need to see an OB/GYN sooner. If the hCG drops, he/she would expect a miscarriage.

Documentation in the medical record reflected the hospital understood P14's signs and symptoms to be a manifestation of pregnancy of unknown location, including a potential ectopic pregnancy. Review of the entire EMR indicated the available on-call OB/GYN physician was not consulted, despite the hospital's knowledge that P14 did not already have an OB/GYN with whom she could follow-up as advised, and there were no specific arrangements made for P14 to return to the ED, her recommended follow-up care for pregnancy of unknown location. The discharge instructions were unclear as to how or where P14 was to follow-up with an OB/GYN in 1-2 days.