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Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to ensure that an emergency medical condition (EMC) was stabilized prior to being discharged, for one patient (#27) out of 31 Emergency Department (ED) sampled cases from 08/09/22 through 01/09/23. The hospital's average monthly ED census over the past six months was 841.

Findings included:

Review of the hospital's policy titled, "Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA)," dated 09/21/22, showed that all persons receive an appropriate MSE within the Hospital's capability to determine whether or not an EMC exists. A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his or her continued care, including diagnostic work up and/or treatment, could be subsequently performed as an inpatient or outpatient, provided the patient is given a plan for appropriate follow up care with the discharge instructions.

Review of Patient #27's ED medical record showed:
- He was an 88-year-old male who presented to the ED on 11/13/22 at 6:27 PM for chief complaint of flank pain. He resided at Facility C, Nursing Home, and reported he had fallen a couple of weeks prior. He had a past medical history of anemia (low amounts of oxygen rich blood, causes paleness and weakness), high blood pressure, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), long term use of blood thinners, congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), kidney failure for which he received dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), falls, fractures of the lower back, anxiety (a feeling of fear or worry experienced intermittently) and depression (extreme sadness that does not go away).
- Head computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan and a neck CT scan were normal, but an abdomen and pelvis CT scan showed retroperitoneal edema (swelling in the space in front of the lower back and behind the abdominal lining), bilateral pleural effusions and pulmonary edema (an abnormal buildup of fluid in the lungs) suggestive of CHF, and an abdominal aortic aneurysm (AAA, enlargement of the main blood vessel that delivers blood to the body at the level of the abdomen, can be life threatening if it bursts) which had increased in size since the previous examination, below the kidneys.
- A chest x-ray (test that creates pictures of the structures inside the body-particularly bones) was ordered for shortness of breath and showed pulmonary edema and pleural effusions suggestive of CHF.
- He was discharged back to Facility C on 11/14/23 at 4:08 AM.
- He presented for a second time to the ED on 11/14/22 at 6:31 PM, with a chief complaint of left flank pain. Facility C, had not filled the prescription for pain medication from the first visit and they were unable to control his pain, so they sent him back to the ED for pain control. He was discharged back to Facility C on 11/15/22 at 12:36 AM.
- He presented a third time to the ED on 11/15/22 at 2:06 AM, with a chief complaint of chest and back pain. The patient received multiple medications and was diagnosed with shingles (viral infection that causes a painful rash). The patient was transferred to Hospital B with mental status changes, for a higher level of care, on 11/15/22 at 5:10 PM. The patient expired on 11/20/22 at Hospital B from pulmonary edema (an abnormal buildup of fluid in the lungs).

Please see citations at A-2407 for further details.



















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Based on interview, record review and policy review, the hospital failed to stabilize within its capabilities, one patient's (#27's) emergency medical condition (EMC) prior to discharge, out of 31 sampled cases from 08/09/22 through 01/09/23. The hospital's average monthly ED census over the past six months was 841.

Findings included:

Review of the hospital's policy titled, "Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA)," dated 09/21/22, showed that all persons receive an appropriate MSE within the Hospital's capability to determine whether or not an EMC exists. A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his or her continued care, including diagnostic work up and/or treatment, could be subsequently performed as an inpatient or outpatient, provided the patient is given a plan for appropriate follow up care with the discharge instructions.

Review of Patient #27's medical record from Hospital A showed the following:
- He was an 88-year-old male who presented to the ED on 11/13/22 at 6:27 PM, for a chief complaint of flank pain. He reported that he had fallen a couple weeks prior. He had a past medical history of anemia (low amounts of oxygen rich blood, causes paleness and weakness), high blood pressure, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), long term use of blood thinners, congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), kidney failure for which he received dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), falls, fractures of the lower back, anxiety (a feeling of fear or worry experienced intermittently) and depression (extreme sadness that does not go away).
- Head computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan and a neck CT scan were normal, but an abdomen and pelvis CT scan showed retroperitoneal edema (swelling in the space in front of the lower back and behind the abdominal lining), bilateral pleural effusions and pulmonary edema (an abnormal buildup of fluid in the lungs) suggestive of CHF, and an abdominal aortic aneurysm (AAA, enlargement of the main blood vessel that delivers blood to the body at the level of the abdomen, can be life threatening if it bursts) which had increased in size since the previous examination, below the kidneys.
- A chest x-ray (test that creates pictures of the structures inside the body-particularly bones) was ordered for shortness of breath and showed pulmonary edema and pleural effusions suggestive of CHF.
- Lasix (medication used to treat water retention, swelling, and high blood pressure) was administered on 11/14/22 at 1:32 AM.
- Patient #27 was given intravenous (IV, in the vein) dilaudid (an opioid medication used to treat severe pain) at 1:53 AM, and droperidol (a sedative medication) at 2:27 AM.
- Patient #27 was discharged on 11/14/22 at 4:08 AM, back to Facility C, Nursing Home. A prescription for Oxycodone-acetaminophen (Percocet, a medication with two different pain medications, one being a synthetic pain medication with a high risk for misuse, the other an over-the counter pain and fever reducer) was sent to Patient #27's pharmacy. Discharge diagnosis included abdominal pain, AAA without rupture, anemia and CHF.
- On 11/14/23, after completion of his routine outpatient dialysis (routine outpatient dialysis was done on Mondays and Fridays at 9:30 AM) and returning to Facility C, Patient #27 continued to complain of left flank pain, and presented a second time to the ED at 6:31 PM. He was discharged back to Facility C on 11/15/22 at 12:36 AM.
- Patient #27 presented a third time to the ED on 11/15/22 at 2:06 AM, with a chief complaint of chest and back pain and was transferred to Hospital B for a higher level of care on 11/15/22 at 5:10 PM. Patient #27 passed away on 11/20/22 from pulmonary edema.

Review of Patient #27's medical record from Hospital B showed the following:
- He was admitted on 11/15/22 at 7:03 PM to Hospital B for recurrent falls and acute metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood caused by an illness or organs that are not working as well as they should).
- A history and physical, dated 11/15/22 at 7:14 PM, showed Patient #27 had been seen in Hospital A's ED on 11/14/22 after a fall and again on 11/15/22 (patient initially presented to Hospital A on 11/13/22, returning to Facility C on 11/14/22 and then presented again on 11/14/22 and 11/15/22). During his stay in the ED, he had increased restlessness and agitation. He was found to have a rash in his left flank region, which was concerning for shingles. Given his change in mental status and rash, there was a concern for encephalitis (inflammation of the brain, caused by infection or an allergic reaction). Patient #27 was in mild distress, shouting from pain, followed commands, and was oriented times one (to self only).
- A death discharge summary, dated 11/20/22, showed Patient #27 was hospitalized for altered mental status. He became hypoxic, a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called, and he was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for a heated high flow nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostril and delivery of oxygen). Imaging studies showed pulmonary edema (an abnormal buildup of fluid in the lungs). Patient #27 underwent aggressive dialysis. Despite interventions, his hypoxia worsened and he had to work harder to breathe. Patient #27's case was discussed with his family, and they ultimately chose to transition him to comfort measures.

During a telephone interview on 01/11/23 at 11:05 AM, Staff S, Physician, stated that he treated Patient #27 in the ED for all three of his visits. Patient #27 was anxious, agitated and just wanted to go home. Facility C, Nursing Home, seemed to have issues with everything going on with Patient #27. Patient #27 was anxious and easily agitated, but Staff S was familiar with Patient #27 and felt that he was at his baseline.

During a telephone interview on 01/12/22 at 10:42 AM, Staff W, Administrator for Facility C, Nursing Home, stated that Patient #27 complained of intermittent flank pain on 11/13/22. He was sent to Hospital A, where they "did not find anything wrong" and he was discharged back to Facility C on 11/14/22. He went to dialysis on 11/14/22 and started to complain of pain that evening and requested to go back to the ED. The ED staff said Patient #27 was impulsive and confused and he did not usually have those behaviors. She was notified and called Staff A, DON of Hospital A, voiced her concerns and requested that Patient #27 be observed for an hour. The ED agreed. Staff X went to assess Patient #27 at the ED and was concerned, but the ED staff assured her that there was nothing further that the ED could do for Patient #27. Staff X transported Patient #27 back to Facility C and was only there for approximately 45 minutes when Patient #27 was screaming in pain, making incoherent statements and he was "not at his baseline at all." Facility C staff had to put Patient #27 on oxygen and were concerned he was having a heart attack, so they called EMS and sent him back to the ED. At that time, there was still no answer for the flank pain. Facility C staff called the ED on 11/15/22 around 2:00 PM and were told that Patient #27 was being transferred.

During a telephone interview on 01/12/23 at 3:17 PM, Staff X, DON of Facility C, Nursing Home, stated that Patient #27 had complained of severe left flank pain on 11/13/22 and had been sent to Hospital A. He was discharged on 11/14/22 and received dialysis later that day (at Facility C). When he returned, he was complaining of left flank pain. She assessed him and saw a rash that looked like shingles (viral infection that causes a painful rash) on his torso. She informed Facility C's physician, who ordered that Patient #27 be sent to the ED for evaluation. She specifically relayed her concern for altered mental status (mental functioning ranging from slight confusion to coma) and the rash to the ED for his 11/14/22 visit. She called Staff A, DON of Hospital A, to ask for Patient #27 to be admitted for observation, and Staff A told her she would call her back. Staff A called back and said to pick up the patient. Staff X went to pick Patient #27 up herself. By the time she got back to Facility C, Patient #27 was oriented times one, incoherent, screaming, said he had chest pain, and his oxygen saturation was dropping. EMS was called and Patient #27 was transported to Hospital A's ED. He was always oriented times four, though on dialysis days, he could be very cantankerous.

During an interview on 01/11/23 at 11:35 AM, Staff T, Physician, stated that she took over care for Patient #27 the morning of 11/15/22 when Staff S, Physician, finished his shift. Staff S reported to her that it was Patient #27's third visit to the ED for the same thing. Staff S told her that he was concerned Facility C, Nursing Home, had not been providing appropriate care to Patient #27 so he spoke with social services who told him that not much could be done. Patient #27 had a work up, had been given pain medications and he was ready for discharge from the ED. She did not expect to have to care for Patient #27, but when she spoke with staff from Facility C they were concerned about Patient #27's mental status changes. Staff S had not reported mental status changes in his report to her. She reviewed her notes from when she had treated Patient #27 in the past and determined that he was different from his baseline. Nursing staff reported to her that when she was turning Patient #27 she noted a rash. She became concerned that Patient #27 could be suffering from herpes encephalitis (inflammation of the brain, caused by the herpes simplex virus). He also had received several medications for pain, doses of dilaudid and ativan and maybe too much medication was the cause of his behavior.