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Based on policy review, medical record review and interviews the hospital failed to ensure that stabilizing treatment was provided for a patient who presented to the hospital's DED for evaluation on 06/07/2020.

The findings include:

1. The hospital failed to ensure that stabilizing treatment was provided for a patient (Patient #3) who presented to the hospital's DED for evaluation of abdominal pain and nausea and vomiting on 06/07/2020.

~cross refer to 489.24(d) (1-3), Stabilizing Treatment - Tag A2407.

Based on policy review, medical record review and interviews the hospital failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition related to abnormal lab values prior to discharge for a patient (Patient #3) who presented to the hospital's DED for evaluation of abdominal pain and nausea and vomiting on 06/07/2020.

The findings included:

Review of hospital policy titled, "EMTALA..." last revised 12/2015 revealed, "...EMTALA is triggered when a person 'comes to the emergency department' and a request is made by that individual ... for an examination or treatment of 'a medical condition' ... The medical screening exam will be provided within the capability of the Hospital's Dedicated Emergency Department and will include ancillary services routinely available to the emergency department ... If it is determined that an Emergency Medical Condition exists ... Stabilize the patient by providing further medical examination and treatment..."

Complainant Subject (Patient #3):

Closed medical record review conducted on 10/13/2020 revealed Patient #3 was a 37-year-old female who presented to Hospital A on 06/07/2020 at 1416 by private vehicle complaining of abdominal pain and nausea and vomiting. Patient #3 was triaged as a Level 3 (Levels are assigned when the patients present to the DED, with Level 1 being the most emergent and Level 5 being the least emergent); and her vital signs at 1521 were: blood pressure (BP) 133/88, pulse (P) 97, respirations (R) 17, pulse oximetry (SPO2) 99 % on room air, and temperature (T) 98.7 F, taken orally. At 1602 Patient #3 reported pain rated at 4 of 10. An MSE was initiated by Nurse Practitioner (NP) #1 at 1524. Review of a Provider Note written by NP #1 on 06/08/2020 at 0054 revealed, "...37-year-old female patient presenting to the emergency department 3 days of nausea and vomiting. Patient denies any diarrhea, fever, or chills. She does report generalized abdominal pain with increased pain to the epigastric area. She states that she threw up bright red blood just prior to arrival. She states it was about one half of a cup. She denies ever having vomited blood in the past. She has had extensive abdominal surgeries to include a (sic) exploratory abdominal surgery after a gunshot wound in 1999 which resulted in a bowel resection. She states a few months later she had a bowel obstruction and had another surgery ... Past Medical History ... Neurological Medical History: Denies: Hx (history) Cerebrovascular Accident, Hx Seizures Traumatic Medical History: Reports: Hx Gunshot Wound - Abdomen Past Surgical History: Reports: Hx Bowel Surgery - Exploratory laparotomy after a gunshot wound ... Laboratory results interpreted by me ... Anion Gap 21 H (high) (high Anion gap is typically produced by too much acid produced by the body) Glucose 269 H ... Urine Glucose (the normal amount of glucose in urine is 0 to 0.8 mmol(millimoles per unit) Diabetes is the most common cause of elevated glucose levels) ... >= (greater than or equal to) 500 H Urine Ketones 80 H ... Discharge Clinical Impression: Nausea and vomiting ... Abdominal pain ... Your work-up today was reassuring. The CAT scan of your abdomen and pelvis did not show any life-threatening causes of your abdominal pain or your vomiting. As discussed it is the best idea to follow-up with a gastroenterologist for possible endoscopy due to the episode of vomiting that you had with blood in it. While waiting to see gastroenterology if your symptoms become worse or you start persistently vomiting blood or you vomit a large amount of blood please return to the emergency department and we will reevaluate you at that time. Take the pain and nausea medicine as prescribed. Follow-up with your primary care provider in the next 3 to 5 days. Call tomorrow to schedule an appointment with the gastroenterologist. Prescriptions: Hydrocodone/Acetaminophen (a pain medication) ... Ondansetron (Zofran - a medication for nausea)..." Medications administered to Patient #3 during the DED visit included Morphine (a pain medication), Zofran, and Pantoprazole (a medication that reduces the acid secreted in the stomach). Patient #3's vital signs at 2122 were: BP 117/82, P 89, R 16, SPO2 95 % on room air, and T 98.0 F, taken orally. At 2136 Patient #3 denied pain. Patient #3 was discharged from the DED on 06/07/2020 at 2137. Review revealed a co-signature on Patient #3's chart by MD (Medical Doctor) #1 on 06/09/2020 at 0324, which read, "I was personally available for consultation in the Emergency Department and serving as supervising physician for the MLP (Mid-Level Provider)." The facility failed to ensure that their own Policy and Procedure was followed as evidenced by failing to provide further medical examination and treatment prior to discharge for patient #3 on 6/7/2020, who had abnormal labs, Metabolic Acidosis, and an elevated anion gap. As the patient required admission for treatment for abnormal labs, and was not stable for discharge.

Patient #3 presented to Hospital B's DED on 06/10/2020 and was subsequently admitted to Hospital B for DKA. Patient #3 was discharged from Hospital B on 06/12/2020 after stabilizing treatment was rendered. Review of a Discharge Note written on 06/12/2020 at 0958 by MD #2 revealed, " ...FINAL DIAGNOSES: 1. Diabetic ketoacidosis. 2. New-onset diabetes mellitus, with a hemoglobin Alc of 10.4. Unclear if this is a late onset type 1 or type 2 diabetes. The laboratory tests have been sent. 3. Acute kidney injury, resolved. 4. Hyponatremia, resolved. 5. Hypokalemia ... MEDICATIONS UPON DISCHARGE ... Lantus (a medication to control blood sugar) 24 units subcutaneously in the a.m. (morning) ... Insulin aspartate/NovoLog (a medication to control blood sugar) 1 unit for every 15 g (grams) of carbohydrates ... DISCHARGE DIET: Diabetic ... DISCHARGE FOLLOWUP: The patient is instructed to contact her case worker for Medicaid for requesting a new primary care provider. She will also have contact information for (Named Primary Care Physician) ... REASON FOR HOSPITALIZATION: The patient is a 37-year-old female, with no past medical history. The patient presented to the emergency room with nausea, vomiting, and abdominal pain for approximately 6 days. Patient also with increasing weakness, fatigue, as well as excessively thirsty. The patient went to (Hospital A Onslow Memorial Hospital ) 3 days prior and had a CT scan of the abdomen and pelvis that was unremarkable. She does not remember anything about her blood work. She was discharged home on Zofran. The patient continued to have vomiting and crampy abdominal pain. She presented to (Named Hospital B), which showed she had initial blood glucose of 461. Her CO2 was less than 10. She had a venous blood gas, which showed a pH of 7.17, pC02 of 22, and a bicarb of 8. The patient was appropriately diagnosed with new-onset diabetes mellitus and she was admitted to the ICU for further monitoring. Again, the patient was admitted to the ICU per the DKA protocol. She was on IV insulin drip ... This is a brand new diagnosis for the patient. She never had any issues with gestational diabetes. She has no significant past medical history whatsoever. She was transitioned off the insulin drip and started on Lantus. She has received a significant amount of education from (Named Hospital B Staff) to help with this transition. She has been able to give herself the insulin shots. She has been receptive to teaching about the diabetic diet as well as learning how to administer her insulin with regards to carbohydrates as well as corrective dosing as well ... The patient, overall, is feeling much better. She is ready to go home. She is comfortable with the insulin shots, She denies any chest pain. There is no further crampy abdominal pain. No nausea or vomiting. She is tolerating a diet..."

Telephone interview was conducted with NP #1 on 10/13/2020 at 1340. Interview revealed NP #1 recalled Patient #3 as her Medical Director brought Patient #3 to NP #1's attention approximately 2 weeks after care was provided. Interview revealed NP #1 did not see Patient #3's laboratory studies prior to discharge. NP #1 recalled having 3 female patients with abdominal pain at the same time, in rooms next to each other. Interview revealed Patient #3 was in room 34, and a nurse reported that "34 felt better and wanted to go home." NP #1 advised she said, "OK I'll write her up for discharge." Interview revealed, "I must have looked at one of the other patient's labs. That was a mistake on my part." Interview revealed upon review of Patient #3's laboratory values she "absolutely had new onset diabetes and was in DKA (Diabetic Ketoacidosis - when the blood sugar is too high, and the blood begins to become acidic). She (Patient #3) should have been admitted to the hospital." Interview revealed NP #1's medical director recommended always re-checking laboratory and any imaging orders prior to any patient's discharge to avoid future confusion.

Telephone interview was conducted on 10/13/2020 at 1517 with the Dedicated Emergency Department Medical Director (DED MD). Interview revealed he was aware of Patient #3's case. Interview revealed it appeared NP #1 was confused on the patient's lab values. Interview revealed midlevel practitioners were not expected to consult with their oversight physicians on every patient they see, for example the level 4 and 5 patients. Some Level 3 patients may require oversight physician consult, depending upon the comfort level of the midlevel practitioner when providing care. Any care provided by a midlevel practitioner to a Level 1 or 2 patient would require oversight provider consult. Interview revealed if NP #1 had looked at Patient #3's lab values correctly she would have been expected to communicate with her oversight provider.

Telephone interview was conducted on 10/14/2020 at 1000 with MD #1. Interview revealed MD #1 did not recall Patient #3. MD #1 had reviewed Patient #3's case with the DED MD. Interview revealed if Mid-Level Providers had concerns with any patients it was customary for them to bring those concerns to the oversight physician, but that did not occur in this case. Interview revealed MD #1 felt confident that if NP #1 had reviewed Patient #3's labs correctly, "she would have brought them to my attention."

NC00167522