HospitalInspections.org

Based on medical record review and physician interview, Emergency Department (ED) staff failed to notify a patient of their final lab result post emergency department discharge for one of 14 patients discharged from the ED.

The findings included:

Review on 02/13/2024 of the closed medical record for Patient #11 revealed a 54-year-old male who presented to Campus B DED (Dedicated Emergency Department) on 05/11/2022 at 2154 with a chief complaint of "Blood in Stool." Review of the Triage note dated 05/11/2022 at 2211 revealed "Blood in stool started today. Had CT (computed tomography - computerized x-ray images that make a series of detailed pictures of areas inside the body) this morning in Puerto Rico. Started in cipro (sic). Vital Signs at 2213 revealed "Temp (temperature): 36.4 ... Heart Rate: 93 ... Resp (respirations): 16; BP (blood pressure): 126/93 ... SpO2 (oxygen saturation) 97%; O2 (oxygen) Device: None (Room air) ..." Patient #11 was assigned a "Patient Acuity:3" at 2216. Review of the Complete Blood Count (CBC) with Differential at 2240 revealed an abnormal result with elevated white blood cells and elevated absolute neutrophils. Review of the Comprehensive metabolic panel (CMP) at 2255 resulted an abnormal result with low sodium, low chloride, low alkaline phosphatase, elevated creatinine and elevated ALT (alanine transaminase - enzyme found in liver released in blood when liver is damaged). Review of the Provider note at 2302 revealed " ... male ... presents to the emergency department with blood in his stool. Patient was just in Puerto Rico for the last 2 weeks. Last night, he had some scant blood on the surface of his stools as well as loose stools. He went to the emergency department in Puerto Rico where CT of the abdomen and pelvis was performed that showed evidence of colitis, without diverticulitis, perforation or abscess formation. He has the CT report with him. He was given a dose of IV (intravenous) Decadron and started on oral ciprofloxacin as well as oral prednisone, with tramadol for breakthrough pain. Today he has had a few more episodes of where he has had some streaks of blood in his stool. He remains with diarrhea. He and his wife are concerned about ongoing blood in his stool which is what prompted him to come to the emergency department. He reports some generalized abdominal cramping but reports this feels significantly improved compared to last night. He denies any fever or chills. He denies any testicular or urinary discomfort. Denies any chest pain or shortness of breath. He denies any neurologic sequela including difficulty speaking, unilateral limb weakness or difficulty walking ... MEDICAL DECISION MAKING & ED COURSE ... Differential diagnosis includes, but is not limited to: Diverticulosis, lower GI (gastrointestinal) bleed, infectious colitis, constipation, gastroenteritis, enteritis. He does have a printout of the CT performed earlier this morning that showed diffuse colitis but without any evidence of diverticulitis, abscess formation or perforation. He has a benign abdominal exam without any focal tenderness to palpation and without any peritoneal signs. Given that he is not complaining of any abdominal pain now and is currently afebrile, ... Patient is well-appearing ... will proceed with a rectal exam to rule out any other source of bleeding or significant melena that may need evaluation with a colonoscopy. GI pathogen panel ordered and the patient was able to provide a stool sample. Will obtain a CBC and CMP as well. His wife is concerned because they were unable to cover for anaerobes given that he does have a Flagyl sensitivity, and requesting reevaluation of his current antibiotic therapy. Update: Patient's rectal exam showed no evidence of gross blood, no melena, Hemoccult negative. He does not have any internal or external hemorrhoids or fissures ... He does have a mild white count of 13,700. His hemoglobin is normal ... and given the findings on his rectal exam it does not appear that he has any significant ongoing bleeding. Given that he was currently in Puerto Rico, do feel that antibiotics are currently still warranted as I suspect his colitis is infectious in nature. However he is afebrile and has no clinical findings of sepsis. His CMP was reviewed and is unremarkable. GI pathogen panel was sent. I do feel the patient is appropriate for outpatient management. His ciprofloxacin was changed to moxifloxacin to offer anaerobic coverage. He has no peritoneal signs and a nonsurgical abdomen and his vital signs are reassuring ... did encourage him to discontinue prednisone as I doubt this is inflammatory as he has no personal history of Crohn's or ulcerative colitis ... did review that he is to follow-up with a GI physician for colonoscopy once his symptoms improve. His wife already has a GI, and will prefer to self refer, which I do feel is reasonable. He was given return precautions to return immediately to the ED for any new or concerning symptoms including high fever, any new or worsening abdominal pain, or any other concerns. He and his wife with (sic) verbalized understanding ... FINAL IMPRESSION: 1. Colitis; DISPOSITION: Discharged home in stable condition with return precautions provided. Review of the ABO/Rh (blood group type/positive or negative) at 2322 revealed "A POS (blood type A Positive)". Review of the Provider Orders revealed a GI Pathogen Panel was ordered on 5/12/2022 at 0103 and collected at 0114. Review of the ED Care Timeline revealed at 0104 the "ED Disposition was set to Discharge." Patient #11 was discharged from the ED at 0124. The GI Panel resulted on 05/12/2022 at 0302 positive for Shiga-like Toxin Producing E. coli PCR (polymerase chain reaction) and E-Coli (Escherichia coli - bacteria). Review of the Pharm D note on 05/12/2022 at 1235 revealed "Spoke with (MD #3) regarding patient's culture and antibiotic regimen prescribed from previous ED visit. Per (MD #3), it is recommended to keep current antibiotic regimen and make no change. No need for follow-up." Medical record review revealed no telephone call to Patient #11 after discharge with his GI Panel results.

Telephone interview on 02/14/2024 at 1035 with RN #2 revealed she did not remember Patient #11. Interview revealed she could only read what she documented in the medical record for Patient #11.

Telephone interview on 02/14/2024 at 1320 with MD #1 revealed Patient #11 was diagnosed with infectious colitis. The antibiotics Patient #11 was prescribed would take care of the symptoms of colitis, technically the patient should not have been on antibiotics. Interview revealed Patient #11 was given handwashing and transmission precautions to prevent the transmission of e-coli to others.

NC00188683, NC00188849, NC00195463, NC00197271