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Based on review of facility policy, review of the Emergency Department (ED) Central Log, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination and failed to provide stabilizing treatment for one patient (Patient #29) who presented to the ED with flank pain of 32 ED patients reviewed.

The findings included:

Patient #29 presented to the ED on 7/8/2021 at 3:02 PM with back and flank pain and shortness of breath. He was triaged with an Emergency Severity Index (ESI) score of a 4, indicating non-urgent needs. The patient's vital signs were obtained in triage, excluding a temperature. A Medical Screening Examination (MSE) was completed for the patient. A chest x-ray was done, which showed inflammatory/pneumonia findings. No further diagnostic testing was ordered related to the chest x-ray findings. On 7/9/2021 the patient presented to Facilty B where a diagnosis of pneumonia was found and the patient was sent to Facilty C for further treatment. At facility C a Computed Tomograpy (CT) of the chest was performed which showed pneumonia, a left pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs) and a partially collapsed left lung. Patient #29 was admitted to Facility C where a chest tube was inserted and the patient was started on antibiotic therapy.

Refer to A-2406 and A-2407

Based on review of facility policy, review of the Emergency Department (ED) Central Log, medical record review, and interviews, the facility failed to provide an appropriate Medical Screening Examination for one patient (Patient #29) who presented to the ED with flank pain of 32 ED patients reviewed.

The findings included:

Review of the facility's policy titled EMTALA [Emergency Medical Treatment and Labor Act], last revised 11/1/2019, showed "...Medical Screening Examination: all individuals who come to a DED [dedicated emergency department] for examination or treatment...shall receive an appropriate Medical Screening Examination [MSE]...[MSE] is the process required to reach, within reasonable confidence, the point at which it can be determined whether an Emergency Medical Condition exists. The scope of the examination must be tailored to the presenting complaint and medical history of the patient. The process may range from a simple examination [such as a brief history and physical] to a complex examination that may include laboratory test...diagnostic imaging, lumbar punctures, other diagnostic test and procedures and the use of on-call physician specialists..."

Review of the ED Central Log showed Patient #29 presented to Facility A's ED on 7/8/2021 at 3:02 PM with complaints of back pain and muscle spasms. He was discharged home on 7/8/2021 at 5:44 PM.

Medical record review of an ED Nurse's Triage record from Facility A dated 7/8/2021 at 3:22 PM showed Patient #29 complained of back pain and muscle spasms. The patient's vital signs were as follows: Blood pressure 131/75, Pulse 88, Respirations 20, and Pulse Oximetry 95% on room air. There was no temperature documented. The patient was triaged using the Emergency Severity Index (ESI) as a level a 4, indicating the patient had non-urgent needs.

Medical record review of an ED Provider's Note by a Mid-Level Practitioner at Facility A dated 7/8/2021 at 3:29 PM showed Patient #29 had "...complaints of pain starting in his shoulder blade and spasms a couple weeks ago. Was treated for URI [upper respiratory infection] with steroids and doxycycline [antibiotic] eased off. Started hurting again. Now radiating around his lateral chest to his anterior chest. States the pain makes him feel short of breath. No coughing or fever...reports initially nothing makes it better or worse but seems to have worsening with movement while sitting in the wheelchair. States he did work on his truck and then tried to go to work today and thinks it may have exacerbated symptoms..." Documentation of a physical examination showed the patient had pain to the left lateral chest and to the right chest wall, bilateral breath sounds, and complained of shortness of breath and chest pain. Further review revealed the Mid-Level Practitioner order a chest x-ray for Patient #29. No further diagnostic tests were ordered.

Medical record review of a Chest X-Ray Imaging report from Facility A dated 7/8/2021 at 4:25 PM showed "...comparison with 1/9/2018 chest x-ray...detail mildly limited due to shallow inspiration and respiratory motion on the lateral view. Moderate worsening. Shallow inspiration...mild to moderate bibasilar [bottom of the lungs] opacities [indicates something else where air should be] extending into the perihilar [lower part of the chest]/infrahilar [central part of the chest] regions left greater than right associated with patchy ill-defined parenchymal [substance denser than air] based opacities. No gross effusion seen on lateral view. Findings are nonspecific but suggest multifocal inflammatory/pneumonia like process...asymmetric pattern suggest multifocal inflammatory/pneumonia like process. Short term follow-up two view chest exam with medical management recommended..."

Medical record review of an ED Provider's Note from Facility A dated 7/8/2021 at 5:14 PM showed "...patient here with pain around his shoulder blade to lateral chest and anterior chest feels like a muscle spasm. Pain is easily reproducible to palpation. Nonspecific findings on chest x-ray. States he got short of breath only with pain. Denies fever or cough..."

Medical record review of the Patient Discharge Instructions for Patient #29 at Facility A dated 7/8/2021 at 5:44 PM showed the patient was given instructions for muscle spasms and discharged home. Further review revealed the patient's vital signs were not re-assessed at the time of discharge.

Medical record review of an Urgent Care Progress Note from Facility B dated 7/9/2021 at 7:26 PM showed Patient #29 presented to the clinic with back pain. His vital signs were as follows: blood pressure 135/72, pulse 96, pulse oximetry 94% on room air, and Temperature 102.2 Fahrenheit (F). Further review showed "...[Patient #29] was at the ED last night and was given pain medicine and a muscle relaxer for back pain. Chest x-ray was read today and showed that he has pneumonia he is now running fever 102.2° F...recommend she [spouse] take him over to the ER [emergency room] she understands is going to take him now..."

Medical record review of an ED Provider Record from Facility C dated 7/9/2021 at 8:12 PM showed Patient #29 presented to the ED with left side pain/muscle spasms for 4 days. The patient advised the ED Provider at Facility C that he was seen in the ED at Facility A the day before and was diagnosed with Muscle Spasms. He reported his pain was worse and he had developed a fever with shortness of breath. His physical examination showed decreased breath sounds to the left side with shortness of breath. Laboratory and radiological diagnostic testing were ordered for the patient.

Medical record review of Laboratory Diagnostic Testing from Facility C dated 7/9/2021 showed the patient's White Blood Count (WBC) was 25.3 (normal 3.5-10.5)

Medical record review of a Radiology Report of a Computed Tomography (CT) of the Chest from Facility C dated 7/9/2021 showed Patient #29 had a large pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs) with multiple areas of loculation (divided into sections), near complete collapse of the left lower lobe and lingula (tip of the upper lobe) with consolidation (lung filled with something other than air) and air bronchograms (something other than air in the alveoli of the bronchus). Differential considerations included compressive atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) versus pneumonia. Clinical correlation showed "...trace of fluid within in the apical pericardial space [fluid filled space within the pericardium of the heart] with adjacent stranding of the mediastinal fat [fatty tissue within the normal fatty structure of the heart]. May be related to suspected infection of the left lung, however, the causes of pericardial inflammation such as pericarditis [swelling and irritation of the tissue surrounding the heart] not excluded..."

Medical record review of an ED Clinical Disposition note at Facility C dated 7/9/2021 at 11:37 PM showed a diagnosis of Community Acquired Pneumonia with collapsed lung to the Left Lower Lobe, Sepsis (a life-threatening complication of an infection), and a Left Pleural Effusion. The hospitalist was consulted, and the patient was admitted to Facility C.

During a telephone interview on 7/19/2021 at 12:15 PM, Patient #29's spouse stated the patient presented to Facility A on 7/8/2021 with left shoulder pain, rib pain, muscle spasms, and shortness of breath. He was triaged and placed in an area in the ED where he was seen by a provider in the ED and a chest x-ray was done. He received a muscle relaxer injection and pain medications but no lab work or any other tests. The patient was told he had pneumonia and was given prescriptions for pain medications and a muscle relaxer and sent home. His pain continued along with shortness of breath. On 7/9/2021 he could not lay down related to shortness of breath and the pain, so the patient went to Facility B where they were told his chest x-ray (done at Facility A on 7/8/2021) showed pneumonia. The patient was told he needed to go to (Facility C) and be evaluated in the ED. The patient's wife stated the patient had a fever of 102.2, an elevated heart rate, and low oxygen levels. His white blood count was 25 and he was septic. A CT scan of the chest was completed which showed pneumonia, fluid in his pleural cavity, and he required a chest tube related to a partially collapsed lung. The patient was admitted to the hospital and was discharged on 7/15/2021.

During an interview on 7/20/2021 at 1:50 PM the ED Nurse Manager at Facility A stated the patient presented with back pain and spasms on 7/8/2021. He was diagnosed with muscle spasms and was given pain medications and muscle relaxers. The ED Nurse Manager confirmed there was no temperature documented in the triage record for Patient #29 and "...we normally obtain a full set of vital signs for all patients..."

During an interview on 7/20/2021 at 3:30 PM, Nurse Practitioner (NP) #1 at Facility A stated Patient #29 presented with flank pain and muscle spasms. The patient stated he had been working on his truck and felt like he was having muscle spasms. His pain was reproduceable with touch and had some tenderness to his left flank area. He denied any fever but did complain of some shortness of breath and pain. His chest x-ray showed some non-specific changes. NP #1 stated "...the chest x-ray report showed some inflammatory/pneumonia and/or cardiogenic [caused by a cardiac condition] versus noncardiogenic ...I did not feel laboratory diagnostic testing was indicated at that point...normally I would consult with the attending physician regarding the patient's clinical presentation and findings...related to his clinical presentation, the nonspecific chest x-ray findings, he denied any fever or infectious complaints, I felt this was musculoskeletal pain and treated him as such..." NP #1confirmed no further diagnostic testing was completed related to the chest x-ray findings.

During a telephone interview on 7/20/2021 at 4:35 PM, ED Physician #1 at Facility A stated she did not specifically remember the patient. ED Physician #1 stated she had signed onto the patient's record on 7/8/2021 at 9:03 PM but did remember seeing the patient while he was in the ED. ED Physician #1 stated"...the chest x-ray may have shown some atelectasis which may be indicative of pneumonia, cardiac, or other findings but clinical correlation would be appropriate for the patient..."

During a telephone interview on 7/21/2021 at 9:00 AM, Radiologist #1 at Facility A stated he had reviewed Patient #29's chest x-ray on 7/8/2021 which was compared to a previous chest x-ray which was performed on 1/9/2018. Radiologist #1 stated "...there was some acute changes with comparison to the x-ray on 1/9/2018...[the x-ray done on 7/8/2021] showed some opacities with possible pneumonia which was worse on the left side. We [Radiologists] do not see the patient but give the clinical providers suggestive findings and they treat the patient based on the clinical findings...there were suggestions of atelectasis which would need to be clinically correlated to the patient's presentation. There was a left asymmetric pattern which may be suggestive of an infection/pneumonia pattern...a chest x-ray was a good place to start related to the pulmonary cause, but a CT scan of the chest would be more sensitive to show the real cause of the problem which would show a pleural effusion, atelectasis, or a collapsed lung. In addition, the patient's clinical presentation, the presence of a fever, elevated WBC, or respiratory symptoms would be diagnostic in conjunction with the chest x-ray..."

During an interview on 7/21/2021 at 9:45 AM, Registered Nurse (RN) #1 stated she completed the patient's triage on 7/8/2021. RN #1 stated a full set of vital signs was normally completed in triage. RN #1 confirmed no temperature was documented for Patient #29.

Based on review of the Emergency Department (ED) Central Log, medical record review, and interviews, the facility failed to provide stabilizing treatment for one patient (Patient #29) who presented to the ED with flank pain of 32 ED patients reviewed.

The findings included:

Review of the ED Central Log showed Patient #29 presented to Facility A's ED on 7/8/2021 at 3:02 PM with complaints of back pain and muscle spasms. He was discharged on 7/8/2021 at 5:44 PM.

Medical record review of an ED Nursing Triage record from Facility A dated 7/8/2021 at 3:22 PM showed Patient #29 presented to the ED with back pain and muscle spasms. The patient's vital signs were as follows: Blood pressure 131/75, Pulse 88, Respirations 20, and Pulse Oximetry 95% on room air. There was no temperature documented. He was triaged using the Emergency Severity Index (ESI) as a level a 4, indicating the patient had non-urgent needs.

Medical record review of an ED Provider Note by a Mid-Level Practitioner at Facility A dated 7/8/2021 at 3:29 PM showed Patient #29 had "...complaints of pain starting in his shoulder blade and spasms a couple weeks ago. Was treated for URI [upper respiratory infection] with steroids and doxycycline [antibiotic] eased off. Started hurting again. Now radiating around his lateral chest to his anterior chest. States the pain makes him feel short of breath. No coughing or fever...reports initially nothing makes it better or worse but seems to have worsening with movement while sitting in the wheelchair. States he did work on his truck and then tried to go to work today and thinks it may have exacerbated symptoms..." Documentation of a physical examination showed the patient had pain to the left lateral chest and to the right chest wall, bilateral breath sounds, and complained of shortness of breath and chest pain.

Medical record review of a Chest X-Ray Imaging report from Facility A dated 7/8/2021 at 4:25 PM showed "...comparison with 1/9/2018 chest x-ray...detail mildly limited due to shallow inspiration and respiratory motion on the lateral view. Moderate worsening. Shallow inspiration...mild to moderate bibasilar [bottom of the lungs] opacities [indicates something else where air should be] extending into the perihilar [lower part of the chest]/infrahilar [central part of the chest] regions left greater than right associated with patchy ill-defined parenchymal [substance denser than air] based opacities. No gross effusion seen on lateral view. Findings are nonspecific but suggest multifocal inflammatory/pneumonia like process...asymmetric pattern suggest multifocal inflammatory/pneumonia like process. Short term follow-up two view chest exam with medical management recommended..."

Medical record review of the Medication Administration Record from Facility A dated 7/8/2021 showed the following medications were administered to Patient #29:
3:59 PM: Hydrocodone (pain medication) 5/325 milligrams (mg) 1 tablet by mouth
4:02 PM: Norflex (muscle relaxer) 60 mg intramuscular (IM)

Medical record review of an ED Provider Note from Facility A dated 7/8/2021 at 5:14 PM showed "...patient here with pain around his shoulder blade to lateral chest and anterior chest feels like a muscle spasm. Pain is easily reproducible to palpation. Nonspecific findings on chest x-ray. States he got short of breath only with pain. Denies fever or cough..."

Medical record review of the Patient Discharge Instructions for Patient #29 at Facility A dated 7/8/2021 at 5:44 PM showed the patient was given instructions for muscle spasms and discharged home. Further review revealed the patient's vital signs were not re-assessed at the time of discharge.

Medical record review of an Urgent Care Progress Note from Facility B dated 7/9/2021 at 7:26 PM showed Patient #29 presented to the clinic with back pain. His vital signs were as follows: blood pressure 135/72, pulse 96, pulse oximetry 94% on room air, and Temperature 102.2 ° Fahrenheit (F). Further review showed "...[Patient #29] was at the ED last night and was given pain medicine and a muscle relaxer for back pain. Chest x-ray was read today and showed that he has pneumonia he is now running fever 102.2° F...recommend she [spouse] take him over to the ER [emergency room] she understands is going to take him now..."

Medical record review of an ED Nursing Triage from Facility C dated 7/9/2021 at 8:02 PM showed "...seen in ED for left rib pain with back spasms, fever, was diagnosed with pneumonia prior to arrival reports symptoms have been present from Tuesday, and a medical screening exam was performed..."

Medical record review of an ED Provider Record from Facility C dated 7/9/2021 at 8:12 PM showed Patient #29 presented to the ED with left side pain/muscle spasms for 4 days. The patient advised the ED Provider at Facility C that he was seen in the ED at Facility A the day before and was diagnosed with Muscle Spasms. He reported his pain was worse and he had developed a fever with shortness of breath. His physical examination showed decreased breath sounds to the left side with shortness of breath. Laboratory and radiological diagnostic testing were ordered for the patient.

Medical record review of Laboratory Diagnostic Testing from Facility C dated 7/9/2021 showed the patient's White Blood Count (WBC) was 25.3 (normal 3.5-10.5)

Medical record review of a Radiology Report of a Computed Tomography (CT) of the Chest from Facility C dated 7/9/2021 showed Patient #29 had a large pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs) with multiple areas of loculation (divided into sections), near complete collapse of the left lower lobe and lingula (tip of the upper lobe) with consolidation (lung filled with something other than air) and air bronchograms (something other than air in the alveoli of the bronchus). Differential considerations included compressive atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) versus pneumonia. Clinical correlation showed "...trace of fluid within in the apical pericardial space [fluid filled space within the pericardium of the heart] with adjacent stranding of the mediastinal fat [fatty tissue within the normal fatty structure of the heart]. May be related to suspected infection of the left lung, however, the causes of pericardial inflammation such as pericarditis [swelling and irritation of the tissue surrounding the heart] not excluded..."

Medical record review of an ED Clinical Disposition note at Facility C dated 7/9/2021 at 11:37 PM showed a diagnosis of Community Acquired Pneumonia with collapsed lung to the Left Lower Lobe, Sepsis (a life-threatening complication of an infection), and a Left Pleural Effusion. The hospitalist was consulted, and the patient was admitted to Facility C.

Medical record review of an Admission History and Physical from Facility C dated 7/10/2021 at 12:49 AM showed Patient #29 had continuous left side pleuritic pain that had worsened over the past 3 days. The patient developed pleuritic pain with feelings of "muscle spasms" and had also developed a fever. A CT of chest was performed which showed "...large left pleural effusion with multiple areas of loculation as well as near collapse of left lower lobe and lingula with consolidation and air bronchograms. Labs showed white count of 25 and patient had a fever of 102°. He was also tachycardiac [fast heart rate]. He was given Solu-Medrol [steroid], Ceftriaxone [antibiotic], and Azithromycin [antibiotic]..." Patient #29 was diagnosed with Sepsis, Acute Hypoxic Respiratory Failure, and a Large Loculated Pleural Effusion of the Left Lung. Pulmonary and surgical consults were obtained. He was continued on Ceftriaxone and Flagyl (antibiotic).

Medical record review of a Pulmonary Consult from Facility C dated 7/10/2021 at 9:23 AM showed the patient had a loculated moderate pleural effusion. General surgery was consulted for chest tube placement and the patient was informed of the diagnostic findings and the need for the chest tube.

Medical record review of a Surgery Consult from Facility C dated 7/10/2021 at 9:30 AM showed the patient was evaluated and a treatment plan for a left chest tube was discussed with the patient related to his pleural effusion.

Medical record review of a Procedure Note from Facility C dated 7/10/2021 at 3:43 PM showed a #32 size french left side chest tube was inserted with a return of serous (pale yellow) fluid.

Medical record review of a Pulmonary Progress Note from Facility C dated 7/11/2021 at 1:15 PM showed "...pulmozyme [medication used to improve breathing and reduce the risk of lung infection] with Alteplase [medication used to prevent blood clots] was inserted into the chest tube and the chest tube was clamped for 1 hour..."

Medical record review of a Surgical Progress Note from Facility C dated 7/11/2021 at 2:34 PM showed the patient continued to have drainage from the chest tube. The chest tube remained on continuous suction and the patient reported his symptoms had improved.

Medical record review of a Physicians Progress Note from Facility C dated 7/12/2021 at 4:30 PM showed the patient's WBC had decreased to 15.3 with improvement of symptoms. His chest x-ray showed "...near complete evacuation of loculated pleural effusion, left lower pneumonia as well as right lower lobe pneumonia versus atelectasis..."

Medical record review of a Surgery Progress Note at Facility C dated 7/14/2021 showed the chest tube was removed.

Medical record review of a Discharge Summary at Facility C dated 7/15/2021 at 3:33 PM showed the patient had improved and was discharged home.

During a telephone interview on 7/19/2021 at 12:15 PM, Patient #29's spouse stated the patient presented to Facility A on 7/8/2021 with left shoulder pain, rib pain, muscle spasms, and shortness of breath. He was triaged and placed in an area in the ED where he was seen by a provider in the ED and a chest x-ray was done. He received a muscle relaxer injection and pain medications but no lab work or any other tests. The patient was told he had pneumonia and was given prescriptions for pain medications and a muscle relaxer and sent home. His pain continued along with shortness of breath. On 7/9/2021 he could not lay down related to shortness of breath and the pain, so the patient went to Facility B where they were told his chest x-ray (done at Facility A on 7/8/2021) showed pneumonia. The patient was told he needed to go to (Facility C) and be evaluated in the ED. The patient's wife stated the patient had a fever of 102.2°, an elevated heart rate, and low oxygen levels. His white blood count was 25 and he was septic. A CT scan of the chest was completed which showed pneumonia, fluid in his pleural cavity, and he required a chest tube related to a partially collapsed lung. The patient was admitted to the hospital and was discharged on 7/15/2021.

During an interview on 7/20/2021 at 1:50 PM the ED Nurse Manager at Facility A stated the patient presented with back pain and spasms on 7/8/2021. He was discharged with muscle spasms and was given pain medications and muscle relaxers. The facility had received a complaint from the patient's wife regarding the patient's care and medical treatment. The patient was admitted to (Facility C) on 7/9/2021 with diagnosis of pneumonia and required a chest tube. The ED Nurse Manager confirmed there was no temperature documented in the triage record for Patient #29 and "...we normally obtain a full set of vital signs for all patients..."

During an interview on 7/20/2021 at 3:30 PM, Nurse Practitioner (NP) #1 at Facility A stated Patient #29 presented with flank pain and muscle spasms. The patient stated he had been working on his truck and felt like he was having muscle spasms. His pain was reproduceable with touch and had some tenderness to his left flank area. He denied any fever but did complain of some shortness of breath and pain. His chest x-ray showed some non-specific changes. There was no documented temperature on the triage record, but the patient denied having a fever. NP #1 stated "...the chest x-ray report showed some inflammatory/pneumonia and/or cardiogenic [caused by a cardiac condition] versus noncardiogenic ...I did not feel laboratory diagnostic testing was indicated at that point...I gave him Norco [hydrocodone] and an injection of Norflex...normally I would consult with the attending physician regarding the patient's clinical presentation and findings...related to his clinical presentation, the nonspecific chest x-ray findings, he denied any fever or infectious complaints, I felt this was musculoskeletal pain and treated him as such..." NP #1confirmed no further diagnostic testing was completed related to the chest x-ray findings.

During a telephone interview on 7/20/2021 at 4:35 PM, ED Physician #1 at Facility A stated she did not specifically remember the patient. ED Physician #1 stated she had signed onto the patient's record on 7/8/2021 at 9:03 PM but did remember seeing the patient while he was in the ED. ED Physician #1 stated"...the chest x-ray may have shown some atelectasis which may be indicative of pneumonia, cardiac, or other findings but clinical correlation would be appropriate for the patient..."

During a telephone interview on 7/21/2021 at 9:00 AM, Radiologist #1 at Facility A stated he had reviewed Patient #29's chest x-ray on 7/8/2021 which was compared to a previous chest x-ray which was performed on 1/9/2018. Radiologist #1 stated "...there was some acute changes with comparison to the x-ray on 1/9/2018...[the x-ray done on 7/8/2021] showed some opacities with possible pneumonia which was worse on the left side. We [Radiologists] do not see the patient but give the clinical providers suggestive findings and they treat the patient based on the clinical findings...there were suggestions of atelectasis which would need to be clinically correlated to the patient's presentation. There was a left asymmetric pattern which may be suggestive of an infection/pneumonia pattern...a chest x-ray was a good place to start related to the pulmonary cause, but a CT scan of the chest would be more sensitive to show the real cause of the problem which would show a pleural effusion, atelectasis, or a collapsed lung. In addition, the patient's clinical presentation, the presence of a fever, elevated WBC, or respiratory symptoms would be diagnostic in conjunction with the chest x-ray..."

During an interview on 7/21/2021 at 9:45 AM, Registered Nurse (RN) #1 stated she completed the patient's triage on 7/8/2021. RN #1 stated a full set of vital signs was normally completed in triage. RN #1 confirmed no temperature was documented for Patient #29.