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Based on interview and record review, the hospital failed to comply with the provisions of CFR 489.24 when one of 28 patients (Patient 1) did not receive an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether or not an emergency medical condition (EMC) existed.

Patient 1 presented to the Emergency Department (ED) on 9/16/17 at 2:24 a.m. via ambulance from home with the chief complaint of altered level of consciousness (ALOC) and hypoglycemia (blood sugar level of 32 mg/dl [normal range for non-diabetics 70-120]). Patient 1's MSE did not include evaluation of potential causes of hypoglycemia (low blood sugar) in this non-diabetic patient, assessment of Patient 1's ability to maintain normal blood sugars without eating, or ongoing assessment and monitoring of Patient 1's blood sugar levels to determine if they remained stable.

This failure resulted in the lack of determination of whether or not an EMC existed and Patient 1 was discharged from the hospital without evaluation of stability. Upon discharge, the hospital arranged transport to an outpatient dialysis center where on arrival Patient 1 had blood glucose level of 54mg/dl, had cardiac arrest and expired shortly thereafter. (refer to A 2406)

The cumulative effect of this problem resulted in the hospital failure to provide care in a safe setting in the Emergency Department.

Based on interview and record review, the hospital failed to ensure that one of 28 patients (Patient 1) received an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether or not an emergency medical condition (EMC) existed when:

Patient 1 presented to the Emergency Department (ED) on 9/16/17 at 2:24 a.m. via ambulance from home with the chief complaint of altered level of consciousness (ALOC) and hypoglycemia (blood sugar level of 32 mg/dl [normal range for non-diabetics 70-120]). Patient 1's MSE did not include evaluation of potential causes of hypoglycemia (low blood sugar) in this non-diabetic patient, assessment of Patient 1's ability to maintain normal blood sugars without eating, or ongoing assessment and monitoring of Patient 1's blood sugar levels to determine if they remained stable.

This failure resulted in the lack of determination of whether or not an EMC existed and Patient 1 was discharged from the hospital without evaluation of stability. Upon discharge the hospital arranged transport to an outpatient dialysis center where on arrival Patient 1 had blood glucose level of 54mg/dl, had cardiac arrest and expired shortly thereafter.

Findings:

On 8/18/18 at 1:00 p.m., during a concurrent interview and record review of Patient 1's electronic health record (EHR), RN 1 verified Patient 1 arrived via ambulance from home to the ED on 9/16/17 at 2:24 a.m. with ALOC and hypoglycemia. RN 1 stated the EHR indicated Patient 1 had no history of diabetes. The EHR indicated Patient 1 had the following diagnoses: hypertension, liver disease, Stage IV prostate cancer, and End Stage Renal Disease (ESRD) receiving hemodialysis (a process used to clean the blood of persons whose kidneys are not working normally) three times per week at an outpatient dialysis center located at a nearby town. RN 1 verified Paramedics assessed Patient 1 at his home and prior to arrival to the ED. RN 1 stated Paramedics obtained the blood glucose (sugar) level which measured 32 mg/dl (milligrams per deciliter), Blood Pressure (BP) 166/95 (normal range 120/80-140/90), Pulse (on monitor) 76/beats per minute (bpm) (normal range 60-100 bpm), Respirations 16/minute (normal range 12-20), Glasgow Coma Scale (GCS- an assessment tool used to assess a patient's neurological status. Scale range is from 3 to a maximum of 15 which indicates a fully awake patient) was 13. Paramedics started an intravenous line (IV-into a vein), and at 2:04 a.m. administered 25 g (50 ml) of IV Dextrose 50% (sugar water) and transported Patient to the hospital. RN 1 stated the MSE was initiated by MD 4 at 2:39 a.m. and fingerstick blood glucose at 2:37 a.m. was 237 mg/dl. RN 1 verified the physician orders included glucose levels every hour. RN 1 verified orders were placed for Computed Tomography (CT: a diagnostic imaging test to examine organs, soft tissue, blood vessels, and bones) of the head and portable chest x-ray, Comprehensive Metabolic Panel (CMP: Test measuring blood sugar levels, electrolyte and fluid balance, kidney function, and liver function), Complete Blood Count (CBC), Blood Glucose test (finger stick) once, and Blood Glucose (finger stick) monitoring every hour. RN 1 verified that at 2:50 a.m. Serum glucose was obtained (as part of a CMP) and measured 143 mg/dl. RN 1 verified that at 3:23 a.m. MD 4 documented the following: "Reexamination/Reevaluation: Symptoms(s) are improved; Following interventions had occurred.. Contemporaneous times are on the chart; Observation; during risk stratification; Engagement with: Patient and Family; Discussed the diagnostic interpretations. Discussed the ability to be discharged. Verbalized the instructions written on the discharged instructions." RN 1 verified the discharge orders were input into the EHR at 4:33 a.m. and Patient 1 was discharged with paperwork at 6:25 a.m. RN 1 stated the EHR indicated an email was sent to a transport company at 4:33 a.m. for transport to the outpatient dialysis center. RN 1 stated there was no indication either in the printed medical record or in the electronic health record of additional blood sugar tests performed, as ordered by MD, either by the lab or as finger sticks by the ED nursing staff. RN 1 stated she would have expected the nursing staff to follow MD 4's orders for hourly glucose tests. RN 1 stated she does not have an explanation as to why the blood glucose monitoring did not occur per the physician's order. RN 1 stated she would have expected a glucose check prior to discharging the patient. She stated the usual routine for a patient who came in with a history of a hypoglycemic episode would be to give them something to eat and recheck blood sugars to make sure the blood sugar levels are not going to drop again. RN 1 verified there is no documentation in the record indicating Patient 1 was ever provided anything to eat or drink while he was in the hospital. RN 1 stated if Patient 1 had been provided something to eat or drink it should have been documented in the record. RN 1 verified there was not an order to feed the patient or provide fluids.

On 8/10/18 at 9:35 a.m., during a telephone interview, an outpatient dialysis center RN (RN 7) stated she knew Patient 1 well; he received dialysis at their facility three times each week. RN 7 stated, on the morning of 9/16/17, she was informed by another nurse (RN 8), the hospital called at 5:30 a.m. to inform them Patient 1 would be coming to the dialysis facility from the hospital. RN 7 stated no other information was provided. RN 7 stated she called the hospital back and was told the patient was brought to the ED because he had low blood sugar during the night, but that his blood sugars had been over 200 mg/dl at the hospital. Patient 1 did not arrive until almost 7 a.m., while RN 7 was on break. RN 7 stated when she saw Patient 1 he was in the dialysis treatment chair with RN 8 at his side. RN 7 stated Patient 1 looked pale and gray, his blood pressure was low and RN 8 had checked his blood sugar which was 54 mg/dl. RN 7 stated she looked for the discharge paperwork that should have been with Patient 1 from the hospital, but the only papers with Patient 1 were discharge papers for a patient with a diagnosis of "cholelithiasis". RN 7 stated she tried to get more information by calling the transport company but they did not have anything, and then she called the hospital but by then Patient 1 was "coding" (heart and breathing stopped). RN 7 stated patient 1 did not have an IV or a saline lock when he arrived. RN 7 stated she did not feel Patient 1 should have left the hospital. RN 7 stated he (Patient 1) was at the hospital for hypoglycemia and was sent to them with a blood sugar on arrival of 54 mg/dl, and if he needed dialysis, he should have had dialysis at the hospital.

On 8/9/18 at 11:05 a.m., during an interview, MD 3 (nephrologist for Patient 1) stated he did not recall the hospital calling him at 5:00 a.m. on 9/16/17 about Patient 1. MD 3 recalled getting a phone call from the dialysis center nurse saying Patient 1 had coded and died. When asked what he would have advised the ED MD, had he spoken with him the morning of 9/16/17, MD 3 stated, "...I probably knew this guy (Patient 1) better than anyone else. He continued dialysis because he wanted to live...He was not a diabetic and he was not a patient that came in to the hospital ever with complaints. For the family to have called an ambulance to bring him in, he must have been sick...Hypoglycemia in someone like him (Patient 1) has a known risk of recurrence because he has no glycogen stores [glycogen is the storage form of glucose in the body and provides a source of glucose when blood glucose levels decline] due to his disease...He came in to the ED after he had low blood sugar and received IV glucose, then was sent out without anyone knowing if his glucose levels were stable...if they didn't admit him, they should have put him on observation. That would be my usual practice. The thing that is the most troubling to me is ... the glucose should have been checked every hour."

On 8/9/18 at 12:50 p.m., during an interview, the Chief of Staff (MD 2), indicated he had been made aware of Patient 1's case yesterday [8/8/18]. When asked what type of medical interventions should have occurred for a patient who presented with a low glucose and brought by ambulance to the ED, MD 2 stated, "...The patient would be evaluated, given a physical exam, and based on their complaint we would order some testing. Someone with low blood sugar we would retest it, as long as it was appropriate we would offer them something to eat...We would look through their history and see what type of medications they are taking...For a patient with labile blood sugars, we would order accuchecks (blood sugar checks) every hour..." MD 2 stated he would consider what the cause of the hypoglycemia could be, such as "...liver failure, sepsis (a potentially life-threatening complication of an infection), maybe he got exposed to another patient's medication...hypoglycemia in someone who is not a diabetic is odd...I wouldn't say someone who is hypoglycemic and not a diabetic needs to be admitted, but it would be looked into...I would be interested to figure out if they were septic...." MD 2 stated IV fluid is not usually given, "...but if we feed them, recheck, and monitor their blood sugar and they are maintaining on their own, I would have a better sense of what is going on...for a patient who comes in with this history of hypoglycemia, serial glucose checks should be performed...that's a reasonable thing that should happen for a patient like this.... Apparently, the documentation isn't there regarding what was done for him in the ED. It would be ideal, if there were documentation that suggested he had eaten, he was reassessed, he was alert and oriented, and documentation of a blood sugar prior to discharge...."

On 8/9/18 at 2 p.m., during a concurrent interview and record review, MD 4 stated he reviewed Patient 1's medical record prior to the interview. Patient 1's blood glucose values were reviewed with MD 4 as follows: Patient 1's blood glucose was 32mg/dl at home taken by paramedics, at 1:41 a.m. and 207 mg/dl after the paramedics gave him 25 grams of dextrose (sugar water). In the hospital, a fingerstick glucose was 237 mg/dl at 2:37 a.m., and 13 minutes later at 2:50 a.m. a serum (blood drawn from vein) glucose test was 143 mg/dl. There was an order for every hour glucose tests, but no other glucose tests were done during Patient 1's 4 hour stay. When Patient 1 arrived at the dialysis center 20 minutes after he left the hospital his blood sugar was 54, and a recheck was 51. When asked to discuss his impression of this patient, MD 4 stated, "Again I don't have an independent recollection of the patient, but generally it's altered mental status work up. I'm looking for CNS [central nervous system- the brain and spinal cord] abnormalities, toxidrome, he's an elderly man with a lot of comorbidities [more than one disease or condition is present in the same person at the same time], so the other issue was cardio pulmonary [related to the heart and lungs] issue, he also is a dialysis patient so hyperkalemia [high level of potassium]." When asked about the blood glucose (sugar) levels, MD 4 stated, "...If I remember right I felt it was stable, and with the x-ray abnormalities I felt he needed to continue with his scheduled dialysis...."

When asked if he would expect there to be more blood sugar checks, MD 4 stated, "...Yes, it would have been nice if more glucose checks had been done; that's why I ordered it [the glucose monitoring every hour]...and it would be on the record...." When asked about the drop in blood glucose from the 237 to 143 in 13 minutes, and the lack of additional glucose tests to make sure Patient 1's blood glucose levels were not dropping again, MD 4 stated, "... Regardless of the glucose going up and down you follow them by their mental status. That's how you follow hypoglycemia....People's brains don't stay awake if the sugar is clinically hypoglycemic...I do expect my orders to be followed...I ordered the hourly blood sugars at the beginning, but what is most important is my observation of the patient...the symptom of hypoglycemia is altered mental status...I knew during the time I was observing him, he was not clinically hypoglycemic. If he was altered then I would have addressed that..."

When asked about the stability of Patient 1, MD 4 stated, "... (Patient 1 was) Stable enough; main symptom of hypoglycemia is altered mental status. So, I was following his mental status. His mental status was better when he arrived in ER; he was stable in ER...he was an elderly man with multiple comorbidities, I didn't expect him to die on discharge. Had I known that...I wouldn't have discharged him...."

When asked if there was anything else he could have done to make sure Patient 1 was stable before discharge, MD 4 stated, "...The easiest thing is to admit every single patient, but if I can go ahead and make a disposition that is more efficient I will...If I can make a disposition for a 75 year old stage 4 cancer patient on dialysis to be more comfortable outside the hospital I will do that...I was wrong...he needed admission to the hospital...I missed that...if he had persistent hypoglycemia...I would have contacted the hospitalist (a physician who specializes in treating hospitalized patients) to admit him and he could get his dialysis in the hospital. That was easy to do... I wanted to be efficient with my care and I blew this case. The only disposition that would have made a difference is admission to the hospital..."

On 8/10/18 at 10:20 a.m., during an interview, the chief nursing officer (CNO), when asked about the order for blood glucose monitoring every hour that was not done by nursing staff, stated it is her expectation for nurses to follow the orders and document appropriately.

The hospital's policy and procedure titled "EMTALA Policy", dated 2/22/17, indicated, " ...III. DEFINITIONS ...Emergency Medical Condition [EMC]: A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in ...placing the health of the individual in serious jeopardy, or serious impairment to bodily functions or serious dysfunction of any bodily organ or part...Medical Screening Exam [MSE]: the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist...Qualified Medical Person [QMP]: an individual qualified by Hospital bylaws or rules and regulations to perform a MSE ...In the Hospital, QMPs are ...physicians, physician assistants [PA], nurse practitioners [NP]...The Hospital will provide an appropriate MSE within the capability of the Hospital's Dedicated Emergency Department [ED], including ancillary services routinely available, to determine whether or not an EMC exists ...As soon as practical after arrival, individuals who come to the ED should be triaged ...to determine the order in which they will receive a MSE ...Triage is not a MSE ...The MSE should be tailored to the patient's complaint, and depending on the presenting symptoms, the MSE may represent ...a simple process involving only a brief history and physical examination to a complex process ...that involves performing ancillary studies and procedures ...the MSE and ongoing patient assessment, must be documented in the medical record ...."


The Emergency Department (ED) policy and procedure titled "Triage Nurse Policy", dated 6/2016, indicated, " ...the responsibilities and function of the triage nurse...greet all patients entering the ambulatory entrance of the ED and obtain a brief initial assessment ...chief complaint, brief history of problem, clinical assessment, complete set of vital signs: temperature, blood pressure, pulse, respiratory rate, pulse oximetry and pain ...screen for reportable findings, nutritional deficits, Tuberculosis symptoms ...Make a determination based on initial assessment as to the need for immediate intervention or observation before registration ...All patients will be classified and prioritized as follows: ESI [Emergency Severity Index] Level 1: the patient requires immediate medical care ...is unstable ...requires immediate life-saving interventions ...Level 2: the patient is assessed as high risk ...condition has the potential for major life and organ threat ...should not wait ...Level 3: the patient is assessed as stable ...vital signs are within accepted normal parameters for age ...require two (2) or more resources to reach disposition ...Level 4 ...Level 5 ...If not in need of immediate intervention or observation, complete an initial nursing history, allergies, vital signs, and initiate appropriate order per protocol ...After the MSE is completed, the patient will be directed to the waiting room if beds unavailable ...All patients are monitored, reassessed, and have repeat of vital signs based on their acuity ...documentation of the triage classification, assessment, and all interventions performed are entered into the ...electronic documentation system ...."


The Emergency Department policy and procedure "Medical Screening Examination", dated 10/25/17, indicated," ...Emergency Medical Condition [EMC]: A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in ...placing the health of the individual in serious jeopardy, or serious impairment to bodily functions or serious dysfunction of any bodily organ or part ...Medical Screening Exam [MSE] ...the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist ...The MSE will be based on the patient's condition and prior history and will include at least the following: Patient's chief complaint, age, sex, duration of onset of chief complaint, date and time, level of distress, allergies, current medication, tetanus status, LMP, private physician, and any pertinent medical history ...Vital signs, general observations, and localized examination ...Initiation and documentation of any necessary testing, treatments and/or procedures ...The scope of the examination is tailored to the patient's presenting symptoms and the medical history of the patient ...The MSE is an ongoing monitoring process, which continues until an EMC is found not to exist or until appropriate steps to stabilize the presenting EMC begin...Documentation of the MSE: The determination of the patient's condition will be made by the Qualified Medical Professional and will be a part of the Emergency Department Medical Record ...."

The Emergency Department policy and procedure "Standard of Care", dated 6/24/15, indicated, " ...These are the fundamental components of care that are to be applied to any patient presenting for treatment to the Emergency Department (ED). This standard of care must be used in conjunction with more specific protocols that are relevant to the patient's chief complaint ...All patient conditions will be classified and prioritized utilizing the Emergency Severity Index (ESI) algorithm as follows: ESI Level 1: the patient requires immediate medical care ...is unstable ...requires immediate life-saving interventions ...Level 2: the patient is assessed as high risk ...condition has the potential for major life and organ threat ...should not wait ...Level 3: the patient is assessed as stable ...vital signs are within accepted normal parameters for age ...require two (2) or more resources to reach disposition ...Level 4 ...Level 5 ...Vital signs will be taken on all patients admitted to the ED ...temperature (rectal temperature on any patient for whom an accurate oral temperature cannot be obtained, BP [Blood Pressure], pulse, and respiratory rate. Repeat vital signs include BP, pulse, respiratory rate and temperature as indicated ...The patient's nurse is responsible for continually assessing the patient's condition and obtaining vital signs as the situation warrants ...patient acuity will determine the frequency of vital signs ...abnormal vital signs will be checked prior to discharge ...Repeat vital signs to be measured and documented as per physician order and/or based on patient acuity and chief complaint ...continued evaluation and care of the patient may include: documentation of any changes in status...documentation of any treatments, patient tolerance of the treatment...patients with IV lines...should have fluid status monitoring with appropriate documentation of intake and output...disposition of patient will be documented, including time of departure and method of transport...actions and documentation related to specific destinations are...Discharge: Repeat of abnormal vital signs, as indicated...discuss aftercare instructions...provide patient teaching as indicated by discharge needs,,,obtain patient signature indicating that aftercare instructions have been received and understood...summary of patient condition upon discharge will be documented...