HospitalInspections.org

Based on Emergency Department (ED) record review for Hospital #1, medical record review for Hospital #2, document review, policy and procedure review, staff interviews, family interview and physician interviews, the hospital failed to comply with 489.24 regarding Patient
#1.


Findings Include:


Cross Refer to A2406 for the hospital's failure to provide Patient #1 with an appropriate Medical Screening Examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to treat and stabilize emergency medical condition(s) prior to discharging Patient #1 from the ED on 4/10/2015.





Cross Refer to A2407 for the hospital's failure to provide Patient #1 with further necessary medical examination and treatment within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, required to stabilize Emergency Medical Condition(s) (EMC) prior to discharge from the ED on 4/10/2015.




Cross Refer to A2408 for the hospital's failure to ensure Patient #1 received an appropriate medical examination and treatment, within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to stabilize Emergency Medical Condition(s) and prevent a delay in examination or treatment.

Based on Emergency Department (ED) record review for Hospital #1, medical record review for Hospital #2, document review, staff interviews, family interview and physician interview, the hospital failed to provide Patient #1, one (1) of 20 patients reviewed, with an appropriate Medical Screening Examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to treat and stabilize an Emergency Medical Condition(s) (EMC).


Findings Include:


COMPLAINT

A letter of complaint was received by the State Office regarding an ED visit to Hospital #1 on 4/10/2015 at 8:00 p.m. by Patient #1. The letter was written by Patient #1's daughter. The daughter stated that her mother was taken by ambulance to Hospital #1 very weak, dizzy, confused and disoriented with a recent diagnosis of atrial flutter. Her blood pressure in was 80s/30s and she had a heart rate in the 50s. The daughter is a nurse and stated that on the cardiac monitor attached to her mother she was in atrial flutter. When the doctor (Physician #1) asked the daughter if her mother was a diabetic she told him that she was not. She was told by the physician, "Well, her blood sugar is over 400 and she has sugar spilling over into her urine. We are going to give her insulin and treat her." The daughter told him again that her mother had a recent diagnosis of atrial flutter, was started on a new medication and the family was told to watch her blood pressure. Physician #1 stated "Well her blood pressure and heart rate are fine. We are going to treat the diabetes with insulin." On recheck her blood sugar was 385. The patient was discharged about 11:30 p.m. with a prescription for Metformin (diabetic medication), no instructions to take her blood sugar at home and to follow up with her primary physician on Monday (4/13/2015). The daughter called and talked to the nursing supervisor on Saturday with complaints and to ask for a prescription for a glucose meter and diabetic supplies for her mother. The nursing supervisor told the daughter that the physician in the ED at that time would not write a prescription for a glucose meter because she had not seen her mother on Friday. "She said my mother's blood sugar would be ok until she follows up with her primary physician on Monday." The daughter also wrote, "Luckily I am a nurse and I know to take my mother's blood sugar until we could follow up. The biggest concern was that my mother required treatment that she did not receive, and was sent home with no instructions. Her blood sugar remained elevated on Sunday (450) and she was very confused and could not walk. I called an ambulance and she was taken to (Hospital #2)...admitted... a cardiologist was consulted to see her for her heart rate. She remained in Atrial Flutter..." Patient #1 was discharged from Hospital #2 on 4/16/2015.


RECORD REVIEWS

HOSPITAL #1
Review of Hospital #1's ED record for Patient #1 revealed she was a 77 year old female admitted on 4/10/2015 at 8:10 p.m. via ambulance, with complaints of shortness of breath (SOB) and confusion. She was given an Acuity Level of 2 (1 is the highest level of acuity and 5 is the lowest level of acuity) and was seen by ED Physician #1 at 8:30 p.m. Review of his assessment revealed that the patient had SOB on exertion and she was coughing. Review of the physician's 8:24 p.m. orders revealed STAT (immediate) orders were given for an Electrocardiogram (EKG) 12 Lead, urinalysis, multiple blood tests and a portable chest X-Ray.

At 10:10 p.m. orders were written by Family Nurse Practitioner (FNP) #1 for Sodium Chloride 0.9% (Normal Saline) Bolus IV (intravenous) and Regular Insulin Novolin R five (5) units IVP (IV Push). Regular Insulin Novolin R five (5) units IVP STAT was ordered again at 11:22 p.m. and Sodium Chloride 0.9% Bolus IV STAT at 11:47 p.m. by Physician #1.


Review of results of the ordered blood work revealed the first Glucose (blood sugar ) level reported was 485 (Normal 70-105). The second Glucose level was documented as 377 at 11:06 p.m. A third Glucose Level was documented as 248 at 12:24 a.m. (11 minutes prior to discharge from ED).


Review of the EKG results revealed Patient #1 had a Normal Sinus Rhythm with Sinus Arrhythmia with 1st Degree AV Block.


Hospital #1 discharged Patient #1 on 4/11/2015 at 12:35 a.m. with non-patient specific Discharge Instruction Sheets on Diabetes and Cough. She was a newly diagnosed diabetic patient and she received a prescription at discharge for the drug Metformin (Glucophage) po (by mouth) 2 times a day was told to follow-up with her primary care provider within one (1) week. There was no documented evidence Hospital #1 gave Patient any instructions regarding when or how to monitor her blood glucose once she got home. There was no documented evidence that Hospital #1 gave Patient #1 any diabetic teaching/instructions or prescriptions for diabetic supplies at any time during her ED visit. Documented evidence showed that the Discharge Instruction sheets provided to Patient #1 were not specific regarding Metformin considerations or contraindications. There was no documented evidence of any consults for cardiology or Diabetic Instructor/Dietician.



HOSPITAL #2
Review of Hospital #2's medical record for Patient #1 revealed that on 4/12/2015 at 9:14 p.m. Patient #1 presented by ambulance to Hospital #2's ED. Review of triage notes revealed the patient's blood pressure during the ambulance transfer was documented as 80/38, her blood glucose was 440 and she was given a 900 ml (milliliter) bolus of normal saline intravenously. During triage in the ED Patient #1's blood pressure was documented as 117/58, pulse rate 58 (low), O2 SAT 94 (low). Patient #1 complained of "Not feeling right." Review of an EKG done 4/12/2015 at 9:20 p.m. revealed: "Sinus Bradycardia. Low QRS voltage in precordial leads. Abnormal rhythm ECG" She was admitted by Physician #2 to Hospital #2's telemetry unit at 10:35 p.m. with bradycardia, hypotension, hyperglycemia, generalized weakness, low calcium, low magnesium level, acute chest pain, acute diabetes, atrial flutter and asthma. Consults were ordered for the Diabetes Educator (she was seen twice during hospital stay), Cardiology for the dyspnea and wheezing, and Pharmacy to adjust the patient's medications for better renal function.

Review of Physician #2's initial 4/12/2015 assessment notes revealed he thought Patient #1 "might be over medicated, making her blood pressure run low... For her (blood) sugar (I) feel that she is going to need insulin do not feel that adequate results will be acheived with Glucophage (Metformin)." She was started on long acting insulin while in the hospital.


History of Present Illness Narrative (4/12/2015) - "Patient has been recently seen at (Hospital #2) Friday night and diagnosed with DKA (Diabetic Ketone Acidosis)...given Glucophage and discharged home. The patient has continued to deteriorate... weakness is worsening... has difficulty ambulating and was found (by family) stuck in a bathtub. When the ambulance was called the EMS found the patient to be bradycardic and hypotensive.."


Review of Cardiology Progress Notes revealed:
4/12/2015 "I suspect the majority of her symptoms are related to atrial fib flutter with rapid ventricular response. Her rates are better controlled and we will adjust her meds further."
4/14/2015 "...is ambulating with minimal difficulty and my plan will be to let her go home in the morning... we will entertain cardioversion if she continues atrial flutter..."
4/15/2015 "... is doing well... to follow up with me in 2 weeks... She continues in atrial flutter with a controlled ventricular response and if she continues in atrial flutter when I see her back we will discuss at that time cardioversion..."


Review of Nurse's Notes from the telemetry unit revealed that atrial flutter was documented in each note.


Review of Patient #1's blood work during her hospital stay revealed:
Blood Glucose at bedside averaged between 129 and 384 (Reference Range 74 - 106);
Hemoglobin A1C on 4/13/2015 was documented as 11.3 (Reference Range 4.2 - 6.3);
Calcium averaged 7.8 to 8.3 (Reference Range 8.5 - 10.1);
Magnesium averaged 1.4 to 2.3 (Reference Range 1.8 - 2.4).


Review of the 4/13/2015 1:42 p.m. Pharmacy Consult notes revealed: "Assessment/Plan: On review of medication, Eliquis amd Metformin were identified for potential adjustment. At this time, renal adjustment is not warranted. Pharmacy following."


On 4/14/2015 and 4/16/2015 Patient #1 received EKGs. Review of the Interpretive Statements for both revealed: "Atrial flutter/tachycardia with rapid ventricular response. Low QRS voltage in precordial leads. Abnormal rhythm ECG"


Discharge diagnoses from Hospital #2 on 4/16/2015 were documented as: 1. Acute Diabetes 2. Acute Chest Pain 3. Acute Generalized Weakness 4. Hypomagnesemia 5.Atrial Flutter and 6. Hyperglycemia.
Discharge instructions were documented as: 1. Diabetic Diet 2. Monitor blood sugars at 7a - 11a - 4p - 9p and take results to the next appointment with primary care provider (2 weeks) 3. Digoxin 0.25mg (milligram) PO (by mouth) daily @1:00 p.m.; Levemir insulin 15 units subcutaneously daily with supper; Lopressor 50 mg PO BID (twice a day) and Magnesium Oxide 4000 mg PO BID. Patient #1 also received prescriptions for insulin test strips, insulin testing supplies and glucometer.


Review of the Patient Instruction Signature Page revealed Patient #1 received instructions regarding Atril Flutter, Atrial Fibrillation and Diabetic Hyperglycemia prior to discharge.



INTERVIEWS


On 5/5/2015 at 9:15 a.m. Physician #1 (Hospital #1) was presented with information about the complaint regarding Patient #1's 4/10/2015 ED visit to Hospital #1. When Physician #1 was asked to review the patient's ED record, since he did not specifically remember the patient, he looked at one (1) or two (2) pages. When asked about the patient's blood pressure decrease to 71/43 at 10:30 p.m. Physician #1 stated, "This was due to fluid resuscitation. She had a 1st degree AV block and this was not related to atrial flutter... atrial flutter can come and go. It can be persistent if there have been heart problems in the past. She did not have atrial flutter while here.... her dizziness and lightheadedness was not related to her heart rhythm... I don't make decisions until laboratory values are back unless the patient is critically ill..." When asked why Patient #1 was not admitted to the hospital as a newly diagnosed diabetic with blood glucose levels abnormally high Physician #1 stated, "Patients with hyperglycemia usually do not require admission." Physician #1 was asked if in retrospect he would have changed anything in regards to the care provided for Patient #1. He said "No... I feel like I did for her what any doctor would have done."


On 5/5/2015 at 11:45 a.m. an interview with Patient #1's daughter revealed that on Friday 4/10/2015 her mother was confused, could not walk or hold up her head and was taken to Hospital #1's ED by ambulance. The daughter stated that her mother's "blood sugar was very high" in the ED at Hospital #1. "She (Patient #1) stayed there several hours, from Friday around 8:30 p.m. until Saturday morning a little after midnight. When they discharged her Metformin was ordered and she was told by the doctor that this would gradually decrease the blood sugar... Before we left the ED (at Hospital #1) I asked for a prescription for a blood glucose machine. They told me, 'We don't teach how to use it, so we don't give prescriptions for them.' They didn't give my mother any instructions on when and how to perform blood sugars and she didn't have a glucose monitor to use or receive instructions on." The daughter stated that during the following weekend she tried to to get her mothers blood sugar down by diet control. "When I took her bood sugar Sunday morning (4/12/2015) it was 450. That's when I called the ambulance. My mother could have easily gone into a diabetic coma. When we got to (Hospital #2) they admitted her to the hospital." The daughter also stated that she received a follow-up call from Hospital #1 while she was still asleep the next morning (Saturday 4/11/2015). When asked how her mother was she said "OK" and hung up. When she woke up later in the morning she contacted the Director of Nurses at Hospital #1, discussed her mother's lack of treatment and lack of discharge instructions from the hospital ED and filed a greivance.


On 5/05/2015 at 10:50 a.m. an interview was held with Registered Nurse (RN) #3 (Hospital #1) regarding Patient #1. The RN stated that she did not remember the patient or the family from the ED visit at Hospital #1 on 4/10/2015. RN #3 was told that Patient #1's daughter was also a nurse, had stated that she could read a heart monitor and that she had seen that her mother's heart monitor showed that she was in atrial flutter while in the ED that day. RN #3 was asked whether she observed atrial flutter at any time during Patient #1's ED visit. She stated, "No. The Nurses' Notes that are in the medical record are what was seen." She also stated that to her knowledge nothing was brought to the attention of the nurses/staff that Patient #1 needed anything and was not receiving it.


An interview was held on 5/5/2015 at 1:40 p.m. with Hospital #1's Pharmacist regarding the diabetic drug Metformin, which had been given to Patient #1 at discharge. The Pharmacist stated that their physicians, nurses and pharmacists used a certain data base for information regarding medications. She printed out information on Metformin for review. Review of the drug information printed out revealed: "Medication Patient Education ...Considerations: Discuss specific use of drug and side effects. Patients may experience diarrhea, flatulence, nausea or asthenia. Have patient report immediately to prescriber severe dyspepsia, signs of hypoglycemia, or signs of lactic acidosis. Educate patient about signs of a significant reaction (wheezing, chest tightness, fever, itching, bad cough, blue skin color, seizures or swelling of face, lips, tongue, or throat.... Contraindications: renal disease or renal dysfunction. " Documented evidence showed that the Discharge Instructions provided to Patient #1 were not specific regarding Metformin considerations or contraindications.


On 5/5/2015 at 3:50 p.m. Hospital #1's FNP #1 stated, "Patients leave the Emergency Room all the time with blood sugars of 248."


On 5/6/2015 12:30 p.m. a telephone message was left for Physician #2 (Hospital #2) to make a return call to discuss Patient #1. No return call was received. On 5/7/2015 another attempt was made to contact Physician #2 by telephone. Another message was left and no return call was ever received. On 5/13/2015 at 11:35 p.m. another effort was made to contact Physician #2. The hospital operator spoken to stated that Physician #2 was not working at the hospital that night. No return call was ever received.





POLICIES AND PROCEDURES


Review of Hospital #1's "Emergency Department (ED)" requirements (Revised 6/17/2014) revealed:
"ED.1 ORGANIZATION SR1. The organization must meet the emergency needs of its patients in accordance with acceptable standards of practice...
The hospital's emergency services must be integrated with the other departments of the hospital (e.g. surgical services, laboratory, ICU, diagnostic services) and be accessible in the delivery of emergency care for patients..."


Review of Hospital #1's "Emergency Department Medical Screening" policy (undated) revealed: "...Definitions -
Medical Screening Exam: A Medical Screening Exam...is defined as 'providing all necessary testing and on-call services within the capability of the hospital to determine whether or not a legally deefined Emergency Medical Condition exists.'
Emergency Medical Condition: 'A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the health of the individual... in serious jeopardy;
2. Serious impairment to any body functions;
3. Serious dysfunction of any bodily organ or part...'..."


Review of Hospital #1's undated (EMTALA (Emergency Medical Treatment and Labor Act)" policy revealed: "The Emergency Medical Treatment and Labor Act ("EMTALA") requires... hospitals to provide medical screeening examinations to all patients who come to the emergency department and request examination or treatment for a medical condition... If the person has an emergency medical condition..., the Hospital must treat or stabilize the person...
1. A. Rights to Treatment: ...the Hospital recognizes the right of the individual to receive, within the capabilities of the Hospital's staff and facilities: i. An appropriate medical screening examination; ii. Necessary stabilizing treatment for an emergency medical condition...; and iii. If necessary, an appropriate transfer to another facility. ..
2. ...D. Stabilized means, with respect to an emergency medical condition, that no material deterioration of the emergency medical condition is likely...
3. Patient Evaluation and Treatment - A. When an individual come to the emergency department seeking medical treatment... the individual must receive a medical screening examination to determine whether the individual has an emergency medical condition. The scope of the screening examination is what is within the capability of the Hospital's emergency department, which include ancillary services that are routinely available in the emergency department... D. ...If... the individual has an emergency medical condition the Hospital must provide...: i. Such additional medical treatment that is within the capabilities of the available staff and facilities, and that is necessary to stabilize the medical condition..."


Review of Hospital #1's "Bylaws of the Medical Staff" (effective 11/25/14) revealed:
"Each member of the Staff, regardless of assigned Staff category, and each Practitioner exercising privileges under these Bylaws shall: (a) provide patients with care, treatment and services at the generally recognized professional level of quality and efficiency within the privileges granted by the Board."



Hospital #1 failed to provide an appropriate Medical Screening Examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to treat and stabilize an Emergency Medical Condition prior to discharging Patient #1 from the ED on 4/10/2015.

Based on Emergency Department (ED) record review for Hospital #1, medical record review for Hospital #2, document review, staff interviews, family interview and physician interview, the hospital failed to provide, within the capabilities of the staff and facilities available at the hospital, Patient #1, one (1) of 20 patients reviewed, further medical examination and necessary treatment required to stabilize an Emergency Medical Condition (EMC).


Findings Include:


COMPLAINT

A letter of complaint was received by the State Office regarding an ED visit to Hospital #1 on 4/10/2015 at 8:00 p.m. by Patient #1. The letter was written by Patient #1's daughter. The daughter stated that her mother was taken by ambulance to Hospital #1 very weak, dizzy, confused and disoriented with a recent diagnosis of atrial flutter. Her blood pressure in was 80s/30s and she had a heart rate in the 50s. The daughter is a nurse and stated that on the cardiac monitor attached to her mother she was in atrial flutter. When the doctor (Physician #1) asked the daughter if her mother was a diabetic she told him that she was not. She was told by the physician, "Well, her blood sugar is over 400 and she has sugar spilling over into her urine. We are going to give her insulin and treat her." The daughter told him again that her mother had a recent diagnosis of atrial flutter, was started on a new medication and the family was told to watch her blood pressure. Physician #1 stated "Well her blood pressure and heart rate are fine. We are going to treat the diabetes with insulin." On recheck her blood sugar was 385. The patient was discharged about 11:30 p.m. with a prescription for Metformin (diabetic medication), no instructions to take her blood sugar at home and to follow up with her primary physician on Monday (4/13/2015). The daughter called and talked to the nursing supervisor on Saturday with complaints and to ask for a prescription for a glucose meter and diabetic supplies for her mother. The nursing supervisor told the daughter that the physician in the ED at that time would not write a prescription for a glucose meter because she had not seen her mother on Friday. "She said my mother's blood sugar would be ok until she follows up with her primary physician on Monday." The daughter also wrote, "Luckily I am a nurse and I know to take my mother's blood sugar until we could follow up. The biggest concern was that my mother required treatment that she did not receive, and was sent home with no instructions. Her blood sugar remained elevated on Sunday (450) and she was very confused and could not walk. I called an ambulance and she was taken to (Hospital #2)...admitted... a cardiologist was consulted to see her for her heart rate. She remained in Atrial Flutter..." Patient #1 was discharged from Hospital #2 on 4/16/2015.


RECORD REVIEWS

HOSPITAL #1
Review of Hospital #1's ED record for Patient #1 revealed she was a 77 year old female admitted on 4/10/2015 at 8:10 p.m. via ambulance, with complaints of shortness of breath (SOB) and confusion. She was given an Acuity Level of 2 (1 is the highest level of acuity and 5 is the lowest level of acuity) and was seen by ED Physician #1 at 8:30 p.m. Review of his assessment revealed that the patient had SOB on exertion and she was coughing. Review of the physician's 8:24 p.m. orders revealed STAT (immediate) orders were given for an Electrocardiogram (EKG) 12 Lead, Urinalysis, multiple blood tests and a portable chest X-Ray.

At 10:10 p.m. orders were written by Family Nurse Practitioner (FNP) #1 for Sodium Chloride 0.9% (Normal Saline) Bolus IV (intravenous) and Regular Insulin Novolin R five (5) units IVP (IV Push). Regular Insulin Novolin R five (5) units IVP STAT was ordered again at 11:22 p.m. and Sodium Chloride 0.9% Bolus IV STAT at 11:47 p.m. by Physician #1.


Review of results of the ordered blood work revealed the first Glucose (blood sugar ) level reported was 485 (Normal 70-105). The second Glucose level was documented as 377 at 11:06 p.m. A third Glucose Level was documented as 248 at 12:24 a.m. (11 minutes prior to discharge from ED).


Review of the EKG results revealed Patient #1 had a Normal Sinus Rhythm with Sinus Arrhythmia with 1st Degree AV Block.


Hospital #1 discharged Patient #1 on 4/11/2015 at 12:35 a.m. with non-patient specific Discharge Instruction Sheets on Diabetes and Cough. She was a newly diagnosed diabetic patient and she received a prescription at discharge for the drug Metformin (Glucophage) po (by mouth) 2 times a day. She was told to follow-up with her primary care provider within one (1) week. There was no documented evidence Hospital #1 gave Patient any instructions regarding when or how to monitor her blood glucose once she got home. There was no documented evidence that Hospital #1 gave Patient #1 any diabetic teaching/instructions/prescriptions for diabetic supplies at any time during her ED visit. Documented evidence showed that the Discharge Instruction sheets provided to Patient #1 were not specific regarding Metformin considerations or contraindications. There was no documented evidence of any consults for Cardiology or Dietician/Diabetic Instructor.




HOSPITAL #2
Review of Hospital #2's medical record for Patient #1 revealed that on 4/12/2015 at 9:14 p.m. Patient #1 presented by ambulance to their ED. Review of triage notes revealed the patient's blood pressure during the ambulance transfer was documented as 80/38, her blood glucose was 440 and she was given a 900 ml (milliliter) bolus of normal saline intravenously. During triage in the ED Patient #1's blood pressure was documented as 117/58, pulse rate 58 (low), O2 SAT 94 (low). Patient #1 complained of "Not feeling right." Review of an EKG done 4/12/2015 at 9:20 p.m. revealed: "Sinus Bradycardia. Low QRS voltage in precordial leads. Abnormal rhythm ECG" She was admitted by Physician #2 to Hospital #2's telemetry unit at 10:35 p.m. with bradycardia, hypotension, hyperglycemia, generalized weakness, low calcium, low magnesium level, acute chest pain, acute diabetes, atrial flutter and asthma. Consults were ordered for the Diabetes Educator (she was seen twice during hospital stay), Cardiology for the dyspnea and wheezing, and Pharmacy to adjust the patient's medications for better renal function.

Review of Physician #2's initial 4/12/2015 assessment notes revealed he thought Patient #1 "might be over medicated, making her blood pressure run low... For her (blood) sugar (I) feel that she is going to need insulin do not feel that adequate results will be acheived with Glucophage (Metformin)." She was started on long acting insulin while in the hospital.


History of Present Illness Narrative (4/12/2015) - "Patient has been recently seen at (Hospital #2) Friday night and diagnosed with DKA (Diabetic Keto-Acidosis)...given Glucophage and discharged home. The patient has continued to deteriorate... weakness is worsening... has difficulty ambulating and was found (by family) stuck in a bathtub. When the ambulance was called the EMS found the patient to be bradycardic and hypotensive.."


Review of Cardiology Progress Notes revealed:
4/12/2015 "I suspect the majority of her symptoms are related to atrial fib flutter with rapid ventricular response. Her rates are better controlled and we will adjust her meds further."
4/14/2015 "...is ambulating with minimal difficulty and my plan will be to let her go home in the morning... we will entertain cardioversion if she continues atrial flutter..."
4/15/2015 "... is doing well... to follow up with me in 2 weeks... She continues in atrial flutter with a controlled ventricular response and if she continues in atrial flutter when I see her back we will discuss at that time cardioversion..."


Review of Nurse's Notes from the telemetry unit revealed that atrial flutter was documented in each note.


Review of Patient #1's blood work during her hospital stay revealed:
Blood Glucose at bedside averaged between 129 and 384 (Reference Range 74 - 106);
Hemoglobin A1C on 4/13/2015 was documented as 11.3 (Reference Range 4.2 - 6.3);
Calcium averaged 7.8 to 8.3 (Reference Range 8.5 - 10.1);
Magnesium averaged 1.4 to 2.3 (Reference Range 1.8 - 2.4).


Review of the 4/13/2015 1:42 p.m. Pharmacy Consult notes revealed, "Assessment/Plan: On review of medication, Eliquis amd Metformin were identified for potential adjustment. At this time, renal adjustment is not warranted. Pharmacy following."


On 4/14/2015 and 4/16/2015 Patient #1 received EKGs. Review of the Interpretive Statements for both revealed: "Atrial flutter/tachycardia with rapid ventricular response. Low QRS voltage in precordial leads. Abnormal rhythm ECG"


Discharge diagnoses from Hospital #2 on 4/16/2015 were documented as: 1. Acute Diabetes 2. Acute Chest Pain 3. Acute Generalized Weakness 4. Hypomagnesemia 5.Atrial Flutter and 6. Hyperglycemia.
Discharge instructions were documented as: 1. Diabetic Diet 2. Monitor blood sugars at 7a - 11a - 4p - 9p and take results to the next appointment with primary care provider (2 weeks) 3. Digoxin 0.25mg (milligram) PO (by mouth) daily @1:00 p.m.; Levemir insulin 15 units subcutaneously daily with supper; Lopressor 50 mg PO BID (twice a day) and Magnesium Oxide 4000 mg PO BID. Patient #1 also received prescriptions for insulin test strips, insulin testing supplies and glucometer.


Review of the Patient Instruction Signature Page revealed Patient #1 received instructions regarding Atrial Flutter, Atrial Fibrillation and Diabetic Hyperglycemia prior to discharge.



INTERVIEWS


On 5/5/2015 at 9:15 a.m. Physician #1 (Hospital #1) was presented with information about the complaint regarding Patient #1's 4/10/2015 ED visit to Hospital #1. When Physician #1 was asked to review the patient's ED record, since he did not specifically remember the patient, he looked at one (1) or two (2) pages. When asked about the patient's blood pressure decrease to 71/43 at 10:30 p.m. Physician #1 stated, "This was due to fluid resuscitation. She had a 1st degree AV block and this was not related to atrial flutter... atrial flutter can come and go. It can be persistent if there have been heart problems in the past. She did not have atrial flutter while here.... her dizziness and lightheadedness was not related to her heart rhythm... I don't make decisions until laboratory values are back unless the patient is critically ill..." When asked why Patient #1 was not admitted to the hospital as a newly diagnosed diabetic with blood glucose levels abnormally high Physician #1 stated, "Patients with hyperglycemia usually do not require admission." Physician #1 was asked if in retrospect he would have changed anything in regards to the care provided for Patient #1. He said "No... I feel like I did for her what any doctor would have done."


On 5/5/2015 at 11:45 a.m. an interview with Patient #1's daughter revealed that on Friday 4/10/2015 her mother was confused, could not walk or hold up her head and was taken to Hospital #1's ED by ambulance. The daughter stated that her mother's "blood sugar was very high" in the ED at Hospital #1. "She (Patient #1) stayed there several hours, from Friday around 8:30 p.m. until Saturday morning a little after midnight. When they discharged her Metformin was ordered and she was told by the doctor that this would gradually decrease the blood sugar... Before we left the ED (at Hospital #1) I asked for a prescription for a blood glucose machine. They told me, 'We don't teach how to use it, so we don't give prescriptions for them.' They didn't give my mother any instructions on when and how to perform blood sugars and she didn't have a glucose monitor to use or receive instructions on." The daughter stated that during the following weekend she tried to to get her mothers blood sugar down by diet control. "When I took her bood sugar Sunday morning (4/12/2015) it was 450. That's when I called the ambulance. My mother could have easily gone into a diabetic coma. When we got to (Hospital #2) they admitted her to the hospital." The daughter also stated that she received a follow-up call from Hospital #1 while she was still asleep the next morning (Saturday 4/11/2015). When asked how her mother was she said "OK" and hung up. When she woke up later in the morning she contacted the Director of Nurses at Hospital #1, discussed her mother's lack of treatment and lack of discharge instructions from the hospital ED and filed a greivance.


On 5/05/2015 at 10:50 a.m. an interview was held with Registered Nurse (RN) #3 (Hospital #1) regarding Patient #1. The RN stated that she did not remember the patient or the family from the ED visit at Hospital #1 on 4/10/2015. RN #3 was told that Patient #1's daughter was also a nurse, had stated that she could read a heart monitor and that she had seen that her mother's heart monitor showed that she was in atrial flutter while in the ED that day. RN #3 was asked whether she observed atrial flutter at any time during Patient #1's ED visit. She stated, "No. The Nurses' Notes that are in the medical record are what was seen." She also stated that to her knowledge nothing was brought to the attention of the nurses/staff that Patient #1 needed anything and was not receiving it.


An interview was held on 5/5/2015 at 1:40 p.m. with Hospital #1's Pharmacist regarding the diabetic drug Metformin, which had been given to Patient #1 at discharge. The Pharmacist stated that their physicians, nurses and pharmacists used a certain data base for information regarding medications. She printed out information on Metformin for review. Review of the drug information printed out revealed: "Medication Patient Education ...Considerations: Discuss specific use of drug and side effects. Patients may experience diarrhea, flatulence, nausea or asthenia. Have patient report immediately to prescriber severe dyspepsia, signs of hypoglycemia, or signs of lactic acidosis. Educate patient about signs of a significant reaction (wheezing, chest tightness, fever, itching, bad cough, blue skin color, seizures or swelling of face, lips, tongue, or throat.... Contraindications: renal disease or renal dysfunction. " Documented evidence showed that the Discharge Instructions provided to Patient #1 were not specific regarding Metformin considerations or contraindications.


On 5/5/2015 at 3:50 p.m. Hospital #1's FNP #1 stated, "Patients leave the Emergency Room all the time with blood sugars of 248."


On 5/6/2015 12:30 p.m. a telephone message was left for Physician #2 (Hospital #2) to make a return call to discuss Patient #1. No return call was received. On 5/7/2015 another attempt was made to contact Physician #2 by telephone. Another message was left and no return call was ever received. On 5/13/2015 at 11:35 p.m. another effort was made to contact Physician #2. The hospital operator spoken to stated that Physician #2 was not working at the hospital that night. No return call was ever received.



POLICIES AND PROCEDURES


Review of Hospital #1's "Emergency Department (ED)" requirements (Revised 6/17/2014) revealed:
"ED.1 ORGANIZATION SR1. The organization must meet the emergency needs of its patients in accordance with acceptable standards of practice...
The hospital's emergency services must be integrated with the other departments of the hospital (e.g. surgical services, laboratory, ICU, diagnostic services) and be accessible in the delivery of emergency care for patients..."


Review of Hospital #1's "Emergency Department Medical Screening" policy (undated) revealed: "...Definitions -
Medical Screening Exam: A Medical Screening Exam...is defined as 'providing all necessary testing and on-call services within the capability of the hospital to determine whether or not a legally deefined Emergency Medical Condition exists.'
Emergency Medical Condition: 'A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the health of the individual... in serious jeopardy;
2. Serious impairment to any body functions;
3. Serious dysfunction of any bodily organ or part...'..."


Review of Hospital #1's undated (EMTALA (Emergency Medical Treatment and Labor Act)" policy revealed: "The Emergency Medical Treatment and Labor Act ("EMTALA") requires... hospitals to provide medical screeening examinations to all patients who come to the emergency department and request examination or treatment for a medical condition... If the person has an emergency medical condition..., the Hospital must treat or stabilize the person...
1. A. Rights to Treatment: ...the Hospital recognizes the right of the individual to receive, within the capabilities of the Hospital's staff and facilities: i. An appropriate medical screening examination; ii. Necessary stabilizing treatment for an emergency medical condition...; and iii. If necessary, an appropriate transfer to another facility. ..
2. ...D. Stabilized means, with respect to an emergency medical condition, that no material deterioration of the emergency medical condition is likely...
3. Patient Evaluation and Treatment - A. When an individual come to the emergency department seeking medical treatment... the individual must receive a medical screening examination to determine whether the individual has an emergency medical condition. The scope of the screening examination is what is within the capability of the Hospital's emergency department, which include ancillary services that are routinely available in the emergency department... D. ...If... the individual has an emergency medical condition the Hospital must provide...: i. Such additional medical treatment that is within the capabilities of the available staff and facilities, and that is necessary to stabilize the medical condition..."


Review of Hospital #1's "Bylaws of the Medical Staff" (effective 11/25/14) revealed:
"Each member of the Staff, regardless of assigned Staff category, and each Practitioner exercising privileges under these Bylaws shall: (a) provide patients with care, treatment and services at the generally recognized professional level of quality and efficiency within the privileges granted by the Board."



Hospital #1 failed to ensure further medical examination and necessary stabilizing treatment was provided for and Emergency Medical Condition, within the capabilities of the staff and facilities available at the hospital, prior to discharging Patient #1 home on 4/11/2015 at 12:35 a.m.

Based on Emergency Department (ED) record review for Hospital #1, medical record review for Hospital #2, document review, staff interviews, family interview and physician interview, the hospital failed to provide Patient #1, one (1) of 20 patients reviewed, further medical examination and treatment required to stabilize an Emergency Medical Condition (EMC) and prevent a delay in treatment.


Findings Include:

COMPLAINT

A letter of complaint was received by the State Office regarding an ED visit to Hospital #1 on 4/10/2015 at 8:00 p.m. by Patient #1. The letter was written by Patient #1's daughter. The daughter stated that her mother was taken by ambulance to Hospital #1 very weak, dizzy, confused and disoriented with a recent diagnosis of atrial flutter. Her blood pressure in was 80s/30s and she had a heart rate in the 50s. The daughter is a nurse and stated that on the cardiac monitor attached to her mother she was in atrial flutter. When the doctor (Physician #1) asked the daughter if her mother was a diabetic she told him that she was not. She was told by the physician, "Well, her blood sugar is over 400 and she has sugar spilling over into her urine. We are going to give her insulin and treat her." The daughter told him again that her mother had a recent diagnosis of atrial flutter, was started on a new medication and the family was told to watch her blood pressure. Physician #1 stated "Well her blood pressure and heart rate are fine. We are going to treat the diabetes with insulin." On recheck her blood sugar was 385. The patient was discharged about 11:30 p.m. with a prescription for Metformin (diabetic medication), no instructions to take her blood sugar at home and to follow up with her primary physician on Monday (4/13/2015). The daughter called and talked to the nursing supervisor on Saturday with complaints and to ask for a prescription for a glucose meter and diabetic supplies for her mother. The nursing supervisor told the daughter that the physician in the ED at that time would not write a prescription for a glucose meter because she had not seen her mother on Friday. "She said my mother's blood sugar would be ok until she follows up with her primary physician on Monday." The daughter also wrote, "Luckily I am a nurse and I know to take my mother's blood sugar until we could follow up. The biggest concern was that my mother required treatment that she did not receive, and was sent home with no instructions. Her blood sugar remained elevated on Sunday (450) and she was very confused and could not walk. I called an ambulance and she was taken to (Hospital #2)...admitted... a cardiologist was consulted to see her for her heart rate. She remained in Atrial Flutter..." Patient #1 was discharged from Hospital #2 on 4/16/2015.


RECORD REVIEWS

HOSPITAL #1
Review of Hospital #1's ED record for Patient #1 revealed she was a 77 year old female admitted on 4/10/2015 at 8:10 p.m. via ambulance, with complaints of shortness of breath (SOB) and confusion. She was given an Acuity Level of 2 (1 is the highest level of acuity and 5 is the lowest level of acuity) and was seen by ED Physician #1 at 8:30 p.m. Review of his assessment revealed that the patient had SOB on exertion and she was coughing. Review of the physician's 8:24 p.m. orders revealed STAT (immediate) orders were given for an Electrocardiogram (EKG) 12 Lead, Urinalysis, multiple blood tests and a portable chest X-Ray.


At 10:10 p.m. orders were written by Family Nurse Practitioner (FNP) #1 for Sodium Chloride 0.9% (Normal Saline) Bolus IV (intravenous) and Regular Insulin Novolin R five (5) units IVP (IV Push). Regular Insulin Novolin R five (5) units IVP STAT was ordered again at 11:22 p.m. and Sodium Chloride 0.9% Bolus IV STAT at 11:47 p.m. by Physician #1.


Review of results of the ordered blood work revealed the first Glucose (blood sugar ) level reported was 485 (Normal 70-105). The second Glucose level was documented as 377 at 11:06 p.m. A third Glucose Level was documented as 248 at 12:24 a.m. (11 minutes prior to discharge from ED).


Review of the EKG results revealed Patient #1 had a Normal Sinus Rhythm with Sinus Arrhythmia with 1st Degree AV Block.


Hospital #1 discharged Patient #1 on 4/11/2015 at 12:35 a.m. with non-patient specific Discharge Instruction Sheets on Diabetes and Cough. She was a newly diagnosed diabetic patient and she received a prescription at discharge for the drug Metformin (Glucophage) po (by mouth) 2 times a day. She was told to follow-up with her primary care provider within one (1) week. There was no documented evidence Hospital #1 gave Patient #1 any instructions regarding when or how to monitor her blood glucose once she got home. There was no documented evidence that Hospital #1 gave Patient #1 any diabetic teaching/instructions/prescriptions for diabetic supplies at any time during her ED visit. Documented evidence showed that the Discharge Instruction sheets provided to Patient #1 were not specific regarding Metformin considerations or contraindications. There was no documented evidence that a Cardiologist or a Diabetic Instructor/Dietition were ever consulted for the patient.



HOSPITAL #2
Review of Hospital #2's medical record for Patient #1 revealed that on 4/12/2015 at 9:14 p.m. Patient #1 presented by ambulance to their ED. Review of triage notes revealed the patient's blood pressure during the ambulance transfer was documented as 80/38, her blood glucose was 440 and she was given a 900 ml (milliliter) bolus of normal saline intravenously. During triage in the ED Patient #1's blood pressure was documented as 117/58, pulse rate 58 (low), O2 SAT 94 (low). Patient #1 complained of "Not feeling right." Review of an EKG done 4/12/2015 at 9:20 p.m. revealed: "Sinus Bradycardia. Low QRS voltage in precordial leads. Abnormal rhythm ECG" She was admitted by Physician #2 to Hospital #2's telemetry unit at 10:35 p.m. with bradycardia, hypotension, hyperglycemia, generalized weakness, low calcium, low magnesium level, acute chest pain, acute diabetes, atrial flutter and asthma. Consults were ordered for the Diabetes Educator (she was seen twice by the educator during hospital stay), Cardiology for the dyspnea and wheezing, and Pharmacy to adjust the patient's medications for better renal function.


Review of Physician #2's initial 4/12/2015 assessment notes revealed he thought Patient #1 "might be over medicated, making her blood pressure run low... For her (blood) sugar (I) feel that she is going to need insulin do not feel that adequate results will be acheived with Glucophage (Metformin)." She was started on long acting insulin while in the hospital.


History of Present Illness Narrative (4/12/2015) - "Patient has been recently seen at (Hospital #2) Friday night and diagnosed with DKA (Diabetic Keto- Acidosis)...given Glucophage and discharged home. The patient has continued to deteriorate... weakness is worsening... has difficulty ambulating and was found (by family) stuck in a bathtub. When the ambulance was called the EMS found the patient to be bradycardic and hypotensive.."


Review of Cardiology Progress Notes revealed:
4/12/2015 "I suspect the majority of her symptoms are related to atrial fib flutter with rapid ventricular response. Her rates are better controlled and we will adjust her meds further."
4/14/2015 "...is ambulating with minimal difficulty and my plan will be to let her go home in the morning... we will entertain cardioversion if she continues atrial flutter..."
4/15/2015 "... is doing well... to follow up with me in 2 weeks... She continues in atrial flutter with a controlled ventricular response and if she continues in atrial flutter when I see her back we will discuss at that time cardioversion..."


Review of Nurse's Notes from the telemetry unit revealed that atrial flutter was documented in each note.


Review of Patient #1's blood work during her hospital stay revealed:
Blood Glucose at bedside averaged between 129 and 384 (Reference Range 74 - 106);
Hemoglobin A1C on 4/13/2015 was documented as 11.3 (Reference Range 4.2 - 6.3);
Calcium averaged 7.8 to 8.3 (Reference Range 8.5 - 10.1);
Magnesium averaged 1.4 to 2.3 (Reference Range 1.8 - 2.4).


Review of the 4/13/2015 1:42 p.m. Pharmacy Consult notes revealed, "Assessment/Plan: On review of medication, Eliquis amd Metformin were identified for potential adjustment. At this time, renal adjustment is not warranted. Pharmacy following."


On 4/14/2015 and 4/16/2015 Patient #1 received EKGs. Review of the Interpretive Statements for both revealed: "Atrial flutter/tachycardia with rapid ventricular response. Low QRS voltage in precordial leads. Abnormal rhythm ECG"


Discharge diagnoses from Hospital #2 on 4/16/2015 were documented as: 1. Acute Diabetes 2. Acute Chest Pain 3. Acute Generalized Weakness 4. Hypomagnesemia 5.Atrial Flutter and 6. Hyperglycemia.
Discharge instructions were documented as: 1. Diabetic Diet 2. Monitor blood sugars at 7a - 11a - 4p - 9p and take results to the next appointment with primary care provider (2 weeks) 3. Digoxin 0.25mg (milligram) PO (by mouth) daily @1:00 p.m.; Levemir insulin 15 units subcutaneously daily with supper; Lopressor 50 mg PO BID (twice a day) and Magnesium Oxide 4000 mg PO BID. Patient #1 also received prescriptions for insulin test strips, insulin testing supplies and glucometer.


Review of the Patient Instruction Signature Page revealed Patient #1 received instructions regarding Atril Flutter, Atrial Fibrillation and Diabetic Hyperglycemia prior to discharge.



INTERVIEWS


On 5/5/2015 at 9:15 a.m. Physician #1 (Hospital #1) was presented with information about the complaint regarding Patient #1's 4/10/2015 ED visit to Hospital #1. When Physician #1 was asked to review the patient's ED record, since he did not specifically remember the patient, he looked at one (1) or two (2) pages. When asked about the patient's blood pressure decrease to 71/43 at 10:30 p.m. Physician #1 stated, "This was due to fluid resuscitation. She had a 1st degree AV block and this was not related to atrial flutter... atrial flutter can come and go. It can be persistent if there have been heart problems in the past. She did not have atrial flutter while here.... her dizziness and lightheadedness was not related to her heart rhythm... I don't make decisions until laboratory values are back unless the patient is critically ill..." When asked why Patient #1 was not admitted to the hospital as a newly diagnosed diabetic with blood glucose levels abnormally high Physician #1 stated, "Patients with hyperglycemia usually do not require admission." Physician #1 was asked if in retrospect he would have changed anything in regards to the care provided for Patient #1. He said "No... I feel like I did for her what any doctor would have done."


On 5/5/2015 at 11:45 a.m. an interview with Patient #1's daughter revealed that on Friday 4/10/2015 her mother was confused, could not walk or hold up her head and was taken to Hospital #1's ED by ambulance. The daughter stated that her mother's "blood sugar was very high" in the ED at Hospital #1. "She (Patient #1) stayed there several hours, from Friday around 8:30 p.m. until Saturday morning a little after midnight. When they discharged her Metformin was ordered and she was told by the doctor that this would gradually decrease the blood sugar... Before we left the ED (at Hospital #1) I asked for a prescription for a blood glucose machine. They told me, 'We don't teach how to use it, so we don't give prescriptions for them.' They didn't give my mother any instructions on when and how to perform blood sugars and she didn't have a glucose monitor to use or receive instructions on." The daughter stated that during the following weekend she tried to get her mothers blood sugar down by diet control. "When I took her bood sugar Sunday morning (4/12/2015) it was 450. That's when I called the ambulance. My mother could have easily gone into a diabetic coma. When we got to (Hospital #2) they admitted her to the hospital." The daughter also stated that she received a follow-up call from Hospital #1 while she was still asleep the next morning (Saturday 4/11/2015). When asked how her mother was she said "OK" and hung up. When she woke up later in the morning she contacted the Director of Nurses at Hospital #1, discussed her mother's lack of treatment and lack of discharge instructions from the hospital ED and filed a grievance.


On 5/05/2015 at 10:50 a.m. an interview was held with Registered Nurse (RN) #3 (Hospital #1) regarding Patient #1. The RN stated that she did not remember the patient or the family from the ED visit at Hospital #1 on 4/10/2015. RN #3 was told that Patient #1's daughter was also a nurse, had stated that she could read a heart monitor and that she had seen that her mother's heart monitor showed that she was in atrial flutter while in the ED that day. RN #3 was asked whether she observed atrial flutter at any time during Patient #1's ED visit. She stated, "No. The Nurses' Notes that are in the medical record are what was seen." She also stated that to her knowledge nothing was brought to the attention of the nurses/staff that Patient #1 needed anything and was not receiving it.


An interview was held on 5/5/2015 at 1:40 p.m. with Hospital #1's Pharmacist regarding the diabetic drug Metformin, which had been given to Patient #1 at discharge. The Pharmacist stated that their physicians, nurses and pharmacists used a certain data base for information regarding medications. She printed out information on Metformin for review. Review of the drug information printed out revealed: "Medication Patient Education ...Considerations: Discuss specific use of drug and side effects. Patients may experience diarrhea, flatulence, nausea or asthenia. Have patient report immediately to prescriber severe dyspepsia, signs of hypoglycemia, or signs of lactic acidosis. Educate patient about signs of a significant reaction (wheezing, chest tightness, fever, itching, bad cough, blue skin color, seizures or swelling of face, lips, tongue, or throat.... Contraindications: renal disease or renal dysfunction. " Documented evidence showed that the Discharge Instructions provided to Patient #1 were not specific regarding Metformin considerations or contraindications.


On 5/5/2015 at 3:50 p.m. Hospital #1's FNP #1 stated, "Patients leave the Emergency Room all the time with blood sugars of 248."


On 5/6/2015 12:30 p.m. a telephone message was left for Physician #2 from Hospital #2 to make a return call to discuss Patient #1. No return call was received. On 5/7/2015 another attempt was made to contact Physician #2 by telephone. Another message was left and no return call was ever received. On 5/13/2015 at 11:35 p.m. another effort was made to contact Physician #2. The hospital operator spoken to stated that Physician #2 was not working at the hospital that night. No return call was ever received.


POLICIES AND PROCEDURES


Review of Hospital #1's "Emergency Department (ED)" requirements (Revised 6/17/2014) revealed:
"ED.1 ORGANIZATION SR1. The organization must meet the emergency needs of its patients in accordance with acceptable standards of practice...
The hospital's emergency services must be integrated with the other departments of the hospital (e.g. surgical services, laboratory, ICU, diagnostic services) and be accessible in the delivery of emergency care for patients..."


Review of Hospital #1's "Emergency Department Medical Screening" policy (undated) revealed: "...Definitions -
Medical Screening Exam: A Medical Screening Exam...is defined as 'providing all necessary testing and on-call services within the capability of the hospital to determine whether or not a legally deefined Emergency Medical Condition exists.'
Emergency Medical Condition: 'A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the health of the individual... in serious jeopardy;
2. Serious impairment to any body functions;
3. Serious dysfunction of any bodily organ or part...'..."


Review of Hospital #1's undated (EMTALA (Emergency Medical Treatment and Labor Act)" policy revealed: "The Emergency Medical Treatment and Labor Act ("EMTALA") requires... hospitals to provide medical screeening examinations to all patients who come to the emergency department and request examination or treatment for a medical condition... If the person has an emergency medical condition..., the Hospital must treat or stabilize the person...
1. A. Rights to Treatment: ...the Hospital recognizes the right of the individual to receive, within the capabilities of the Hospital's staff and facilities: i. An appropriate medical screening examination; ii. Necessary stabilizing treatment for an emergency medical condition...; and iii. If necessary, an appropriate transfer to another facility. ..
2. ...D. Stabilized means, with respect to an emergency medical condition, that no material deterioration of the emergency medical condition is likely...
3. Patient Evaluation and Treatment - A. When an individual come to the emergency department seeking medical treatment... the individual must receive a medical screening examination to determine whether the individual has an emergency medical condition. The scope of the screening examination is what is within the capability of the Hospital's emergency department, which include ancillary services that are routinely available in the emergency department... D. ...If... the individual has an emergency medical condition the Hospital must provide...: i. Such additional medical treatment that is within the capabilities of the available staff and facilities, and that is necessary to stabilize the medical condition..."


Review of Hospital #1's "Bylaws of the Medical Staff" (effective 11/25/14) revealed:
"Each member of the Staff, regardless of assigned Staff category, and each Practitioner exercising privileges under these Bylaws shall: (a) provide patients with care, treatment and services at the generally recognized professional level of quality and efficiency within the privileges granted by the Board."



Hospital #1 failed to ensure that an appropriate Medical Screening Exam, necessary stabilization and treatment were provided for Patient #1 to ensure no delay in her treatment for Atrial Flutter and newly diagnosed acute Diabetes Mellitus.