HospitalInspections.org

Based on review of the Hospital's ED policies and procedures, observations, review of medical records, and staff interviews, it was determined the Hospital failed to comply with the provider agreement as defined in ?489.20 and ?489.24.

The findings included:

A2407 - The Hospital failed to ensure the patient's Emergency Medical Condition (EMC) was stabilized prior to discharge for patients reviewed who presented to the ED for care and services.

Based on medical record reviews and staff interviews, it was determined the Hospital failed to ensure the patient's EMC was stabilized prior to discharge for three patients (#23, #24, and #31) reviewed who presented to the ED for care and services. The findings included:

1. Patient #23 presented to the ED on 12/31/2009 at 2337 (11:37 PM) after suffering a stab wound in the left side of the neck. The ED record indicated "1 liter blood loss". The MSE notations indicated the patient was found by the EMS staff in a "huge pool of blood & clothes soaked".
a. The patient had signs/symptoms of moderate blood loss including:
1) The patient's blood pressure at initial triage assessment was 95/42 with a pulse of 102.
2) The patient's hemoglobin was low (11.1).
3) An 8 inch by 8 inch hematoma was noted in the left trapezius muscle.
4) The patient continued to exhibit tachycardia and a low blood pressure prior to his/her transfer to a tertiary care hospital.
b. The patient was typed and screened for a blood transfusion but no blood was given to the patient prior to his/her transfer to another facility. There was no indication of why the blood was not given.
c. In an interview with the blood bank supervisor on 01/07/2010 at 12:05 PM he indicated the patient was typed but no blood was transfused.
d. Although the transfer record indicated "blood products" under the "preparation for transfer", the patient did not receive any blood products until his/her arrival at the receiving hospital.
e. This patient's injury with moderate blood loss and persistent tachycardia despite IV fluid replacement required blood replacement be initiated. This blood replacement was not provided.
f. Records from the tertiary hospital indicated the patient had a blood loss of greater than one liter and had a drop in his/her hemoglobin to 9.7. Upon arrival in the tertiary hospital ED, there was "arterial blood coming out of the wound". The patient required two units of packed red blood cells at the tertiary hospital.
2. Patient #24 presented to the ED on 01/05/2010 at 0816 (8:16 AM) with complaints of urinary/flank discomfort. Initial triage assessment indicated a pain level of 8/10.
a. Although the QMP conducted the MSE at 9:12 AM, the patient did not receive any pain medication until 1305 (1:05 PM), almost five hours after presenting to the ED and just prior to transfer to another hospital.
b. The patient's temperature was initially normal at 98.2 degrees Fahrenheit. During the course of the ED visit the patient's temperature increased to 103.6 at 1127 (11:27 AM) and was 102.6 degrees at the time of discharge. The patient's blood studies showed an elevated white blood count (WBC) and another test conducted showed the patient had a probable infection. There was no evidence the QMP addressed this elevation in the patient's temperature, elevated WBC or the probable infection.
c. The patient did not receive any medication for the fever or any antibiotic. Although the patient was in the ED for almost five hours, there was no indication of the reason these modalities were not considered or provided.
3. Patient #31 presented to the ED on 01/03/2010 at 1218 (12:18 PM) with complaints of knee pain (9/10).
a. The patient also had a history of diabetes mellitus. A blood test conducted at 1305 (1:05 PM) indicated the patient's BG was critically elevated at 546 mg/ml.
b. The MSE was not conducted until 1450 (2:50 PM), over 2 ? hours after presenting to the ED. The QMP ordered "5 U (units) Insulin (R) (regular) IV" at 1355 (1:55 PM), fifty minutes after identification of the critically high BG. The nurse did not give this insulin until 1455 (2:55 PM) another hour later.
c. Triage assessment indicated the patient weighed 220 pounds. Although the patient received Vicodin 1 tablet and Morphine 2 mg IV, his/her pain continued and was at a level of 7/10 at the time of transfer. Only 2 mg of Morphine for this 220 pound patient did not adequately control the patient's pain.
d. The patient's WBC was elevated and the MSE indicated inflammation and possible cellulitis of his/her knee (hot, swollen, increasingly painful, and loss of mobility). There was no indication of the reason antibiotics were not considered or provided. Given the patient's potential for sepsis due to his/her poorly controlled diabetes and indications of a probable infection, antibiotics should have been considered.