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Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an appropriate Medical Screening Exam (MSE) to determine if an emergency medical condition existed in order to provide appropriate treatment for such conditions and ensure the patient was stabilized prior to being transferred from the DED for 1 of 12 (Patient#4) sampled patients with falls.

Refer to findings in deficiency V 2406.

Based on document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) received an appropriate medical screening examination (MSE) according to hospital policy and within the capability of the hospital to determine if an emergency medical condition existed in order to ensure all medical emergency conditions were identified, treated and stabilized for 1 of 12 (Patient #4) sampled patients presenting with falls.

The findings included:

1. Review of the Medical Staff Rules and Regulations for Hospital #1 approved 10/16/12 revealed on page 24, "Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition ... Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department ... Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge ... A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be performed as an outpatient ... the patient requires no further treatment and the treating physician has provided written documentation of his/her findings ... A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at the second facility, with no material deterioration in his/her medical condition ... "


Review of the Medical Screening Exam [Examination] policy for Hospital #1 revised 12/12 revealed, the MSE must be performed on all patients who present to the DED and request medical care and that the purpose of the MSE is to determine if the patient has an emergency medical condition. Documented under the heading Procedure/Special Instructions was the following: The MSE consists of:.. Assessment of chief complaint ... Vital signs ... Mental status ... Ability to walk, gait ... Focused physical exam; an exam appropriate to the organ system related to the chief complaints must be done ... General appearance. The policy further documented the results of the MSE will be recorded in the medical record. Additionally, the policy documented, The following Conditions are Deemed " Emergent " : ...Inability to walk ... Abnormal mental status ... "

2. Medical record review for Patient #4 revealed on 9/11/13 at 10:17 the 58 year old patient presented to Hospital #1's DED via emergency medical services (EMS) with complaints of altered mental status, vomiting and a fall from a syncopal episode.

The nursing facility Resident Transfer Form that accompanied the patient to the DED documented the patient had a change in mental status, was weak and could not stand.

Review of the EMS trip report signed by the DED nurse revealed the patient's glucose was 429 upon arrival to the DED.

At 10:40 a complete blood count (CBC) and a comprehensive metabolic panel (CMP) were collected per routine protocol. Review of the CBC and CMP results revealed the patient's glucose was elevated at 344 (normal 74 - 106), red blood cells (RBCs) low at 3.77 (normal 4.20 - 5.40), hemoglobin (Hgb) low at 8.8 (normal 12.0 - 16.0), and hematocrit (Hct) low at 29.1 (normal 37.0 - 47.0). The abnormal lab values were reported on 9/11/13 at 11:46. There was no documentation the patient was examined, assessed or triaged until 13:04.

Review of the triage assessment at 13:04 revealed the patient, "Complains of pain in the head." The nurse documented the patient was cooperative, awake and alert. The nurse documented the patient's at home medications included Coumadin 7.5 milligrams daily and Humalog sliding scale insulin. There was no documentation the nurse assessed the patient's ability to stand/walk or the abnormal lab values. The pt was triaged at an acuity level of 3.

At 13:08 the DED physician performed a MSE and documented the patient complained of "Near Syncope" with onset of symptoms occurring suddenly. The physician documented he reviewed "initial and all vital signs and nurse's notes." There was no documentation the physician reviewed the abnormal lab values, treated the abnormal lab values, or performed further examination to determine the cause of the abnormal lab values and syncopal episode. There was no documentation the physician ordered additional lab testing. There was no documentation the physician assessed the patient's complaints of pain in the head. The physician documented the patient had a musculoskeletal contusion. The physician documented the patient's Neurological exam was negative for "Mentation, Memory, Lethargic." There was no documentation the physician assessed the patient's ability to stand/walk.

At 13:13 the nurse documented the patient continued, "Complains of pain in the head." There was no documentation of further assessment or treatment of the patient's complaints of head pain.

At 13:24 the physician ordered and the patient was administered Narcan 0.4 milligrams intravenously. There was no documentation to explain why the medication was administered. There was no further examination or treatment of the patient by the physician to determine if an emergency medical condition existed in order to provide stabilization treatment.
At 14:20 the physician ordered the patient to be discharged. There was no documentation the physician assessed the patient again prior to writing a discharge order. The physician documented at 14:22 the patient's Differential Diagnosis was "contusion, fracture." There was no evidence an X-ray had been performed at this time to determine if the patient had a fracture.
A X-ray dated 9/11/13 at 14:24 o "Three-view Right Shoulder documented the patient did not have a fracture dislocaton.
At 14:30 the nurse assessed the patient and documented, "Swelling present in right bicep other moderate amount of bruising noted to upper arm...has increased since presentation to ED [name of physician] notified..." There was no documentation the physician assessed or examined the patient after being notified.
At 14:47 the nurse documented, "Discharge undone."
At 16:30 the nurse documented the patient required suctioning. There was no further nursing assessment or documentation until 19:10. There was no documentation the physician performed an examination or assessment of the patient until 19:35.
At 19:10 the nurse documented, "pt [patient] is unresponsive to verbal and tactile stimuli, pupil dilated and non-reactive."
At 19:20 the nurse notified the physician of the change in the patient's status.
At 19:35 the physician examined the patient and documented, "Patient was alert upon arrival [to the DED]. When seen by me was lethargic, but improved after a dose of Narcan. Orders had been written to discharge...Because of delays in ER [emergency room] today, was not transported immediately. When checked on again by nurse, pt unresponsive. Narcan given without change. Was going to get a head CT [computerized tomography scan] too heavy for table..." The physician documented he would call other hospitals to transfer the patient for a CT scan. There was no documentation the physician performed further examination, treatment or assessment of the patient or the abnormal lab values prior to the patient being transferred.
At 19:27 the patient's glucose was 521 and the patient was administered Humulin R 10 units of insulin. There was no documentation the physician assessed the patient at this time.
At 20:32 the patient's glucose was rechecked and was 497 and the patient was administered humulin R 10 units of insulin. There was no documentation the physician assessed the patient at this time.
At 21:40, prior to transferring to Hospital #2, a protime (PT), prothrombin time (PTT) and an international normalized ratio (INR) were collected. The results were called to the DED at 22:27, after the patient had transferred to Hospital #2. The patient's PT was elevated at >100 (normal 9.0 -12.0), PTT elevated at >169 (normal 22.8 - 34.5) and the INR elevated at >10.0 (normal 0.9 - 1.2).
At 22:00 EMS transported the patient to Hospital #2. Review of DED record at Hospital #2 revealed the Patient #4 was admitted to the DED on 9/11/13 at 23:29. The patient was "completely unresponsive with pupils fixed and dilated..." The patient was admitted to the intensive care unit.
Review of the History and Physical at Hospital #2 revealed the patient had a CT scan performed upon admission which revealed the patient had a large subdural hematoma and "Coumadin Intoxification."
Review of the electroencephalogram (EEG) performed at Hospital #2 on 9/12/13 revealed there was no EEG activity. The impression was "indicative of brain death."
Review of Hospital #2's nurse's notes revealed on 9/12/13 at 14:00 the patient expired.
3. During an interview in the conference at Hospital #1 on 9/18/13 at 08:45 the DED physician confirmed the documentation in the medical record to be accurate. The physician stated the only delay was during the time when they were trying to find a hospital with the appropriate CT scan capable of accommodating this patient related to the patient's weight. MD stated,"I physically lifted the patient's head and examined it for any abnormalities and found none." There was no documentation of this examination in the patient's medical record.