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Based on document review and staff interview, the hospital's administrative staff failed to ensure the hospital staff followed the hospital's policies and provided an adequate medical screening examination to 1 of 22 patients (Patient #15) who presented to the hospital's dedicated emergency department between 12/01/17 and 05/20/18 and requested medical care. The hospital's administrative staff identified an average of 1603 patients per month who presented and requested medical care.

Failure to follow the hospital's policy and provide an adequate medical screening examination to an 85 year old patient (# 15) prescribed a blood thinner for treatment of a heart condition resulted in his discharge with an undetected emergency medical condition. Patient # 15 presented to the emergency department (ED) following a physical altercation with another resident at a local facility which caused him to black out. Approximately fifteen (15) hours after discharge, patient # 15 returned to the ED by ambulance in significant pain and unable to walk due to a fractured hip. The hospital's failure placed patient # 15 at risk for severe bleeding and other complications due to trauma while taking a blood thinning medication.

Findings included:

1. Review of policies "EMTALA.001 - Definitions and General Requirements" effective 04/27/2017 and "EMTALA.002 - Medical Screening Examination and Stabilization" effective 04/27/2017 revealed in part, "hospital ....will provide to any individual who "comes to the emergency department" an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available ...to determine whether or not an EMC exists,.."

2. Review of Patient #15's medical records revealed he presented to the ED by ambulance on 03/20/17 at 5:50 PM with chief complaint of Altered Mental Status, Change in Mental Status following an altercation with another resident at the assisted living facility where the patient resided. Documentation showed the patient took medication to treat his heart condition and thin his blood to prevent blood clots. Further documentation showed patient # 15 had a history of dementia and that all parts of his examination were limited "due to the patient's clinical condition." Approximately one hour and 15 minutes after arriving in the ED, staff discharged patient # 15 prior to obtaining any blood work to check for abnormal internal bleeding or to determine the type of injury that caused him to black out.

Please see A-2406 for additional information.

Based on documentation review and staff interviews, the hospital's Emergency Department (ED) staff failed to provide an adequate medical screening examination within the hospital's capabilities prior to discharging 1 of 22 sampled patients that presented to the emergency department (ED) for a possible emergency medical condition. The hospital's failure to use its capabilities and capacity to provide an appropriate and sufficient medical screening examiation placed patient # 15, an 85 year old prescribed blood thinning medication at significant risk for unrelieved pain, deterioration, abnormal bleeding and/or death following a physical altercation with another resident at a local care facility. The hospital's failure to provide an appropriate and sufficient examination significantly delayed treatment of patient # 15's injury following the altercation and placed all patients at risk for undetected, untreated emergency medical conditions. The Administrative staff identified an average of 1,603 patients per month who present seeking medical care at the hospital's dedicated ED.

Findings included:

1. Review of Patient #15's medical record revealed the patient presented to the hospital's ED by ambulance on 3/20/2108 at 5:50 PM from an assisted living facility's dementia unit. Documentation in the medical record showed the patient experienced mental status changes following an altercation with another resident. Documentation showed that staff from the assisted living facility witnessed patient # 15 black out, "his eyes rolled to the back of his head which lasted a minute in duration." Staff also stated that patient # 15 had returned to his baseline. ED nurse A documented patient # 15 suffered from dementia, had an abnormally low heart rate of 43 beats per minute (normal is 60-120 beats per minute) and took a blood thinner (Xarelto) for treatment of atrial fibrillation (an irregular heart beat that can cause blood clots to form placing the patient at high risk for a stroke).

Mid-level practitioner B documented in the medical record that patient # 15's history of present illness, review of systems, past medical history and physical examination were limited "due to the patient's clinical condition." The medical record did not contain evidence that Mid-level practitioner B assessed patient # 15's extremities for range of motion or neuro-vascular status, whether the patient's loss of consciousness was due to a fall, the patient's ability to walk while in the ED or prior to arrival, or determine the cause of patient 15's abnormally low heart rate. Approximately one hour and fifteen minutes after arriving in the ED, Mid-level practitioner A doucmented that patient # 15 was stable and ready for discharge but the medical documentation did not support this. The medical record did not contain evidence that an EKG (heart tracing) was obtained based on the patient's bradycardia (abnormally slow heart rate), or any blood testing, neurological checks, or a CT scan (specialized radiological imaging study) to determine if patient # 15 had experienced any abnormal internal bleeding associated with his altered level of consciousness.

Patient #15 was discharged back to the assisted living facility 3/20/2018 at 7:05 PM with documentation that he had returned to his baseline and no injury was found.

2. Review of a second medical record showed that approximately fifteen hours after discharge, patient # 15 returned to the ED by ambulance on 3/21/18 at 10:44 AM. Documentation by the hospital's ambulance crew revealed that staff at the local care facility reported that patient # 15 was hit by another resident yesterday and "is unable to walk on his own" and "this is new for [the] patient." Further documentation showed that the local care facility staff reported that after being hit yesterday, patient # 15 "fell straight onto his bottom and rolled to his left side."

Upon arrival to the ED, staff documented that patient # 15 had not been able to bear weight since his fall and that he appeared in pain with facial grimacing, "he now has obvious external rotation and shortening of his left hip."

3. During an interview on 5/22/2018 1:15 PM ED Medical Director stated he believed patient # 15 had the hip fracture on 3/20/18 "but you can't tell with the documentation." The ED Medical Director also reported that he discussed with Mid-level practitioner B the need to document more clearly and to "road test" a patient if possible before discharge; meaning check to see if the patient can walk before the incident and check to be sure they can walk after the incident.

4. During an interview on 5/23/2018 9:55 AM Paramedic C revealed that Patient #15 was sitting in a chair when they arrived at scene on 3/20/18. Paramedic C received report from facility staff that patient#15 had been in an altercation, was punched in the chest, fell and lost consciousness but was back to baseline. Facility staff wanted the patient checked out due to his fall and loss of consciousness. Paramedic C and an Emergency medical technician (EMT) assisted Patient #15 to stand and move onto the cot. Paramedic C stated he also assisted the patient upon discharge on 3/20/2018 at 7:05 PM. He assisted the patient into a wheelchair and then into the patient's daughter's vehicle. Paramedic C reported Patient #15 was unable to bear as much weight as he had and was exhibiting different behaviors than upon arrival.

5. During an interview on 5/23/2018 2:27 PM RN D revealed that RN D was the ER Charge nurse 3/20/2018 and received a call from the ambulance that a patient with dementia was in route that had been punched, passed out and fell to the floor. RN D reported this information was passed on to Mid-level practitioner B along with a comment that Patient #15 would probably need an EKG. RN D reported that Mid-level practitioner B said she would look into things.

6. During a telephone interview on 5/23/2018 9:30 AM RN A reported she remembered the patient because he had been in an altercation, fell down, and was sent to the ER to see if anything was wrong. RN A revealed she cannot remember any other specific details of the ER visit.

7. During a telephone interview on 5/23/2018 ARNP B revealed Mid-level practitioner B was unable to remember specific details regarding the ER visit on 3/20/2018. Mid-level practitioner B reported receiving a letter about Patient #15's 3/20/2018 ER visit and a face to face conversation with the ED Medical Director. Mid-level B verbalized the ED Medical Director provided education and the expectation to "road test" patients we receive to ensure they are at their baseline before discharge and to always obtain a CT scan and x-ray on patients who fall and experience a loss of consciousness.

8. During an interview on 5/22/2018 4:55 PM EMT E reported arriving by ambulance to pick up Patient #15 at the assisted living residence on 3/21/2018 at 10:17 AM. Facility staff revealed that Patient #15 was able to walk on his own prior to the fall and now he can't. Patient #15 was assisted from the bed to the stretcher and the Patient #15 did not want to use his left leg. EMT E noted while laying on the cot, patient # 15's left leg rotated outward and there was swelling in the left hip. In route to the hospital we noted swelling in Patient #15's left wrist area.

9. During an interview on 5/23/2018 2:27 PM RN D stated RN D volunteered to take care of Patient #15 on 3/21/2018 at 10:44 AM and was aware the patient had been seen in the ED on 3/20/2018. RN D confirmed that patient #15 was not able to bear weight, could not verbalize pain, and was grimacing.

10. During an interview on 5/22/2018 Dr. H recalled receiving Patient #15 in the ER on 3/21/2018. Dr. H revealed the external rotation of the left leg was obviously visible and Patient #15 grimaced in pain at one point. Patient #15 could not tell me about the pain, Patient #15's family member was his advocate. Dr. H reported he ordered x-rays, a CT scan and lab work because Patient #15 would need surgery and was taking a blood thinner called Xarelto.

11. During an interview on 5/22/2018 3:30 PM Dr. I, Orthopedic Surgeon, revealed it was likely that the fracture was present on the first visit; it was an unstable intertrochanter fracture. Dr. I verbalized it is possible for the fracture to have displaced later (some point after injury) but believed based on the type of fracture that it was displaced when Patient #15 was knocked down. Dr. I revealed Patient #15 had severe dementia and a history of atrial fibrillation (condition where the atria of the heart do not contract normally) and was on blood thinners. Patient #15 when examined did not point to the left hip or localize pain, just grimaced. The most confounding and complicated is Patient #15's dementia and inability to make needs known. Dr. I stated Patient #15 did require a blood transfusion and the majority of the blood loss was from the fracture then continued with surgery. Dr. I reported surgery was withheld until 3/22/2018 due to Patient #15 taking Xarelto, a blood thinner. Dr. I stated a minimum of 24 hours is the usual waiting period to perform surgery on patient's taking this drug.

12. During an interview on 5/22/2018 12:51 Dr. K reported being called to the ED on 3/21/2018 to see Patient #15 and was the admitting physician for Patient #15's inpatient stay. Dr. K revealed it would have been prudent to have done testing including a CT scan of the brain and laboratory tests to determine Patient #15's status during the initial 3/20/2018 ER visit.

13. During an interview on 5/24/2018 7:50 AM Dr. J revealed he was the supervising physician on duty 3/20/2018. Dr. J reported being unaware of Patient #15's ED visit on 3/20/2018 until he saw the medical record after Patient #15 was discharged. Dr. J was not consulted regarding Patient #15's examination or treatment. Dr. J revealed the notes indicated Patient #15 was back to baseline and his head was without trauma. Dr. J reported he would have ordered a CT scan of the head because of Patient #15's age, his fall and taking Xarelto. Dr. J revealed due to the patient's loss of consciousness, he most likely would have ordered lab work, an EKG, and a urinalysis. Dr. J reported having a low threshold for ordering a CT scan especially when a patient is prescribed blood thinners.