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Based on record review and policy review, the facility failed to follow their policies and provide stabilizing treatment, within its capabilities and capacity for two patients (#4, and #8), and failed to follow their policies and provide a thorough medical screening examination (MSE) for one patient (#8) who presented to the Emergency Department (ED) seeking treatment for an emergency medical condition (EMC). Twenty-six medical records from April 1, 2019 through October 1, 2019 were randomly selected for review. The facility saw an average of 992 ED patients per month.

This failure placed all patients at risk for not receiving a thorough MSE and/or treatment to stabilize a potential or actual EMC and resulted in an immeidate jeaoprdy of actual harm to two patients (#4 and #8) and the likelihood of harm to current and future patients.

Findings included:

1. Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with emergency medical conditions]-Medical Screening/Stabilization," revised 11/2018, showed that:
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonable be expected to result in serious impairment or dysfunction of any bodily organ/function.
- A Medical Screening Examination (MSE) is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. The MSE must be done within the hospital's capabilities and available personnel, including on-call physicians. The medical records must reflect continued monitoring based on the patient's needs and continue until the patient is stable or appropriately transferred.
- The ED physician maintains responsibility for the MSE until the patient's private physician or an on-call specialist assumes that responsibility.

Review of the facility's policy titled, "EMTALA - ER [Emergency Room] Physician Call Coverage," revised 03/2019, showed that:
- EMTALA requires hospitals to screen and stabilize patients.
- The hospital must have a list of on-call physicians that are on duty, after the initial examination, to provide further treatment necessary to stabilize an individual.
- Cardiology (a specialty pertaining to the heart) was required to be on-call a minimum of ten days a month.
- Orthopedics (a specialty pertaining to bones) was required to be on-call a minimum of 365 days a year.

Review of Patient #4's ED medical record showed that the patient presented to the facility's ED on 09/09/19 at 12:06 AM, by Emergency Medical Services (EMS, ambulance personnel), with the following documented:
- A 70 year old female presented with a low blood sugar level of 21 (normal range is 70 - 120) and low oxygen saturation (the amount of oxygen in the blood, normal range is 95 to 100%) of 60%.
- She was coughing up mucus (a slimy substance) thru her tracheostomy (trach, an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs).
- A chest x-ray was completed, and interpreted as "No acute process" (indicated that there was no new illness or injury).
- She had a knee immobilizer in place on her left leg.
- Her Troponin (a cardiac specific protein found in the blood that is released when heart muscle is damaged, a small increased level can indicate damage to the heart as a result of a heart attack) level resulted at critical high level of 0.093 nanograms (ng, a unit of measure)/milliliter (a measurement of liquid) (normal level is 0.0 to 0.056 ng/ml).
- She was discharged to the nursing home with diagnoses of hypoglycemia (low blood sugar) and dyspnea (shortness of breath).

Staff failed to identify that the patient had pneumonia, failed to assess critical lab values, and failed to identify an open fracture (a break in a bone whereby the bone protrudes through the skin) of the left leg, which was located under the immobilizer, and had occurred prior to her arrival at NRMC).

2. Review of Patient #8's ED record showed that she had presented to the ED on three separate occasions between 04/12/19 and 04/15/19, with Staff N, Doctor of Osteopathy (DO), as the provider on duty for each visit.

Review of Patient #8's first ED record showed that the patient presented to the facility's ED on 04/12/19 at 12:10 PM, by EMS, with the following documented:
- She presented with a generalized complaint of "not feeling well," a poor appetite, and left shoulder pain, (not rated or documented on a pain scale - left shoulder pain can be indicative of a heart attack).
- She was a 98 year old female, with a past medical history of dementia (a loss of cognitive/thinking abilities and an impairment of memory), breast cancer, lung cancer, hyperlipidemia (high level of fat in the blood), and hypertension (high blood pressure [BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80]).
- Multiple labs were obtained, along with an Electrocardiogram (EKG, a recording of the electrical activity of the heart) and an Echocardiogram (Echo, a test that uses ultrasound [radiology equipment that is used to create images of internal organs or blood vessels] to evaluate your heart muscle and heart valves), however, no cardiology consult was documented.
- Her EKG reading was documented as 1st degree heart block (a delay in electrical activity of the heart that is usually asymptomatic [producing or showing no symptoms]), with no changes to the Q waves or ST segments (specific measurements of the electrical activity of the heart that determines whether or not an Myocardial Infarction [MI, heart attack] has occurred).
- She continued to complain of left shoulder pain.
- She was discharged to home with diagnoses of dehydration (low body fluid volume) and heart failure (a chronic condition in which the heart cannot pump or fill adequately).

Staff failed to address her left shoulder pain, and cardiology was never consulted, even though available.

Review of Patient #8's second ED record showed that the patient presented on 04/14/19 at 11:52 AM , by personal transportation, with the following documented:
- She presented with continued left shoulder pain, she described as sharp, rated as an "8," with a ten being the worst pain ever.
- She appeared uncomfortable and anxious.
- Multiple labs, EKG, and a chest radiograph were ordered per nursing.
- Her EKG reading was documented as Left Ventricular Hypertrophy (LVH, the thickening of the heart muscle in response to excess stress or workload, LVH increases the risk of an MI, a cardiovascular accident [CVA, a stroke], and death) with changes in the PR and the QRS measurements.
- The physician canceled all labs and the chest radiograph.
- Her discharge diagnosis were as Bursitis (inflammation of the fluid filled sacs in the joints) of left shoulder and unspecified dementia.

Staff failed to request a cardiology consult, failed to obtain diagnostic labs, and failed to document the descriptive aspects of her pain, or if the pain had been addressed.









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Based on interview, record review and policy review, the facility failed to perform a medical screening exam (MSE) within the capability and capacity of the hospital, sufficient to determine that an emergency medical condition (EMC) existed for one patient (#8) out of 26 discharged Emergency Department (ED) records reviewed from April 1, 2019 through October 1, 2019. This failed practice, had the potential to cause harm to the patients who sought treatment for an EMC. Over the past six months, the facility saw on average 992 ED cases monthly and transferred a total of 376 patients.

Findings included:

1. Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with emergency medical conditions] - Medical Screening/Stabilization," revised 11/2018, showed that:
- An EMC is 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 serious impairment or dysfunction of any bodily organ/function.
- An MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. The MSE must be done within the hospital's capabilities and available personnel, including on-call physicians. The medical records must reflect continued monitoring based on the patient's needs and continue until the patient is stable or appropriately transferred.
- An MSE includes both a generalized assessment and a focused assessment based on the patient's chief complaint.
- An MSE can be as simple as obtaining a medical history and completing a physical, or as detailed and complex as performing clinical laboratory tests or diagnostic test and procedures.
- The ED physician maintains responsibility for the MSE until the patient's private physician or an on-call specialist assumes that responsibility.

Review of Patient #8's ED record showed that she had presented to the ED on three separate occasions between 04/12/19 and 04/15/19, with Staff N, DO, being the provider on duty for each visit.

Review of Patient #8's second ED encounter medical record, dated 04/14/19, showed the following:
- She presented to the ED at 11:52 AM, with continued left shoulder pain and weakness.
- At 12:00 PM, multiple labs, EKG, and a chest x-ray were ordered.
- At 12:08 PM, the patient's shoulder pain was described as sharp.
- At 12:11, the EKG reading was documented as left ventricular hypertrophy (LVH, the thickening of the heart muscle in response to excess stress or workload, LVH increases the risk of an MI, a cardiovascular accident [CVA, a stroke], and death) with changes in the PR (an electrical measurement of an EKG tracing that reflects whether impulse conduction of the heart from the atria to the ventricles is normal) and the QRS measurements (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles of the heart).
- At 12:15 PM, all labs and the chest x-ray were canceled by the doctor.
- At 12:20 PM, Staff N, DO, documented Patient #8's diagnoses as bursitis (inflammation of the fluid filled sacs in the joints) of left shoulder and unspecified dementia.
- At 12:28 PM, it was documented that she rated her left shoulder pain as an eight out of 10 on a pain scale and that she appeared uncomfortable and anxious.
- At 12:39 PM, Patient #8 left the ED, discharged to home.
- There was no documentation of a cardiology consult, the descriptive aspects of her pain, or that the pain had even been addressed.

Review of patient #8's hospital history showed she presented to the ED on 04/15/19, via ambulance, unresponsive. The patient subsequently died.

During an interview on 10/02/19 at 3:00 PM, Staff N, DO, ED Physician, stated that:
- He did not specifically recall Patient #8.
- Any descriptive information, conversation, or consultations would have been documented in the medical record by himself or the scribe.
- With regards to the diagnosis of bursitis on Patient #8's second visit, he would have made that diagnosis if her pain had been reproducible.
- He would have documented any redness or edema associated with the joint, and whether or not the pain radiated.
- He had no knowledge that Patient #8's death had triggered a peer review of all three medical records, he had never discussed her case prior to this interview, and had never been contacted by anyone from the facility to discuss her death.

Review of Patient #8's ED medical record showed the facility failed to recognize/address, and intervene, for her EKG changes, and perform diagnostic labs related to her weakness complaints.

Based on interview, record review and policy review the facility failed to provide, within its capabilities, necessary stabilizing treatment when an emergency medical condition (EMC) existed for two patients (#4 and #8) out of 26 discharged Emergency Department (ED) records reviewed from April 1, 2019 through October 1, 2019. The facility had the capability and capacity to treat these patients when they presented. This failed practice, had the potential to cause harm to the patients, when stabilizing treatment was delayed, or omitted, when the patients were discharged from the ED. Over the past six months, the facility saw on average 992 ED cases monthly and transferred a total of 376 patients.

Findings included:

1. Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with emergency medical conditions] - Medical Screening/Stabilization," revised 11/2018, showed that:
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonable be expected to result in serious impairment or dysfunction of any bodily organ/function.
- A Medical Screening Examination (MSE) is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. The MSE must be done within the hospital's capabilities and available personnel, including on-call physicians. The medical records must reflect continued monitoring based on the patient's needs and continue until the patient is stable or appropriately transferred.
- The ED physician maintains responsibility for the MSE until the patient's private physician or an on-call specialist assumes that responsibility.

Review of the facility's policy titled, "EMTALA - ER [Emergency Room] Physician Call Coverage," revised 03/2019, showed that:
- EMTALA requires hospitals to screen and stabilize patients.
- The hospital must have a list of on-call physicians that are on duty, after the initial examination, to provide further treatment necessary to stabilize an individual.
- Cardiology (a specialty pertaining to the heart) was required to be on-call a minimum of ten days a month.
- Orthopedics (a specialty pertaining to bones) was required to be on-call a minimum of 365 days a year.

Review of the ambulance "Prehospital Care Report," dated 09/18/19, for Patient #4, showed that:
- Emergency Medical Services (EMS, in this case, and ambulance), arrived at the nursing home at 11:14 PM, and Patient #4 was noted to have a tracheostomy (trach, an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) tube in place and oxygen administered.
- EMS documented that when a portable pulse oximeter (a machine that monitors the percentage of hemoglobin saturation with oxygen in the bloodstream, a normal reading would be 95 to 100%) was applied, the reading was low, however, no numerical documentation was noted.
- A blood glucose reading was obtained and documented at 21 milligram (mg, a unit of measure)/deciliter (dl, a unit of liquid measure), with a normal blood glucose level being 70 to 130 mg/dl depending on the time of day.
- Multiple attempts were made to place an intravenous catheter (IVC, a small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream), then an intraosseous access (the insertion of a needle through the skin directly into the bone marrow in order to inject medications and fluids directly into the venous system when IV access is not available or not feasible), all resulted in failure, which made administering glucose impossible.

Review of facility's documents titled, "On Call Schedule" for 09/19/19 showed that the facility had an orthopedist available for consult.

Review of the ED medical record, dated 09/19/19, for Patient #4, showed that:
- At 12:06 AM, a 70 year old female, presented to the Emergency Department (ED) via EMS, with a low blood sugar level and low oxygen saturation (the amount of oxygen in the blood, normal range is 95 to 100%).
- At 12:17 AM, the nurse documented that Patient #4 was coughing up mucus (a slimy substance secreted by the mucous membranes and glands for lubrication and protection) thru her trach.
- At 12:10 AM, Patient #4 was given eight ounces of orange juice and four packets of sugar via her percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tube.
- At 12:30 AM, the nurse documented that Patient #4 had limited range of motion in her left knee, left ankle and right knee with an immobilizer on her left knee.
- At 12:38 AM, the ED physician documented that the patient had a splint on the left leg.
- At 1:08 AM, arterial blood gases (ABG's, a blood test that measures the amount of oxygen and carbon dioxide in the blood) were drawn.
- At 1:18 AM, multiple labs were drawn.
- At 1:37 AM, Bi-level Positive Airway Pressure (bi-pap, a non-invasive machine that provides two levels of pressure by mask to deliver oxygen by pressure into the lungs, used to treat lung disease and respiratory weakness) settings were documented with an inspiratory pressure of 21, an expiratory pressure of 8, with a rate of 21, and with 50% oxygen.
- At 1:56 AM, chest x-ray was completed.
- At 2:01 AM, her Troponin (a cardiac specific protein found in the blood that is released when heart muscle is damaged, a small increased level can indicate damage to the heart as a result of a heart attack) level resulted at critical high level of 0.093 nanograms (ng, a unit of measure)/milliliter (a measurement of liquid) (normal level is 0.0 to 0.056 ng/ml).
- At 2:02 AM, her blood urea nitrogen level (BUN) resulted at critical high level of 135 milligrams (mg, unit of measure)/deciliter (dl, unit of liquid measure) (normal level is 8.0 to 23.0 mg/dl) and her creatinine level resulted as high at 2.8 mg/dl (normal level is 0.55 to 1.02 mg/dl), can be indicative of kidney failure.
- At 2:02 AM, her C-reactive protein (CRP, a blood test that measures the amount of this protein made by the liver, it is sent into the bloodstream in response to inflammation in the arteries of the heart, individuals with a higher level are at a higher risk of a heart attack) level resulted as high at 2.20 mg/dl (normal level is 0 to 0.3mg/dl).
- At 2:03 AM, Staff K, Doctor of Osteopathy (DO, a physician that practices and treats medical disorders with an emphasis on manipulation and massage of the bones, joints, and muscles), interpreted Patient #4's chest x-ray as "No acute process" (indicates there is no new illness or injury).
- At 3:43 AM, Patient #4's discharge diagnoses were determined to be hypoglycemia (low blood sugar) and dyspnea (shortness of breath).
- At 4:13 AM, Staff G, RN, called a report to Patient #4's nursing home, to inform them that her decrease in oxygenation was a result of not cleaning the trach's inner cannula, and the low blood sugar was attributed to a lack of tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube) during transport earlier in the day from a hospital to the nursing home.
- At 5:05 AM, Patient #4 was discharged to the nursing home by EMS transport.

During an interview on 10/02/19 at 9:00 AM, Staff K, DO, ED Physician, stated that:
- His priorities for Patient #4 were her respiratory status and low glucose (sugar) level.
- Once the inner cannula (one of three parts of an tracheostomy tube, a smaller tube that fits inside the outer tube, is locked in place to prevent if from being coughed out, that is removable for cleaning) of the trach was cleaned and she had been suctioned, her respiratory status improved, and she was then placed on bi-pap.
- Her blood sugar improved with sugar given via her PEG, and dextrose given after an IV access was established.
- He ordered multiple labs in order to determine if there was any underlying issues.
- He interpreted the chest x-ray himself, because there was not a radiologist to interpret standard x-rays during the night. A radiologist re-read them in the morning, and notified the primary care physician if there was a change in interpretation.
- If he heard any abnormalities with her breath sounds, he would have documented them.
- He had a difficult time obtaining her history during the night, and he assumed she was treated for pneumonia at the facility she was admitted to, prior to the nursing home.
- He initially had concerns that she might have pneumonia, but did not start her on antibiotics due to the lack of an elevated white blood cell count, and no fever.
- It was common for trach patients to have thick secretions, and Patient #4's secretions were thick, stringy, and had almost completely occluded the inner cannula.
- He had spoken with Patient #4's son a couple of times about transferring to her another facility, but decided that she had improved significantly and was stable enough to return to the nursing home.
- He was unable to find any documentation related to those conversations in the medical record.
- He did not address her elevated blood urea nitrogen (BUN, blood test that indicates kidney function) and Creatinine (blood test that indicates kidney function), and he felt the elevated Troponin was a result of her renal (pertaining to the kidneys) insufficiency.
- He did not remove the immobilizer/splint on her left leg, and examine her, because it was not what she presented for, and not a priority.

During an interview on 10/01/19 at 3:45 PM, Staff G, ED Registered Nurse (RN), stated that:
- The ED did not receive paperwork or history information from the nursing home, but the hospital had the capability to call for additional information, if needed.
- Priorities for Patient #4 were to establish IV access, to stabilize her blood sugar and stabilize her respiratory status.
- Personnel in the ED were notified by EMS that Patient #4 had a trach, and would need respiratory assistance.
- Patient #4's trach was full of mucus, sticky, slimy phlegm.
- Respiratory therapy handled suctioning, changed the inner cannula, and placed her on bipap, but she was unable to locate supporting documentation in the record.
- She did not remove the immobilizer/splint on the patient's left leg and examine what was underneath it.
- Staff K, DO, ordered his own labs for Patient #4, and she was not notified of abnormal values.
- Staff K, DO, had talked to Patient #4's Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own), to obtain more information, but she was not able to locate documentation of those conversations in the medical record.

During a telephone interview on 10/01/19 at 4:15 PM, Staff H, ED RN, stated that Patient #4 had a cough, her trach was almost completely clogged, and respiratory therapy handled all the suctioning.

During an interview on 10/02/19 at 8:20 AM, Staff J, Respiratory Therapist (RT), stated that:
- Patient #4 had arrived to the ED unresponsive, her color was poor, and her oxygen saturation was around 70%.
- He suctioned her, manually ventilated (process of using a bag valve device connected to oxygen to force air into the lungs and bring up the oxygen saturation in an emergency) her by her trach, and changed the inner cannula.
- She was placed on bipap for approximately two hours with 100% oxygen initially, which was able to be decreased to 30%.
- He was unable to find where these interventions were documented in the medical record, and admitted that he did not document them.

During an interview on 10/02/19 at 9:42 AM, family member L, stated that:
- He was Patient #4's POA.
- He had spoken with the ED physician two separate times during the night.
- He had informed Staff K, DO, ED physician, that Patient #4's trach had been in place for over a year, and that typically if she had secretions and a low oxygen saturation, she had pneumonia.
- He was under the impression that they were going to move Patient #4 to another hospital for treatment, but then he received another call to notify him of the decision to send her back to the nursing home.

On 09/19/19, within a couple of hours after being discharged back to her nursing home, Patient #4 was sent to another ED with respiratory distress. She was diagnosed with pneumonia, an open (bone protrudes through the skin) fracture of the lower left leg, and admitted.

Staff failed to identify the patient's pneumonia and examine the patient's left leg.

2. Review of facility's documents titled, "On Call Schedule" for dates 04/12/19, and 04/14/19 showed that the facility had a Cardiologist available for consult.

Review of Patient #8's ED record showed that she had presented to the ED on three separate occasions between 04/12/19 and 04/15/19, with Staff N, DO, being the provider on duty for each visit.

Review of Patient #8's ambulance Patient Care Report, dated 04/12/19, showed that the ambulance crew made contact with the patient at 11:51 AM. Her complaint consisted of dull, burning, non-radiating left shoulder pain, generalized weakness, and feeling unwell.

Review of Patient #8's first ED encounter medical record, dated 04/12/19, showed the following:
-She presented to the ED via ambulance at 12:10 PM, with a generalized complaint of "not feeling well", a poor appetite, and left shoulder pain (not rated or documented on a pain scale).
- She was a 98 year old female, with a past medical history of dementia (a loss of cognitive/thinking abilities and an impairment of memory), breast cancer, lung cancer, hyperlipidemia (high level of fat in the blood), and hypertension (high blood pressure [BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80]).
- Multiple labs were obtained, along with an electrocardiogram (EKG, a recording of the electrical activity of the heart) and an echocardiogram (echo, a test that uses ultrasound [radiology equipment that is used to create images of internal organs or blood vessels]) to evaluate your heart muscle and heart valves), however, no cardiology consult was documented.
- At 12:20 PM, Staff N, DO, documented her EKG reading as 1st degree heart block (a delay in electrical activity of the heart that is usually asymptomatic [producing or showing no symptoms]), with no changes to the Q waves or ST segments (specific measurements of the electrical activity of the heart that determines whether or not an Myocardial Infarction [MI, heart attack] has occurred), and no cardiology consult.
- At 4:26 PM, it was documented that she had continued to complain of left shoulder pain which was not rated or documented on a pain scale, and was not medicated.
- She was discharged to home at 4:26 PM, with diagnoses of dehydration (low body fluid volume) and heart failure (a chronic condition in which the heart cannot pump or fill adequately).

Review of Patient #8's second ED encounter medical record, dated 04/14/19, showed the following:
- She presented to the ED at 11:52 AM, with continued left shoulder pain.
- At 12:00 PM, multiple labs, EKG, and a chest x-ray were ordered.
- At 12:08 PM, the patient's shoulder pain was described as sharp.
- At 12:11, the EKG reading was documented as left ventricular hypertrophy (LVH, the thickening of the heart muscle in response to excess stress or workload, LVH increases the risk of an MI, a cardiovascular accident [CVA, a stroke], and death) with changes in the PR (an electrical measurement of an EKG tracing that reflects whether impulse conduction of the heart from the atria to the ventricles is normal) and the QRS measurements (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles of the heart).
- At 12:15 PM, all labs and the chest x-ray were canceled by the doctor.
- At 12:20 PM, Staff N, DO, documented Patient #8's diagnoses as bursitis (inflammation of the fluid filled sacs in the joints) of left shoulder and unspecified dementia.
- At 12:28 PM, it was documented that she rated her left shoulder pain as an eight out of 10 on a pain scale and that she appeared uncomfortable and anxious.
- At 12:39 PM, Patient #8 left the ED, discharged to home.
- There was no documentation of a cardiology consult, the descriptive aspects of her pain, or that the pain had even been addressed.

During an interview on 10/02/19 at 3:00 PM, Staff N, DO, ED Physician, stated that:
- He did not specifically recall Patient #8.
- Any descriptive information, conversation, or consultations would have been documented in the medical record by himself or the scribe.
- With regards to the diagnosis of bursitis on Patient #8's second visit, he would have made that diagnosis if her pain had been reproducible.
- He would have documented any redness or edema associated with the joint, and whether or not the pain radiated.

During an interview on 10/02/19 at 11:20 AM, Staff D, Cardiovascular and Emergency Room Director, stated that: she reviewed all patient charts that have a return ED visit within 48 to 72 hours of their initial ED visit, and that her review of Patient #8's ED visits triggered a peer review based on EKG changes.

Review of Patient #8's ED medical records showed the failure of the facility to recognize, address, and intervene for her EKG changes, abnormal laboratory values and pain levels.

The facility failed to stabilize Patient #8's EMC, prior to discharge, on both occasions.






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