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Based on medical record reviews, EMS (Emergency Medical Services) ambulance reports, and interviews, the hospital failed to ensure that an individual who presented to the hospital's emergency department with an emergency medical condition (respiratory distress) was stabilized prior to discharge, as the hospital had the capabilities to stabilize 1(Patient #8) of 38 sampled patients medical records reviewed.

Findings include:

Refer to findings in Tag A-2407.

Based on medical record reviews, EMS (Emergency Medical Services) ambulance reports, and interviews, the hospital failed to ensure that an individual who presented to the hospital's emergency department with an emergency medical condition (respiratory distress) was stabilized prior to discharge, as the hospital had the capabilities to stabilize 1(Patient #8) of 38 sampled patients medical records reviewed.


The findings included:

Closed medical record review for patient #8 was conducted on 07/16/2019. Review of the EMS (Emergency Medical Services) ambulance report dated 5/30/2019 at 09:35 a.m., revealed in part, "Assessment was a 15- YOM(year-old male ) lying in a hospital bed of his home in the care of his mother. Language barrier in place and EMS communicates w/ (with) Google Translate at times. Mother reports pt (patient) began to appear as if her (sic) was going to vomit and began foaming at the mouth. Pt did not vomit and currently appears in minimal respiratory distress breathing shallowly and rapidly w/ a minimal amount of foam at the left corner of his mouth. Pt is at baseline which is not verbal and a hx (history) of muscular dystrophy (sic) (a group of diseases that cause progressive weakness and loss of muscle mass). Pt is found to be tachycardic but stable ... Pt is moved from hospital bed to stretcher w/out (without) incident. Once in ambulance, pt's SPO2 (pulse oximetry) drops down to 92 and is place (sic) on 3 lmp (liters per minute) O2 (oxygen) brining (sic) his SPO2 to 97. Pt remains stable en route to hospital continuing to breathe irregularly at times and rapidly. Once at (Duke University Hospital -Hospital A), verbal report is given to receiving RN (Registered Nurse) as charted ..." Patient #8 arrived at Duke Hospital -Hospital A on 05/30/2019 at 0959, with initial vital signs of: Temp (T) 97.4 Fahrenheit (F); Pulse (P) 115 (Normal Heart Rate-60-100); Blood Pressure (BP) 103/81; Respirations (R) 52 (normal respirations 16-20); SPO2 97 % (percent) on 3lpm O2. Patient #8's finger stick blood glucose was 119 on 05/30/2019 at 1024. The triage nurse documented the patient's triage level as a 2 (Emergent). Documentation on the ED notes dated 5/30/2019 revealed in part that at "10:32 AM, L (left) BS (breath sounds), Rhonchi...R (right) BS:Rhonci. Resp pattern Accessory muscle use (Subcoastal) (subcoastal-mild to moderate difficulty breathing) ...12:48 P.M. Resp. at this time-Pt. continues to have subcoastal retractions. A MSE was initiated by Medical Doctor (MD) #1 on 05/30/2019 at 1022. During the DED admission the following diagnostic studies were ordered: Total Parenteral Nutrition (TPN) Panel, Complete Blood Count (CBC) with differential, Shock Panel, venous; ECG (Electrocardiogram), and a chest and abdominal X-ray. The out of Reference Range (RR) results were as follows: TPN Panel - Potassium: 3.5 mmol/L (RR: 3.8 - 5.2); Shock Panel, Venous - Hemoglobin: 19.0 g/dL (RR: 12.0 - 16.0), Hematocrit: 58.4 % (RR: 36.0 - 50.0), % O2 Hemoglobin: 85.3 % (RR: 60.0 - 85.0), Volume % O2: 22.7 % (RR: 7.0 - 18.0), Potassium: 3.3 mmol/L (RR: 3.8 - 5.0), Lactate: 3.6 mmol/L (RR: 0.6 - 2.2); CBC - WBC (White Blood Cell count) 16.0 x 10^9/L (RR: 3.2 - 9.8), Hemoglobin: 18.4 g/dL (RR: 12.0 - 16.0), RBS (Red Blood Cell Count): 5.88 x 10^12/L (RR: 3.80 - 5.50), Neutrophil Count: 9.9 x 10^9/L (RR: 1.8 x 7.2), Lymphocyte Count: 5.0 x 10^9/L (RR: 1.7 - 4.4), Monocyte Count: 1.0 x 10^9/L (RR: 0.1 - 0.9), Immature Granulocyte Count: 0.09 x 10^9/L (RR: <= 0.06). A repeat Lactate was resulted on 05/30/2019 at 1354 (2 hours and 49 minutes after the initial): 3.5 mmol/L (0.1 less than the initial). Patient #8 was administered Solu-Cortef (a steroid medication) 100 mg intravenous on 05/30/2019 at 1053, and a Pedialyte (an oral, nutrient rich fluid) tube feed on 05/30/2019 at 1344. Review of a Provider Note written by MD #1 on 05/30/2019 at 2001 revealed, "...Patient presents with - Respiratory Distress HPI (History of Present Illness) (Duke University Hospital -A) was used for the history portion of this note. 15 yo (year-old) M (male) w/ PMH (Past Medical History) of adrenoleukodystrophy (genetic disorder -several inherited conditions that affect the nervous system and adrenal glands), adrenal insufficiency, and seizure who presents this morning for respiratory distress. Mom states that he was in his usual state of health yesterday. This morning he woke up with moaning and grunting which concerned mom for pain. He also had some bubbling of spit at his mouth and possible choking but no emesis. He did have increased work of breathing and shallow breathing. No diarrhea or constipation or changes in urination. He received all his morning meds and tolerated them. She did not give stress dose Solucortef (a steroid medication). Mom gave his morning feed which he did okay with. (sic) Mom called (Home Health Agency #1 Named) nurse line who recommended not giving the water flush due to possible aspiration and to come to ED (Emergency Department) ... Past Medical History ... Adrenal insufficiency ... Adrenoleukodystrophy ... Oropharyngeal dysphagia (difficulty initiating a swallow) Seizure ... Review of Systems Constitutional: Positive for diaphoresis. Negative for activity change and fever. HENT (Head Ears Nose Throat): Positive for drooling. Negative for rhinorrhea. Respiratory: Positive for shortness of breath. Negative for wheezing. Gastrointestinal: Negative for abdominal distention, blood in stool. Constipation, diarrhea and vomiting. Genitourinary: No urinary changes Neurological: Positive for tremors. Negative for seizures. Pain (sic) ... Physical Exam HENT: Head: Atraumatic ...Eyes: Pupils are equal, round, and reactive to light. Conjunctivae are normal ... Cardiovascular: Normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: He is in respiratory distress. He has no wheezes. Shallow breathing, decreased air movement in bilateral lung bases, no wheezing or crackles Abdominal: Soft. He exhibits no mass. There is no tenderness. There is no guarding. Genitourinary: Rectum normal and penis normal ... Musculoskeletal: He exhibits no edema or tenderness. Full passive ROM (Range of Motion) throughout Lymphadenopathy: He has no cervical adenopathy. Neurological: Hypertonic extremities, intermittent tremors in lower extremities, intermittent grunting and groaning Skin: Skin is warm. Capillary refill takes less than 2 seconds. No rash noted. He is diaphoretic. Skin is clear, no evidence of skin infection on full body skin exam. ED Course MDM (Medical Decision Making) 12:10 PM DDx (Differential Diagnosis very likely aspiration (lung infection caused by inhaled or gastric contents) -event given his foaming at the mouth and possible choking behaviors earlier this morning. Will rule out MI (Myocardial Infarction) with EKG (Electrocardiogram) as he is tachycardic (elevated heart rate), diaphoretic, and tachpeic (sic-tachypnea- elevated and rapid breathing)) 12:42 PM RR (Respiratory Rate) improved to 30s, HR (Hear Rate) High 110s, satting (sic) well. Diaphoresis improved. CXR (Chest X-ray) w/o (without) significant changes from prior, no signs of consolidation on personal read. AXR (Abdominal X-ray) with gaseous distension and stool personal read. CBCd (sic-CBC), BMP WNL (Within Normal Limits). EKG reassuring. Will trial 8 oz (ounces) of pedialyte via tube. Patient tolerated pedialyte and VS (Vital Signs) improved. Symptoms likely due to unwitnessed aspiration event. Will d/c (discharge) to home with return precautions ..." Review of an ED Attestation Note written by MD #2 on 05/30/2019 at 1344 revealed, "...Assessment 15-year-old medically complex patient with mild respiratory distress, who mom feels is not some type of discomfort, with otherwise reassuring vital signs. Differential diagnosis is broad but may include aspiration pneumonia, community acquired pneumonia, metabolic derangement, adrenal crisis, pain from occult injury, intra-abdominal process ... Course See resident note for details Patient showed significant improvement over the course of several hours of observation the (sic) emergency department Mother comfortable and prefers to go home ..." Review of a radiology report of the abdominal X-ray written by MD #4 at 05/30/2019 at 1440 (15 minutes prior to Patient #8 ' s discharge) revealed, "... Comparison: 5/17/2017 Findings: G-tube projects over the gas-filled stomach. Nonobstructive bowel gas pattern. No supine evidence of free air, pneumatosis (presence of air in abnormal places in the body) or portal venous gas. No acute bony abnormalities. Impression: Nonobstructive bowel gas pattern ..." Review of a statement added to the radiology report by MD #5 on 05/30/2019 at 1525 (40 minutes after Patient #8 ' s discharge) revealed, "I have reviewed the images and concur with the above findings." Review of a radiology report of the chest X-ray written by MD #4 at 05/30/2019 at 1440 (15 minutes prior to Patient #8 ' s discharge) revealed, "... Comparison: 9/15/2018 Findings: Stable cardiac mediastinal silhouette. Decreased lung volumes with bronchovascular crowding. Bibasilar opacities. Pleural spaces are normal. No pneumothorax. No free air below the diaphragm. No acute osseous abnormalities. Impression: Decreased lung volumes with bibasilar atelectasis, note that aspiration could appear similarly ..." Review of a statement added to the radiology report by MD #5 on 05/30/2019 at 1525 (40 minutes after Patient #8's discharge) revealed, "I have reviewed the images and concur with the above findings." Patient #8's vital signs on 05/30/2019 at 1446 were as follows: T 99.1 F, P 110, BP 116/87, R 26, SPO2 95 % room air. Review of an ED Note written by RN #1 on 05/30/2019 at 1454 revealed, "Patient's mother verbalized understanding of discharge instructions. Patient was opening his eyes to verbal and tactile stimuli. Color is pink, Patient discharged home with mother and family ..." Patient #8 was discharged from the DED on 05/30/2019 at 1455. The facility failed to ensure that that on 5/30/2019 patient #8's respiratoty status was stabilized as required within the capabilities of the hospital's staff and facilities prior to discharging patient #8 at home.

Patient #8 returned to the DED via ambulance on 05/31/2019 at 0503. Review of a note written on 05/31/2019 at 0619 by Paramedic #2 revealed, "... Advance Directive State/EMS DNR Form ... Medic 6 was dispatched for Breathing problem. Upon arrival, find a 15y.o. male, conscious but not fully alert, laying in his hospital bed. Pt's family and home health nurse are on scene ... Pt was transported to the ER (Emergency Room) yesterday for the same complaint and was discharged. Nurse advises that the pt's SPO2 had decreased tonight which is why EMS was called. Provider advised that the pt's baseline mental status is not fully alert and oriented but he is usually more alert than he is presently. Nurse did give pt ibuprofen tonight for a low grade fever ... Pt's SPO2 is in the 80s initially. Pt's breathing is rapid and shallow with rales noted bilaterally. Pt is placed on O2 via ETCO2 N/C (a nasal cannula oxygen delivery device that can measure end-tidal carbon dioxide in exhaled air) with some improvement noted in SPO2. He is afebrile and his BGL (blood glucose) is noted to be low but does not have and history of diabetes. Pt is transferred to the stretcher via draw sheet method. Pt is secured with seatbelts and transferred to the truck via stretcher. IV (intravenous) attempted but unsuccessful. Pt breathing is assisted with BVM (Bag Valve Mask) and O2. IO (intraosseous access) initiated. Pt is administered D10 via IV (sic). Suction PRN (as needed) due to oral secretions. No other changes are noted en route. He is transferred to the ER via stretcher. He is transferred to the bed in peds (pediatrics) rm (room) #2 via draw sheet method. Pt care and report are given to ER staff. Upon transfer of care, it is noted by ER staff that the pt has lost pulses and TOD (Time of Death) is called." Review of an ED Provider Note written on 05/31/2019 at 0513 by MD #3 revealed, "...MDM Pt is a 15 yo M w/ active medial hx (history) as below who p/w (presents with) c/o (complaint of) respiratory distress. On arrival pt w/ IO access and DNAR (sic) paperwork at bedside placed on monitor being actively bagged w. EMS. No pulses felt, no spontaneous respiration being bagged by RT (Respiratory Therapy), asystole on monitor, on BSUS (Bed Side Ultrasound) no cardiac activity noted. TOD called at 0508 ..."

Interview conducted with MD #2 on 07/17/2019 at 1120 revealed he vaguely recalled Patient #8 but did evaluate the patient after the resident (MD #1). Interview revealed he did have an elevated WBC count, which could have been a stress reaction. Interview revealed when the CBC differential was evaluated, the differential was normal. Interview revealed the Lactate level elevation was mild, and it was repeated prior to Patient #8's discharge, to ensure the level was not worsening. Interview revealed the patient's clinical presentation was not unstable, and his treatment included observing him for "4 or 5 hours" to ensure his clinical presentation did not deteriorate. Interview revealed Patient #8's mother was present and via a Spanish interpreter, directly involved in the patient's care. Interview revealed, parents of children with complex medical histories know the child's baseline better than anyone; and MD #2 advised he always collaborates with children's parents. Interview revealed Patient #8's mother was comfortable with discharging the patient, and continuing care at home. Interview revealed if his mother verbalized any concern about his condition, he would have arranged for admission. Interview revealed normal process regarding radiology reporting involves a "wet call," referring to an initial call, usually from a radiology resident, to the ED provider to give an initial report, which can range from "3 words" to a more detailed report, depending on what they must report. The report itself is then written by the resident, and later reviewed by the radiology attending, who either agrees or makes changes. Interview revealed MD #2 did not recall whether he received the "wet call" prior to Patient #8's discharge; and if he did, he could not recall what was reported. Interview revealed there were no clinically significant changes in Patient #8's vital signs prior to discharge compared to his initial vital changes, and after multiple conversations with his treatment team, Patient #8 was deemed safe for discharge.

Review of Patient #8's medical record for the 05/30/2019 ED admission, conducted on 07/17/2019 revealed no evidence of any "wet call" telephone report from radiology staff to ED provider staff.

Interview conducted with MD #4 on 07/18/2019 at 1045 revealed he was the radiology resident that interpreted Patient #8's x-rays on 05/30/2019. Interview revealed his attending physician (MD #5) was with him during the interpretation, which is standard practice. Interview revealed both x-rays performed on Patient #8 were compared to prior films and were determined to have no acute processes, so no telephone report was made to the DED providers, and if there had been a telephone report, it would have been documented. Interview revealed the only time an ED provider is called regarding x-ray findings is when a picture reveals an acute or emergent finding, for example free air or a pneumothorax (a collapsed lung). Interview revealed this is standard practice in all of radiology, regardless of facility. Interview revealed an x-ray cannot tell the difference between atelectasis and aspiration. You can only see that something is in the lungs. Interview revealed, "That's why we give differential diagnosis." What was seen on the chest x-ray wasn't a focal consolidation, which would have indicated pneumonia. Interview revealed determining atelectasis versus aspiration depends on interpretation of the history of present illness and the clinical presentation and assessment of the patient.

Interview conducted with RN #1 on 07/18/2019 at 1100 revealed she did remember Patient #8, but not specifically his discharge. Interview revealed ED staff always have access to Spanish speaking interpreters. RN #1 did recall at the end of Patient #8's care the providers were okay with his discharge. Interview revealed if she ever has hesitation about a discharge her first step would be to discuss the discharge with the physicians, and she always has a charge nurse and nursing leadership to communicate with as well.

Telephone interview conducted with MD #1 on 07/18/2019 at 1140 revealed she recalled Patient #8. MD #1 characterized Patient #8's respiratory distress upon arrival as moderate. Some suctioning was initially required to maintain a clear airway, but it was not continually required throughout the admission, and none was required prior to discharge. Interview revealed MD #1 collaborated with her attending (MD #2) throughout Patient #8's care, including reviewing all diagnostic studies, and medication administered. Interview revealed the treatment team deemed Patient #8 safe for discharge. Interview revealed a Spanish interpreter was utilized throughout care, and Patient #8's mother verbalized understanding of the discharge instructions and did not express any concern regarding the discharge.