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Based on record review, policy review, and interview, the facility failed to comply with the conditions of participation outlined in §489.24. Specifically, the facility failed to provide stabilizing treatment for 1 of 15 patients who were reviewed in twenty emergency department (ED) records, (Patient #6). Upon discharge, the facility failed to thoroughly assess patient #6's ability to participate in his own care, including his cognitive status, ability to eat, drink, and swallow, and failed to stabilize critical lab values for which the patient was brought to the ED. (See C2407).

Based on interview, clinical record review, and policy review, the facility failed to provide stabilizing treatment for 1 of 15 patients who were reviewed in twenty emergency department (ED) records, (Patient #6). Upon discharge, the facility failed to thoroughly assess patient #6's ability to participate in his own care, including his cognitive status, ability to eat, drink, and swallow, and failed to stabilize critical lab values for which the patient was brought to the ED. This deficient practice placed patient #6 and his caregivers in a position to be unable to implement and achieve discharge planning treatment instructions and goals, and required the patient to be returned to the hospital the following day. Findings include:

Review of patient #6's ER Assessment dated 4/6/21, showed under Emergency Room Note, "[Patient #6] presents to the ER, from our nursing home, with a C/C of abnormal labs, Na: 176, CL: 141. They state his mental status has changed today also. They state [patient #6] has become more lethargic. Exam: he will respond by opening his eyes when he is touched. Pupils are dilated and sluggish. He appears dehydrated with poor skin turgor. Review of his labs show that most of his labs are abnormal...." Patient #6 DX/Impression: 1. Dementia, 2. UTI, 3. Hypernatremia. Patient #6 ED Course included; exam, reviewed his labs drawn today, IV with LR 1 liter given over 1 hour, UA-positive for UTI, Rocephin 2 Grams IVPB, repeat BMP, NL [sic]1 liter given over 1 hour; 2nd liter, Ativan 1 mg IVP, and "Pt became agitated and thrashing around on the cot. Daughter states "this is very abnormal". After the Ativan Pt has calmed down." Patient #6 was discharged back to the nursing home with a plan to push fluids and stop NaCL tabs, follow up with PCP. "Patient was advised to return if symptoms worsen or do not improve. Patient verbalizes understanding of these instruction and is in agreement with this plan of care. Given discharge instructions. "

Review of patient #6's ER clinical records, dated 4/6/21, showed the following assessment recorded:
"...
4:10 p.m., "... Ativan 1 mg IV given per orders. Pt was very agitated and on the fight, settled down after Ativan. Daughter at bedside. Pt confused ...."
4:50 p.m., "Pt sleeping in ER ...."
5:30 p.m., "Pt wheeled over to (nursing home) by [facility] staff, discharge instruction given to charge nurse."

Review of patient #6's labs collected at the nursing home on 4/6/21 at 8:04 a.m.;
sodium 176, with L=136 and H=145
chloride 141, with L=98 and H=107.

Review of patient #6's BMP, collected in the ED on 4/6/21 at 3:06 p.m.;
sodium level of 175, with a range of L=136 and H=145
chloride 140, with L=98 and H=107.

Patient #6 was discharged back to the nursing home on 4/6/21 at 5:30 p.m., with sodium and chloride levels still in the high-high range, confused/sleeping, and with an unknown ability to participate in his own care, specifically his ability to consume liquids as prescribed in the discharge instructions. Patient #6's IV was discontinued on discharge from the ED. The discharge assessment failed to include assessment of patient #6's ability to participate in his own care, including; cognitive status, ability to eat, drink, and swallow. Patient #6 was released as stable.

Review of patient #6's ER Assessment, dated 4/7/21, showed under Chief Complaint, "Pt has hypernatremia and was seen yesterday in the ER, Nursing home sent pt back to Er due to no improvement." Under the patient history, "Pt sent back to the ER today for lethargy and elevated sodium. Pt is reported as lethargic and unable to participate in his own care. [Physician] called with report on the pt and was very concerned the pt was here yesterday and was sent back with the sodium at the same level on ER arrival as on discharge. [Pt #6] has a significant history including cva, bed sores, seizures and chronic renal issues." Patient #6 was ultimately admitted to an observation status and then transferred out to another facility. Patient #6's differential diagnosis: "acute renal injury, dehydration, altered mental status, hypernatremia, and UTI."

Review of patient #6's labs dated 4/7/21 at 1:33 p.m. showed multiple labs fell within the high range: sodium and chloride fell into the high-high range:

sodium 178 HH: range L=136 H=145
chloride 141 HH: range L=98 H=10

In a phone interview on 4/25/21 at 12:30 p.m., community member F said patient #6 had been sent to the ER on 4/6/21 and was semi-comatose when he was sent. She said patient #6 was sent back with the same critical lab values and was unable to participate in any of his cares. She said the hospital had given patient #6 Ativan and he was unable to drink fluids. She expressed concerns that patients were being sent back to the nursing home without concerns for the facilities ability to care for the patients. Some concerns expressed were the inability to acquire medications at a late hour, lack of staffing, and lack of trained staff who could attend to an IV. Community member F said her concern was that patient #6 had the same critical lab values he had when being sent into the ED, the labs had not improved when patient #6 was discharged back to the nursing home, and that patient #6 could do nothing to assist himself, especially after having been administered Ativan.

In an interview on 5/26/21 at 8:51 a.m., staff member D said, "[Patient #6] had urinary retention, they sent him over more confused. We gave LR 1 liter over an hour to lower the sodium, ran UA positive, was given 2 gms of Rocephin, a one shot ABT, vs PO meds like Bactrim (patient #6 was unable to swallow the Bactrim), and 1 mg Ativan after he became agitated. A second liter of LR was given and a D/C order to stop the sodium chloride because it was high. This guy has quite a few things going on and his labs are going to be all over the place. He had a history of renal failure and a history of seizures. I do not remember talking to the family about transferring [patient #6]. He was a DNR. My thought was basically addressing the high values of sodium chloride and UTI. We gave Ativan." Staff member D could not find further documentation of patient #6's mental status after treatments were provided. Staff member D said, "This patient was DNR and you have to look at the whole picture. The treatments given were with the aim to bring down the labs at a slower rate and he was D/C'd with instructions to follow up with PCP. They [the nursing home]did the initial labs and I don't know why they couldn't order labs again."

Staff member D said, "I don't feel like he was unstable on D/C. We had given ABT for the infection, given LR. I felt at that point it was just a matter of time for the patient to respond to the treatment. I don't think that 1 mg of Ativan would have caused a drastic response. The provider over at the care center was very adamant on the phone to me when I went to send him back, that DNR did not mean do not give care. She called later after the nurses called her and said the facility did not have the means to take care of him. This call was still while I was on shift. I don't know why they didn't send him back then. Primarily she was upset just because of his agitation. She did mention that they were short staffed because of having gone through the COVID. I had not deemed that as part of the consideration when sending him back."

In an interview on 5/26/21 at 9:42 a.m. staff member B said any documentation regarding mentation of the patient would have been found in the nurse's notes and Pt #6's assessment documentation at the time of discharge. The documentation did not cover the patient's cognitive status or ability to participate in caring for himself. A request for a copy of the discharge documentation was made and the facility could not provide a signed copy of discharge orders.

In an interview on 5/26/21 at 9:57 a.m., staff member E said, I would have ordered P/O antibiotic when he [patient #6] left. The nursing home could have given Rocephin IM or found an alternative route. It would have been of benefit if the provider had documented a discussion with the family and the decision making there. On the 7th, Rocephin and Ativan was given and calcium. The results for the Urine culture didn't come in until the 10th, but the treatment was appropriate. Gram negative rods are sensitive to Rocephin. Staff member D said, "The number one cause of increased sodium in elderly patient would be dehydration. How aggressive do you want to be when a person is [omit], and DNR. I think there could have been better documentation, but it's easy to be a Monday Morning Quarterback."

In an interview on 5/26/21 at 10:42 a.m., staff member B said, "There is a documentation problem on the 6th for discharge of the patient back to the nursing home, and assessment of the patient before transfer. The documentation does not paint a picture of the patient before discharge. Also, on the 7th, there is no documentation of the vitals until 9:00 p.m."

In an interview on 5/26/21 at 10:50 a.m., community member G said, " I don't feel I knew how critical he was before he was transferred to the nursing home. They told me what was going on and the treatment given, and said that the numbers had come down a little. My [family member] was incoherent. I was there and talking to him, but when he talked he did not make any sense. He could not eat or drink anything. He was extremely agitated. They gave him something to relax him. He was resting and then agitated, resting and agitated. They explained to me the agitation was because of high sodium levels."

Review of the EMTALA-Reporting; Policy #: ER. 0050-M-B, Effective Date: 06/2012, showed, "... 8. Medical Screening Examination is the process required to reach with reasonable clinical confidence the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor. Such screening must be done within the hospital's capabilities and available personnel, including on-call physicians. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...."